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Evidence suggests that the patient-centered medical home (PCMH) model of primary care improves management of chronic disease, but there is limited research contrasting this model's effect when financed by a single payer versus multiple payers, and among patients with different types of health insurance. This study evaluates the impact of a statewide medical home demonstration, the Maryland Multi-Payer PCMH Program (MMPP), on adherence to antihypertensive medication therapy relative to non-PCMH primary care and to the PCMH model when financed by a single payer. The authors used a difference-in-differences analytic design to analyze changes in medication possession ratio for antihypertensive medications among Medicaid-insured and privately insured non-elderly adult patients attributed to primary care practices in the MMPP ("multi-payer PCMHs"), medical homes in Maryland that participated in a regional PCMH program funded by a single private payer ("single-payer PCMHs"), and non-PCMH practices in Maryland. Comparison sites were matched to multi-payer PCMHs using propensity scores based on practice characteristics, location, and aggregated provider characteristics. Multi-payer PCMHs performed better on antihypertensive medication adherence for both Medicaid-insured and privately insured patients relative to single-payer PCMHs. Statistically significant effects were not observed consistently until the second year of the demonstration. There were negligible differences in outcome trends between multi-payer medical homes and matched non-PCMH practices. Findings indicate that health care delivery innovations may yield superior population health outcomes under multi-payer financing compared to when such initiatives are financed by a single payer.

Background: There is mixed evidence about the relations of current versus past cancer with severe COVID-19 outcomes and how they vary by patient and cancer characteristics. Methods: Electronic health record data of 104,590 adult hospitalized patients with COVID-19 were obtained from 21 United States health systems from February 2020 through September 2021. In-hospital mortality and ICU admission were predicted from current and past cancer diagnoses. Moderation by patient characteristics, vaccination status, cancer type, and year of the pandemic was examined. Results: 6.8% of the patients had current (n = 7,141) and 6.5% had past (n = 6,749) cancer diagnoses. Current cancer predicted both severe outcomes but past cancer did not; adjusted odds ratios (aOR) for mortality were 1.58 [95% confidence interval (CI), 1.46–1.70] and 1.04 (95% CI, 0.96–1.13), respectively. Mortality rates decreased over the pandemic but the incremental risk of current cancer persisted, with the increment being larger among younger vs. older patients. Prior COVID-19 vaccination reduced mortality generally and among those with current cancer (aOR, 0.69; 95% CI, 0.53–0.90). Conclusions: Current cancer, especially among younger patients, posed a substantially increased risk for death and ICU admission among patients with COVID-19; prior COVID-19 vaccination mitigated the risk associated with current cancer. Past history of cancer was not associated with higher risks for severe COVID-19 outcomes for most cancer types. Impact: This study clarifies the characteristics that modify the risk associated with cancer on severe COVID-19 outcomes across the first 20 months of the COVID-19 pandemic. See related commentary by Egan et al., p. 3

Electronic referrals provide an efficient solution for clinicians to connect patients to free tobacco cessation services, such as the tobacco Quitline. However, strategic planning is necessary for the successful adoption of this method across the health care system. The purpose of this study was to develop an implementation strategy for electronic referrals to the tobacco Quitline in a large health system. A clinical decision support tool created a closed-loop e-referral pathway between the electronic health record system and the Quitline. Multilevel strategies were developed to implement the e-referral process across the entire health system, including leadership buy-in, Epic tip sheets, newsletters, training for practice champions and staff, physician educator, patient-focused advertisements, and video clips distribution by the Maryland Department of Health Center for Tobacco Prevention and Control. The implementation of a system-wide e-referral pathway for tobacco cessation involved continuous clinician education and training, systematic quality control, and engaging “champion” clinicians. Postimplementation data analysis revealed that 1,790 e-referrals were received by the Quitline in 2018–2019, of which 18% accepted follow-up services, 18% declined, and 64% were not reached after multiple attempts. Among 322 patients who accepted Quitline services, 55% requested nicotine replacement therapy. Overall, 282 clinicians referred patients, including 107 primary care physicians and 175 specialists; 62 clinicians e-referred 72% patients, thereby emerging as “tobacco champions.” The e-referral process is an efficient method for tobacco users to receive a cessation referral from clinicians. Sustainability can be achieved through leadership buy-in, physician ease of use, patient motivation, information technology supports, and reminders.

Introduction Available evidence is mixed concerning associations between smoking status and COVID-19 clinical outcomes. Effects of nicotine replacement therapy (NRT) and vaccination status on COVID-19 outcomes in smokers are unknown. Methods Electronic health record data from 104 590 COVID-19 patients hospitalized February 1, 2020 to September 30, 2021 in 21 U.S. health systems were analyzed to assess associations of smoking status, in-hospital NRT prescription, and vaccination status with in-hospital death and ICU admission. Results Current (n = 7764) and never smokers (n = 57 454) did not differ on outcomes after adjustment for age, sex, race, ethnicity, insurance, body mass index, and comorbidities. Former (vs never) smokers (n = 33 101) had higher adjusted odds of death (aOR, 1.11; 95% CI, 1.06–1.17) and ICU admission (aOR, 1.07; 95% CI, 1.04–1.11). Among current smokers, NRT prescription was associated with reduced mortality (aOR, 0.64; 95% CI, 0.50–0.82). Vaccination effects were significantly moderated by smoking status; vaccination was more strongly associated with reduced mortality among current (aOR, 0.29; 95% CI, 0.16–0.66) and former smokers (aOR, 0.47; 95% CI, 0.39–0.57) than for never smokers (aOR, 0.67; 95% CI, 0.57, 0.79). Vaccination was associated with reduced ICU admission more strongly among former (aOR, 0.74; 95% CI, 0.66–0.83) than never smokers (aOR, 0.87; 95% CI, 0.79–0.97). Conclusions Former but not current smokers hospitalized with COVID-19 are at higher risk for severe outcomes. SARS-CoV-2 vaccination is associated with better hospital outcomes in COVID-19 patients, especially current and former smokers. NRT during COVID-19 hospitalization may reduce mortality for current smokers. Implications Prior findings regarding associations between smoking and severe COVID-19 disease outcomes have been inconsistent. This large cohort study suggests potential beneficial effects of nicotine replacement therapy on COVID-19 outcomes in current smokers and outsized benefits of SARS-CoV-2 vaccination in current and former smokers. Such findings may influence clinical practice and prevention efforts and motivate additional research that explores mechanisms for these effects.

IntroductionReferrals through the electronic health record (EHR) system provide an efficient evidence-based method to connect patients to the Tobacco Quitline. However, patients frequently do not respond to Quitline phone calls or accept services. The goal of this study was to characterize factors associated with successful engagement with Quitline following e-referrals by physicians in Maryland.Aims and MethodsThis is a cross-sectional study with hierarchical data modeling. Data for 1790 patients e-referred in 2018–2019 by the University of Maryland Medical System (UMMS) were analyzed. Patients’ engagement was assessed using a generalized estimating equation multivariable regression model for ordinal outcomes at two levels: Picking up a phone call from Quitline (1-800-QUIT-NOW) and enrollment in tobacco cessation programs.ResultsOlder age, female gender, black race, low socioeconomic status, and provider’s skills were significantly associated with successful outcomes of Quitline referral. The engagement with Quitline was higher in black non-Hispanic patients compared to other racial/ethnic groups (phone call response odds ratio [OR] = 1.99, 95% confidence interval [CI] = 1.35% to 2.93% and service acceptance OR = 1.89, 95% CI = 1.28% to 2.79%). Patients residing in socioeconomically deprived areas were more likely to respond to Quitline phone calls compared to those from affluent neighborhoods (OR = 1.52, 95% CI = 1.03% to 2.25%). Patients referred by faculty or attending physicians were more likely to respond compared to those referred by residents (OR = 1.23, 95% CI 1.04, 1.44, p = .0141).ConclusionsMultiple factors impact successful engagement with Quitline. Additional means to improve Quitline engagement success may include focused messaging on tobacco cessation benefits to patients, and skillful counseling by the provider.ImplicationsImplementation of the clinical decision support (CDS) tool for electronic referrals to the Tobacco Quitline at the UMMS was successful in providing evidence-based free service to elderly patients and socioeconomically disadvantaged racial and ethnic minorities. The CDS also served to engage physicians in conversation about tobacco use and cessation with every tobacco-using patient. Curricular content for physicians in training should be enriched to expand tobacco use and treatment.

The health care sector is mobilizing to identify and intervene on social risks that impact health.[1][1] Social risk screening under the Centers for Medicare and Medicaid Innovation Accountable Health Communities demonstration project has led to multiple observations of high acceptability of social

INTRODUCTION: Recent data demonstrated that socioeconomic, environmental, demographic, and health factors can contribute to vulnerability for coronavirus 2019 (COVID-19). The goal of this study was to assess association between severe acute respiratory syndrome coronavirus (SARS CoV-2) infection and demographic and socioeconomic factors in patients from a large academic family medicine practice to support practice operations. METHODS: Patients referred for SARS CoV-2 testing by practice providers were identified using shared patient lists in the electronic health records (Epic). The Health Information Exchange (CRISP) was used to identify additional practice-attributed patients receiving testing elsewhere. RESULTS: Compared with white non-Hispanic patients, the odds of COVID-19 detection were higher in black non-Hispanic (odds ratio [OR] = 1.75; 95% CI, 1.18-2.59, P = .0052) and Hispanic patients (OR = 5.40; 95% CI, 3.11-9.38, P < .0001). The latent class analysis revealed additional patterns in health disparities. Patients living in the areas with Area Deprivation Index 8-10 who were predominantly black had higher risk for SARS CoV-2 infection compared with patients living in less socioeconomically deprived areas who were predominantly white (OR = 1.68; 95% CI, 1.25-2.28; P = .0007). CONCLUSION: Our data provide insight into the association of COVID-19 with race/ethnic minority patients residing in highly socioeconomically deprived areas. These data could impact outreach and management of ambulatory COVID-19 in the future.

The Garden Practice Transformation Network in Maryland brought together primary and specialty practices working toward value-based models and efficient care delivery. Practices were provided with coaching and live and multimedia education regarding practice transformation and quality improvement. Coaches supported practices in multipronged approaches to quality improvement. Practice champions and clinical staff were trained on appropriate documentation of blood pressure (BP) and diabetes measures, and new workflows to optimize care delivery. Quality improvement staff were trained in extracting data from electronic health records, providing feedback to practice clinicians, and reporting to Practice Transformation Network staff. Final measurement of BP control was 66%, and final measurement of blood glucose control was 28%. Quality improvement activities in a practice transformation network led to the delivery of high-quality care and quality improvement.

Supplemental Digital Content is available in the text., Objective: To evaluate impact of the Maryland Multipayor Patient-centered Medical Home Program (MMPP) on: (1) quality, utilization, and costs of care; (2) beneficiaries’ experiences and satisfaction with care; and (3) perceptions of providers. Design: 4-year quasiexperimental design with a difference-in-differences analytic approach to compare changes in outcomes between MMPP practices and propensity score-matched comparisons; pre-post design for patient-reported outcomes among MMPP beneficiaries. Subjects: Beneficiaries (Medicaid-insured and privately insured) and providers in 52 MMPP practices and 104 matched comparisons in Maryland. Intervention: Participating practices received unconditional financial support and coaching to facilitate functioning as medical homes, membership in a learning collaborative to promote education and dissemination of best practices, and performance-based payments. Measures: Sixteen quality, 20 utilization, and 13 cost measures from administrative data; patient-reported outcomes on care delivery, trust in provider, access to care, and chronic illness management; and provider perceptions of team operation, team culture, satisfaction with care provided, and patient-centered medical home transformation. Results: The MMPP had mixed impact on site-level quality and utilization measures. Participation was significantly associated with lower inpatient and outpatient payments in the first year among privately insured beneficiaries, and for the entire duration among Medicaid beneficiaries. There was indication that MMPP practices shifted responsibility for certain administrative tasks from clinicians to medical assistants or care managers. The program had limited effect on measures of patient satisfaction (although response rates were low) and on provider perceptions. Conclusions: The MMPP demonstrated mixed results of its impact and indicated differential program effects for privately insured and Medicaid beneficiaries.

Purpose: The CMS Transforming Clinical Practice Initiative (TCPI) provided coaching and learning support to practices during transition to new models of value-based care. Maryland ambulatory practices participated in the Garden Practice Transformation Network (GPTN) as a part of the TCPI. During practices assessment, we measured prevalence of burnout and identified its remediable predictors among GPTN-Maryland practices. Methods: A modified Mini Z tool survey was distributed among clinicians and staff in November 2018 - July 2019. Association between presence of burnout and burnout drivers was assessed using a Generalized Estimating Equation regression model for ordinal outcome. Results: Data from 166 responses were analyzed. Prevalence of burnout symptoms was 22%, with 35% enjoying their work. A 100-point Time Constraints/Teamwork (T/T) score was constructed using factors significantly associated with burnout symptoms. T/T score increase by 1 unit was associated with 10% increase in the odds of moving from the group experiencing burnout or stress to the group who found ‘joy in work’ (OR = 1.1, 95% CI 1.07, 1.13, p Conclusions: The Mini Z-derived T/T score could be useful for quick assessment of the degree of burnout and identifying burnout drivers related to effective organizational structure and supportive teamwork in practice personnel.

Patient portals allow both patients and clinicians to share information such as test results, visit summaries, and correspondences. Solo and small primary care practices, however, are challenged with limited resources and with electronic health records (EHRs) that have limited patient portal

PURPOSE Practice transformation in primary care is a movement toward data-driven redesign of care, patient-centered care delivery, and practitioner activation. A critical requirement for achieving practice transformation is availability of tools to engage practices. METHODS A total of 48 practices with 109 practice sites participate in the Garden Practice Transformation Network in Maryland (GPTN-Maryland) to work together toward practice transformation and readiness for the Quality Payment Program implemented by the Centers for Medicare & Medicaid Services. Practice-specific data are collected in GPTN-Maryland by practices themselves and by practice transformation coaches, and are provided by the Centers for Medicare & Medicaid Services. These data are overwhelming to practices when presented piecemeal or together, a barrier to practices taking action to ensure progress on the transformation spectrum. The GPTN-Maryland team therefore created a practice transformation analytics dashboard as a tool to present data that are actionable in care redesign. RESULTS When practices reviewed their data provided by the Centers for Medicare & Medicaid Services using the dashboard, they were often seeing, for the first time, cost data on their patients, trends in their key performance indicator data, and their practice transformation phase. Overall, 72% of practices found the dashboard engaging, and 48% found the data as presented to be actionable. CONCLUSIONS The practice transformation analytics dashboard encourages practices to advance in practice transformation and improvement of patient care delivery. This tool engaged practices in discussions about data, care redesign, and costs of care, and about how to develop sustainable change within their practices. Research is needed to study the impact of the dashboard on costs and quality of care delivery.

Purpose: Each of the participating patient-centered medical home (PCMH) received coaching and participated in learning collaborative for improving teamwork. The objective of the study was to assess the impact of trainings on patient-centered teamwork. Methods: The Teamwork Perception Questionnaire (TPQ) was administered once in spring 2014 and then in fall 2015. The TPQ consists of 35 questions across 5 domains: mutual support, situation monitoring, communication, team structure, and leadership. Based on our objective we compared the frequencies of strongly agree/agree by domain. The difference was tested using chi-square test. We compared the scores on each domain (strongly agree/agree = 1; maximum score = 7) via Wilcoxon rank sum test. Results: The response rate for this survey was n = 29 (80.6%) in spring 2014, and n = 31 (86.1%) in fall 2015. We found that the practice members significantly ( P < .05) strongly agreed/agreed more in fall 2015 than spring 2014 for characteristics—“staff relay relevant information in a timely manner” (64.5% vs 83.9%) and “staff follow a standardized method of sharing information when handing off patients” (67.7% vs 90.3%) under communication domain and for characteristic—“staff within my practice share information that enables timely decision making” (74.2% vs 90.3%). However, there was no statistical significant difference observed in the scores for the overall TPQ at the 2 time points. Conclusion: Despite the statistical insignificance, the observations in PCMHs across the spectrum of practices participating in the Maryland Multi-Payer Program demonstrated enhanced teamwork specifically in communication and in leadership. This we believe will continue to result in enhanced patient access to care and safety.

The Maryland Learning Collaborative together with the Maryland Multi-Payer Program transformed 52 medical practices into patient-centered medical homes (PCMH). The Maryland Learning Collaborative developed an Internet-based 14-question Likert scale survey to assess the impact of the PCMH model on practices and providers, concerning how this new method is affecting patient care and outcomes. The survey was sent to 339 practitioners and 52 care management teams at 18 months into the program. Sixty-seven survey results were received and analyzed. After 18 months of participation in the PCMH initiative, participants demonstrated a better understanding of the PCMH initiative, improved patient access to care, improved care coordination, and increased health information technology optimization (p > .001). The findings from the survey evaluation suggest that practice participation in the Maryland Multi-Payer Program has enhanced access to care, influenced patient outcomes, improved care coordination, and increased use of health information technology.

The American Diabetes Association and European Association for the Study of Diabetes issued a new patient-centered approach for the management of hyperglycemia in patients with Type 2 diabetes. With a focus on older adults and the elderly, the authors explored the alignment of elements of the suggested framework with patients' reports of receiving combination or monotherapy using US national survey data (National Health and Nutrition Examination Survey 2001-2010) and a physician survey. Combination therapy was positively associated with age (range: 1.56-1.63; p = 0.04-0.07), obesity (odds ratio [OR]: 1.40; p = 0.01), HbA(1c) ≥7.0 (OR: 2.00; p0.01), number of years of living with diabetes (OR: 1.02 per year; p = 0.01) and hyperlipidemia (OR: 1.36; p = 0.02). An interaction term between years of living with diabetes and comorbidities1 pointed to a trend of those with comorbidities1 to be less probable to report combination therapy (OR: 0.98; p = 0.07) per additional year of diabetes history. Results suggest that sicker, older patients might benefit from more aggressive therapy, in the context of diabetes prevalence, this is expected to continue rising in that population.

Long-acting reversible contraceptives (LARCs) are very effective methods of pregnancy prevention. To ensure autonomy over childbearing, women need access to contraception and abortion services. Family physicians can improve access by increasing numbers and locations of trained providers. In 2014, the University of Maryland (UMD) Reproductive Health EDucation In family medicine (RHEDI) program sought to enhance LARC and abortion training by increasing: (1) resident participation in LARC services, (2) resident participation/interest in abortion care, (3) patient access to LARCs and medication abortions (MABs).We used a pre-post framework comparing years 2013 and 2014 with respect to number of resident-provided LARC services, number of residents participating in abortion, and total number of LARCs and MABs provided practice-wide.The setting is an urban residency practice.(1) increased dedicated appointments for LARC and MABs, (2) dedicated appointment scheduler, (3) comprehensive family planning didactics and clinical workshops, (4) faculty-supported Residents for Choice group.2014: Residents provided substantially more LARC services compared to 2013. Placement increased from 50 to 90, and removals tripled (25 to 73). 2014 site-wide LARC placement also increased (160 versus 98), removals increased (44 in 2013, 106 in 2014). Twelve residents per year are eligible to participate in abortion care. In 2013, two participated: in 2014, 10 participated. MABs provided in 2014 (18) did not change from 2013 (17).The UMD RHEDI program demonstrated that attention to care-provision systems and education enhances resident training and increases patient access to family planning services. Programs with similar goals may find our methods helpful.

Hypertension is a major risk factor for developing cardiovascular disease and is more prevalent in African Americans compared with Caucasians. African Americans are often underrepresented in clinical trials. This study was composed of a largely urban African American cohort of hypertensive patients. This was a prospective, 4-arm, randomized controlled trial designed to evaluate the comparative effectiveness of both physician and patient education (PPE), patient education only (PAE), and physician education only (PHE) vs usual care (UC). Hypertension specialists gave a series of didactic lectures to the physicians, while a nurse educator performed the patient education. The mean adjusted difference in systolic blood pressure (SBP) from baseline in the PPE group was an average reduction of 12 mm Hg (95% confidence interval [CI], -4.5 to -19.4) at 6-months, followed by average reductions of 4.6 mm Hg (6.9 to -16.12) in the PAE group, 4.1 mm Hg (3.4 to -11.7) in the PHE group, and 2.6 mm Hg (3 to -8.2) in the UC group. The PPE group achieved a significantly better reduction in SBP compared with the UC group. Additional research should be conducted to evaluate whether the use of certified hypertension educators in collaboration with physicians will result in a similar blood pressure reduction.

Background To recognize and better understand barriers to dental care, the authors studied behavioral and socioeconomic factors specific to low-income and minority populations that contribute to patterns of professional health care-seeking. Methods A stratified random sample of 27,002 Maryland households participated in a cross-sectional telephone survey. The authors targeted respondents who were low-income non-Hispanic white, non-Hispanic black or Hispanic who had experienced a dental problem or injury during the previous 12 months, as well as similar people with higher incomes for comparison. A total of 94.8 percent (401 of 423) of eligible people completed the survey. Results Logistic regression modeling (95 percent confidence interval) revealed that the respondents' race or ethnicity and sex were associated with the number of dental problems experienced during the previous 10 years, and that having a regular source of medical care and the type of dental problem experienced were associated with earlier health care-seeking. The first choice of treatment site (physician's office, emergency department or dentist's office) was associated with the respondents' income, pain level, number of problems experienced in the past 10 years and the degree to which their problem was a burden. Conclusions The authors found that predisposing, enabling and need-based factors were associated with dental problem experience and patterns of professional health care service use. Practice Implications Health care providers should recognize barriers to the receipt of dental care sometimes experienced by low-income and minority groups.

Objectives: Our understanding of the use of emergency departments (EDs) and physician offices for the management of dental problems is limited. We undertook this study to examine whether there are differences in their use by low-income White and minority adults as compared with higher-income adults. Methods: Participants included White, Black, and Hispanic adults who had experienced a dental problem during the previous 12 months and who visited a physician, ED, or dentist for treatment. We selected a stratified random sample of 27,002 Maryland households with listed telephones to screen for eligibility. We identified 1,387 households with an eligible adult, selected 423 for interviews, and completed interviews with 401 (94.8%). Results: To restore correct proportionality to the sample, and to adjust for nonresponse and the distribution of demographic characteristics, weights were created for use in the analyses. Only 7.1 percent of respondents contacted an ED, while 14.3 percent contacted a physician and 90.2 percent a dentist. The vast majority of respondents who contacted an ED (96.0%) or a physician (92.2%) also contacted a dentist. Lower-income respondents were more likely to seek care from an ED, while higher-income respondents were more likely to seek care from a dentist. Overwhelmingly, respondents visiting EDs (89.4%) and physicians (51.7%) were instructed to see a dentist or given prescriptions/samples. Treatment provided by EDs, physicians, and dentists was not associated with the respondent's income or race/ethnicity. Conclusions: Respondents visiting EDs and physicians typically did not receive definitive care and subsequently visited a dentist for treatment.

Objectives: This safety study of terameprocol (also called M4N, EM-1421) daily vaginal application in healthy women explores its potential application as a microbicide in interrupting human immunodeficiency virus sexual transmission and additional interruption of human papillomavirus and herpes simplex virus transmission. Methods: A double-blind placebo controlled phase I repeat dose tolerability and pharmacokinetic, crossover study of 90 mg terameprocol (2% w/w ointment) administered intravaginally for 7 consecutive days in healthy female subjects. The pharmacokinetics after administration was examined on days 1 and 7 of dosing. Subjects underwent vaginal examination following the 6-hour pharmacokinetic sample on day 7 of each study period. Results: Recruitment started January 2006 and ended May 2006, and 14 subjects completed the study. Median age was 24 years. No treatment-related serious adverse events were reported, and there were a total of 17 treatment-emergent adverse events (AE) reported by 11 participants. The most common AE was headache. Terameprocol was not detectable in serum in pharmacokinetic samples. Conclusions: Terameprocol was well tolerated at a 90 mg dose (2% wt/wt) administered vaginally daily for 7 days. No serious adverse events occurred and any AEs were mild. The excellent safety profile supports future clinical trial to evaluate the application of intravaginal terameprocol in women.

Objectives To review the epidemiology and natural history of human papillomavirus (HPV), summarize relevant clinical trials of the prophylactic HPV vaccines, and describe the practice and policy implications that HPV vaccine represents for pharmacists. Data sources Search of Medline through June 2007 using keywords human papillomavirus vaccine, Gardasil, and Cervarix; meeting abstracts; bibliographies from selected articles; and National Institutes of Health clinical trials registry. Study selection English language review articles, clinical trials, and published abstracts were considered for inclusion. Data synthesis HPV is a sexually transmitted infection that is necessary for the development of cervical cancer, and types 16 and 18 are associated with 70% of cases of invasive cervical cancer worldwide. A quadrivalent prophylactic vaccine against HPV-6, −11, −16, and −18 is currently available, and a bivalent vaccine targeting HPV–16 and −18 is under review by the Food and Drug Administration. Both are highly effective at preventing persistent HPV infection and precancerous lesions caused by vaccine-specific HPV. HPV vaccine is currently indicated for girls aged 9 to 26 years, but ongoing trials are evaluating the efficacy in other populations. Implementation of a vaccine administration program is an area of opportunity for new policies to include pharmacists in the administration of prophylactic HPV vaccines. Pharmacists are allowed to administer vaccinations in 46 states and can potentially play a role in HPV vaccine administration. For this to happen, however, multiple legal and regulatory changes must occur. Conclusion Prophylactic HPV vaccines safely and effectively prevent HPV infection and precancerous lesions in the cervix. The availability of these vaccines also create new clinical opportunities for community pharmacists, provided needed legal, regulatory, and policy changes are made.

We present data on quality of care (QC) improvement in 35 of 45 National Quality Forum metrics reported annually by 52 primary care practices recognized as patient-centered medical homes (PCMHs) that participated in the Maryland Multi-Payor Program from 2011 to 2013.We assigned QC metrics to (1) chronic, (2) preventive, and (3) mental health care domains. The study used a panel data design with no control group. Using longitudinal fixed-effects regressions, we modeled QC and case mix severity in a PCMH.Overall, 35 of 45 quality metrics reported by 52 PCMHs demonstrated improvement over 3 years, and case mix severity did not affect the achievement of quality improvement. From 2011 to 2012, QC increased by 0.14 (P.01) for chronic, 0.15 (P.01) for preventive, and 0.34 (P.01) for mental health care domains; from 2012 to 2013 these domains increased by 0.03 (P = .06), 0.04 (P = .05), and 0.07 (P = .12), respectively. In univariate analyses, lower National Commission on Quality Assurance PCMH level was associated with higher QC for the mental health care domain, whereas case mix severity did not correlate with QC. In multivariate analyses, higher QC correlated with larger practices, greater proportion of older patients, and readmission visits. Rural practices had higher proportions of Medicaid patients, lower QC, and higher QC improvement in interaction analyses with time.The gains in QC in the chronic disease domain, the preventive care domain, and, most significantly, the mental health care domain were observed over time regardless of patient case mix severity. QC improvement was generally not modified by practice characteristics, except for rurality.

Objectives. Terameprocol (M4N, EM-1421) is a novel transcription inhibitor that selectively interferes with HPV viral genes E6/E7 with Sp1-dependent promoters, and induces apoptosis by inactivation of the CDC2/cyclin B complex (maturation promoting factor)and production and phosphorylation of survivin. This trial was designed to define the maximum tolerated dose (MTD), dose-limiting toxicity and determine the pharmacokinetic profiles of intravaginal terameprocol in women with HPV-linked cervical squamous intraepithelial neoplasia. Methods. An open label, dose escalation Phase I/II clinical trial enrolled women with biopsy confirmed CIN 1, 2 or 3. Terameprocol (45 or 90 mg) was physician-administered directly to the cervix uteri in 3 once weekly applications. The pharmacokinetics after administration were examined on Day 1 of dosing. Patients underwent colposcopic examinations, HPV testing, biomarker assessments, cytology and cervical punch biopsy. Results. Recruitment ended March 30, 2006 and 7 patients were enrolled. Median age was 24 years. There were no serious adverse events (SAEs) and possible treatment-related Adverse Events (AEs) reported were mild and self-limiting. There was no detectable absorption of terameprocol from the vaginal ointment application. Conclusions. Terameprocol in 1% and 2% vaginal ointment use in Phase I/II trials with women with HPV-linked cervical intraepithelial neoplasia has an excellent safety profile, no SAEs reported and mild, self-limiting treatment-related AEs. There was no detectable absorption of terameprocol. These data support the continued evaluation of terameprocol in in vitro and animal efficacy models followed by definitive human Phase II clinical trials in CIN.

Medical education curricula increasingly are incorporating courses on cultural competency and skills development in working with ethnically diverse patient populations as well as courses on genetics and genomics. The authors support these efforts and believe the next step is integration of genetics into cultural competency programs and similarly, cultural competency into genetics curricula. In this paper, the authors describe the work of the Genetics in Primary Care Faculty Development Working Group on Cultural Competency, a federally-funded initiative to prepare generalist faculty to teach genetics as part of ambulatory education. Over a 12-month period, this team wrote a module on cultural competency and nine new clinical cases, and developed the PRACTICE mnemonic (prevalence, risk, attitude, communication, testing, investigation, consent, empowerment) to help health care professionals integrate cultural competency skills in genetics into primary care. More specifically, the PRACTICE mnemonic integrates information emerging from experts in health disparities and doctor-patient communication to build a comprehensive model for addressing the relevance of culture and ethnicity in the delivery of genetic services. Lastly, this paper illustrates a systematic method of covering key areas of cultural competency through discussion of a patient with a genetic disorder as well as presents an argument as to why cultural competency is highly relevant to the delivery of genetic services especially as part of generalists' clinical practice.

A case of intestinal pseudo-obstruction as a presenting manifestation of systemic lupus erythematosus is presented. Systemic lupus erythematosus is an autoimmune disease with a wide spectrum of unpredictable multisystemic presentations. A case of systemic lupus erythematosus that was diagnosed in a patient whose initial presentation for the disease was acute renal failure, hydronephrosis, intestinal pseudo-obstruction, and false-positive syphilis serologies is presented. There have been 18 other cases of intestinal pseudo-obstruction associated with systemic lupus erythematosus to date in the English literature. A variety of gastrointestinal syndromes have been increasingly recognized as possible manifestations of systemic lupus erythematosus, and this case illustrates in particular that intestinal pseudo-obstruction may be a presenting manifestation of this disorder.

Promoting clinical-community linkages is at the heart of Maryland’s efforts systematically to transform health care delivery, with community health workers (CHW) playing a central role. This article describes how Maryland is using the evidence-base on CHW effectiveness and training to develop a workforce capable of most effectively connecting communities with care.

B ackgr ound: Part ne r sh i p b etw een M aryl and ’ s M ulti- pa y er Pa tie nt C en ter ed M edi c a l H o m e p rogr am and M a ryl and M illi on H e art s p r o gr am has been t he ca t a ly st f or f o c u s ed qu alit y im p r o vem ent s tr a t e gi es sp e c ifi c t o ch r o ni c dis ease m ana gem ent and co ntrol . Meth od s : Thi s proj e c t w as i n iti a t ed i n t he 52 NCQ A r eco g n iz ed P C MH pra cti ces fr om t he M M P P . A n e st ed c o ho r t of 19 pr a cti ces re ce iv ed t e c hn i c a l a s si s t an c e t o i n cl u d e s taf f tr a ini n g , new w o rkflow s im p l e m en t a ti on, d i s s e mi na ti on of e vi den c e-ba s ed g u id e li n e s, optimizi ng HI T us e , p atie nt s elf-m a n a gem ent and li n k a g e t o co mm un it y and stat e r e s ou r ces. Ob s e rv a ti ons w e r e do c u m en t ed i n 2 011, 20 1 2, 2 0 13 and a t t he e nd of th e P D SA i n J une 2014. A n n u all y r ep ort ed q u a lit y m e tric s by p r ac ti c e s d uri ng thi s tim e pe ri od wer e a n alyz ed by each i n divi du a l m e tri c a nd t he o v e r a l l a v e r a g e cha ng e was c al cu l a te d and te s te d f or s t a tistic al s ig n ifi ca n ce. Al l t e st s w e r e two-t a il ed. R es u lts : NQ F 18 and NQ F 28A m a i n tai ned t h ei r ac hi e v e m ent t h r e sh o l d fr om D ece m ber 2 013 t o June 2014. NQ F 28A de m ons trat ed non - s ig n ifi ca n t d e c re a s e fr om 94.6% i n D ece m ber 20 1 3 t o 93 . 4% i n J u n e 2014 ( p v a l ue=0.6 4 6), b u t m a i n t a ine d v a l ues gr e ate r th an a ch i e v e m ent t h r e s h ol d. NQ F 28B de m ons trat ed s ig n ifi ca n t c han g e fr om 2011 at 2 3. 5 % foll o w ed by p r ac ti c e s trai n i ng and r e s ou rc e li n k a g es t o 52. 2 % i n Ju ne 2 0 14 ( p v a l ue

Patient-centered care has a positive impact on patient health status. This report compares patient assessments of patient centeredness during treatment in hospital emergency departments (EDs) and physician and dentist offices for dental problems and injuries.Participants included low-income White, Black, and Hispanic adults who had experienced a dental problem or injury during the previous 12 months and who visited an emergency department, physician, or dentist for treatment. A stratified random sample of Maryland households participated in a cross-sectional telephone survey. Interviews were completed with 94.8% (401/423) of eligible individuals. Multivariable logistic regression analyses were performed.The measure of predictive power, the pseudo-R2s, calculated for the logistic regression models ranged from 12% to 18% for the analyses of responses to the measures of patient centeredness (satisfaction with treatment, careful listening, thorough explaining, spending enough time, and treated with courtesy and respect). EDs were less likely than dentists to treat patients with great courtesy and respect.Further research is needed to identify factors that support patient-centered care.

Tobacco use and depression are highly prevalent among methadone maintenance (MM) treatment programme participants. Our aim was to study the relationship between nicotine dependence, depression, and readiness to change smoking behaviour among women smokers in MM compared to women smokers attending a primary care clinic (Control group).We conducted a cross-sectional survey of 117 MM women smokers and 50 controls attending a family medicine clinic. All participants completed a computerized self-administered questionnaire, including demographic information, medical history, and drug and tobacco use history. Participants also completed the Fagerström Test for Nicotine Dependence (FTND), the Center for Epidemiologic Studies Depression Scale (CES-D), and the University of Rhode Island Change Assessment (URICA) instrument.In this study 83% African American women had an average age of 43 years. Of the women smokers in the MM group, 95% were daily smokers compared to 46% in the Control group (P0.05). The MM women smokers had CES-D scores of 22.5 compared to 14.7 in women of the Control group (P0.0001). Women smokers in MM were significantly more likely to be depressed, more dependent on nicotine, and more ready to change their smoking behaviour.Our data show a higher level of nicotine dependence and depression, and greater readiness to change among women smokers in methadone maintenance programmes compared to women smokers attending primary care clinics. Methadone treatment programmes present a need and an opportunity to assess and intervene in nicotine dependence and depression and in addressing and eliminating health disparities.

Our understanding of the use of emergency departments (EDs) and physician offices for the management of dental problems is limited. We undertook this study to examine whether there are differences in their use by low-income White and minority adults as compared with higher-income adults.Participantsincluded White, Black, and Hispanic adults who had experi enced a dental problem during the previous 12 months and who visited a physician, ED, or dentist for treatment. We selected a stratified random sample of 27,002 Maryland households with listed telephones to screen for eligibility. We identified 1,387 households with an eligible adult, selected 423 for interviews, and completed interviews with 401 (94.8%).To restore correct proportionality to the sample, and to adjust for nonresponse and the distribution of demographic characteristics, weights were created for use in the analyses. Only 7.1 percent of respondents contacted an ED, while 14.3 percent contacted a physician and 90.2 percent a dentist. The vast majority of respondents who contacted an ED (96.0%) or a physician (92.2%) also contacted a dentist. Lower-income respondents were more likely to seek care from an ED, while higher-income respondents were more likely to seek care from a dentist. Over whelmingly, respondents visiting EDs (89.4%) and physicians (51.7%) were instructed to see a dentist or given prescriptions/samples. Treatment provided by EDs, physicians, and dentists was not associated with the respondent's income or race/ethnicity.Respondents visiting EDs and physicians typically did not receive definitive care and subsequently visited a dentist for treatment.

The cone biopsy described in the case series discussed by Mulhem et al[1][1] touches on several key issues in cervical cancer prevention and within the scope of practice of family physicians. In the current medical environment health care reform to bolster primary care to reduce health care costs

Family medicine has evolved into a specialty deeply rooted in clinical service. Because of high demands for clinical practice productivity, family physicians have drifted away from participation in scientific inquiry. There is even an effort in some institutions to reinvent family medicine as a community-based ambulatory specialty, resulting in a further "disconnect" between research and family physicians. A new movement for the efficient translation of laboratory science into clinical applications in the community supports the need for trained community-based clinician scientists. This translational science seeks to take the findings from bench research and clinical trials and study their introduction and dissemination into community-based clinical practice. There is an opportunity for family physicians to become involved in translational research. But, to develop a cadre of translational researchers within the family medicine community, education programs need to train and develop those researchers. Residency education may be an ideal time to begin that training and development.

Human papillomavirus (HPV) detection is an integral part of cervical cancer screening, and a range of specimen collection procedures are being tested. Preliminary studies have found that the majority of women prefer self-collection of vaginal specimens instead of clinician-collected specimens of the cervix. The purposes of the current study were to explore the social and behavioral predictors of acceptance of self-collection of vaginal specimens among patients and to assess concordance in detection of HPV between clinician-collected cervical specimens and self-collected vaginal specimens. The study was conducted at a university family medicine clinic using a cross-sectional study design, and enrollment of women presenting for routine gynecological examination consecutively in a period of 1 year, self-administered questionnaires, collection of paired vaginal and cervical specimens for HPV DNA using Hybrid Capture 2, and cytologic analysis. Most women (79.8% [398/499]) agreed to collect vaginal specimens. In our study, 76.6% (216/282) African American women (AA), 88.1% (156/176) white non-Hispanic (WNH) women, and 63.4% (26/41) women of other races (P < 0.0001) agreed to self-collect vaginal specimens. HPV was detected in 16.0% (80/499) of clinician-collected cervical specimens and 26.1% (104/398) of self-collected vaginal specimens (P < 0.001). HPV detection was concordant in 13.4% (53/398) women in both cervical and vaginal specimens. Self-collection of vaginal specimens for HPV DNA detection is acceptable to most women presenting for routine gynecological examination. WNH women were more likely to obtain self-collected specimens than AA women. Vaginal specimens were more likely to be positive for HPV than were cervical specimens.

OBJECTIVES: Study the role of highly active antiretroviral therapy (HAART) in cervical disease in women with human immunodeficiency virus (HIV) and human papillomavirus (HPV) infections. MATERIALS AND METHODS: A systematic review of current literature and the results summarized in the following headings: HIV and cytological evidence of disease, HIV and HPV, and HAART and HIV in women with HPV-associated cervical disease. RESULTS: Limited data is available to study the influence of HAART on HPV-related cervical disease in women with HIV. There is evidence that the use of HAART may lead to immune restoration and thereby prevent severe recurrent HPV disease, thus influencing associated cervical disease. CONCLUSIONS: Little data is available on HAART and its role in HPV-associated cervical disease in women with HIV. Immune restoration may decrease the severity and recurrence of HPV infection and potentially impact cervical disease. Population-based studies are needed to further evaluate the role of HAART in HPV associated cervical disease.

Background: Women infected with human immunodeficiency virus (HIV) are at increased risk for the development of dysplastic genital lesions. Traditionally, markers of immunosuppression were predictive of the development of dysplasia. Recent advances in antiretroviral medications allow restoration of a once-depressed CD4 cell count and suppression of HIV replication. In this new era, additional predictive markers of genital dysplasia are needed for management of women infected with with HIV. Objective: To find predictive markers of genital dysplasia in women infected with HIV. Design: Observational study of a consecutive sample of 200 women infected with HIV from an urban university clinic. Measurements of histopathology, CD4 count, CD4 nadir, HIV viral load, human papillomavirus (HPV), and usage of highly active antiretroviral therapy (HAART) were evaluated for an association with genital dysplasia. Results: There was a trend toward a protective effect against any genital dysplasia when HAART had been prescribed [relative risk 0.77, 95% confidence interval (CI) 0.56, 1.06] and HAART therapy resulted in an immune response (relative risk, 0.61; 95% CI, 36, 1.02). High-risk HPV DNA was a strong predictor of dysplasia (P .0003). A lower CD4 count nadir was strongly associated with genital dysplasia (P .0003). Conclusion: A history of greater immunosuppression, as measured by the nadir of a patient’s CD4 count, is the strongest predictor of genital dysplasia in women infected with HIV. (J Am Board Fam Pract 2004;17:108 ‐13.) There is an increase in the rates of both detection and persistence of human papillomavirus (HPV) infection in women coinfected with human immunodeficiency virus (HIV). Up to 20% of these coinfected patients develop HPV-induced premalignant lesions of the uterine cervix within 3 years of HIV diagnosis. 1– 6 The progression of an untreated HPV-induced dysplastic lesion may lead to invasive cervical cancer, an AIDS-defining illness. 6,7

To examine physician factors associated with ovarian cancer screening.Postal questionnaires to Maryland primary care physicians. Bivariate tests for statistical significance used X-Square and Student's t tests. Multivariate analysis and logistic regression were used to analyze responses based on specialty type, gender, and work experience.Fifty-six percent of the 375 were male, 44%, females; 33%, OB/GYN; and 67%, family/internal medicine (FM/IM). The mean age was 47 and the mean number of years in practice was 16. OB/GYNs provided more ovarian cancer counseling, OR 2.64 (CI 1.55, 4.48) and were more likely to respond correctly to knowledge questions--i.e., reduction of ovarian cancer risk with oral contraceptive (OCP) use than IM/FM, OR 8.57 (CI 3.54, 20.8). Overall, there were few gender differences in approach to evaluation, but male physicians were less likely to be aware of the relationship of OCP use to ovarian cancer risk than females, OR 0.48 (CI 0.25, 0.91). IF/FM physicians were less likely to order CA-125 for patients (of any age) based upon symptoms of bloating or physical examination alone. OB/GYN physicians, OR 4.77 (2.73, 8.34) and physicians with15 years in practice, OR 2.79 (1.46, 5.35) attended more meetings on ovarian cancer than non OB/GYNs or those with less experience. Although 74% indicated access to the Internet, just 16% to 26% used the Internet for cancer information; OB/GYNs used the Internet less frequently than FM/IMs, OR 0.53 (0.28, 0.97).Specialty was more predictive of knowledge, approach to evaluation, and counseling than gender or experience.

This is a case report of a 16-year-old girl with renal failure in pregnancy in association with bilateral ureteral obstruction and hydronephrosis. The presenting symptom was a common nonspecific type of abdominal pain. The diagnosis was made on incidental laboratory work to rule out preeclampsia. Renal function reverted back to normal after induced vaginal delivery.