BackgroundThe patient-centered medical home (PCMH) is a widely adopted primary care model. However, it is unclear whether changes in provider and staff perceptions of clinic PCMH capability are associated with changes in provider and staff morale, job satisfaction, and burnout in safety net clinics.ObjectiveTo determine how provider and staff PCMH ratings changed under a multi-year PCMH transformation initiative and assess whether changes in provider and staff PCMH ratings were associated with changes in morale, job satisfaction, and burnout.DesignComparison of baseline (2010) and post-intervention (2013–2014) surveys.SettingSixty clinics in five states.ParticipantsFive hundred thirty-six (78.2%) providers and staff at baseline and 589 (78.3%) post-intervention.InterventionCollaborative learning sessions and on-site coaching to implement PCMH over 4 years.MeasurementsProvider and staff PCMH ratings on 0 (worst) to 100 (best) scales; percent of providers and staff reporting good or better morale, job satisfaction, and freedom from burnout.ResultsAlmost half of safety net clinics improved PCMH capabilities from the perspective of providers (28 out of 59, 47%) and staff (25 out of 59, 42%). Over the same period, clinics saw a decrease in the percentage of providers reporting high job satisfaction (-?12.3% points, p?=?.009) and freedom from burnout (-?10.4% points, p?=?.006). Worsened satisfaction was concentrated among clinics that had decreased PCMH rating, with those clinics seeing far fewer providers report high job satisfaction (-?38.1% points, p?

BackgroundBenzodiazepines are the standard medication class for treating alcohol withdrawal. Guidelines recommend dosing based on objectively measured symptoms (symptom-triggered therapy) rather than fixed dose regimens. However, the superiority of symptom-triggered therapy has been questioned, and concerns have been raised about its inappropriate use and safety. We aimed to assess whether symptom-triggered therapy is superior to fixed dose schedules in terms of mortality, delirium, seizures, total benzodiazepine dose, and duration of therapy.MethodsA systematic literature search using Medline, Embase, and the Cochrane Registry through February 2018 was conducted for randomized controlled trials of patients with alcohol withdrawal syndrome comparing fixed dose benzodiazepine schedules to symptom-triggered therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Outcomes were pooled using random effects meta-analysis. Heterogeneity was estimated using the I2 statistic. Strength of evidence was assessed using methods outlined by the Agency for Healthcare Research and Quality.ResultsSix studies involving 664 patients were included. There were no deaths and only one seizure in each group. Four studies reported delirium, which occurred in 4 out of 164 patients randomized to symptom-triggered therapy compared to 6 out of 164 randomized to fixed dose therapy (odds ratio, 0.64 [95% CI, 0.17–2.47]). Three studies reported duration of therapy, which was 60.4 h less with symptom-triggered therapy (95% CI, 39.7–81.1 h; p?

Trauma is pervasive in the USA, but disproportionately present in individuals and communities burdened by poverty, violence, and exposure to the criminal justice system. Engagement in clinical care, especially community-based primary care, is particularly important in the immediate period following community reentry from incarceration, where opportunities to engage clients in services are essential for improved health and reduced recidivism. Trauma-informed care offers an important and innovative opportunity for healthcare systems and primary care providers to improve quality of care and the patient experience, thereby increasing longitudinal engagement of marginalized and hard-to-reach patient populations like persons with criminal justice system exposure. Trauma-informed care implementation includes educating providers and transforming practices to incorporate safety, trust, peer support, collaboration, empowerment, and cultural perspectives into everyday operations and care delivery. While comprehensive trauma-informed care involves transformation on a system level, trauma-informed approaches can also be adopted by the individual provider to improve the clinical consultation. By recognizing the role of trauma and its impact on an individual’s physical, emotional, and behavioral health, providers and clients can build mutual trust, focus on individual growth, and begin to foster healing.

BackgroundMeta-analysis combines multiple independent studies, which can increase power and provide better estimates. However, it is unclear how best to deal with studies with zero events; such studies are also known as double-zero-event studies (DZS). Several statistical methods have been proposed, but the agreement among different approaches has not been systematically assessed using real-world published systematic reviews.MethodsThe agreement of five commonly used methods (i.e., the inverse-variance, Mantel–Haenszel, Peto, Bayesian, and exact methods) was assessed using the Cohen’s ? coefficients using 368 meta-analyses with rare events selected from the Cochrane Database of Systematic Reviews. Three continuity corrections, including the correction of a constant 0.5, the treatment arm continuity correction (TACC), and the empirical (EMP) correction, were used to handle DZS when applying inverse-variance and Mantel–Haenszel methods.ResultsWhen the proportion of DZS studies was lower than 50% in a meta-analysis, different methods had moderately high agreement. However, when this proportion was increased to be over 50%, the agreement among the methods decreased to different extents. For the Bayesian, exact, and Peto methods and the inverse-variance and Mantel–Haenszel methods using the EMP correction, their agreement coefficients with the inverse-variance and Mantel–Haenszel methods using a constant 0.5 and TACC decreased from larger than 0.70 to smaller than 0.30. In contrast, the agreement coefficients only decreased slightly among the Bayesian, exact, and Peto methods and the inverse-variance and Mantel–Haenszel methods using the EMP correction.ConclusionsTo utilize all available information and reduce research waste and avoid overestimating the effect, meta-analysts should incorporate DZS, rather than simply removing them. The Peto and other conventional methods with continuity correction should be avoided when the proportion of DZS is extremely high. The exact and Bayesian methods are highly recommended, except when none of the included studies have an event in one or both treatment arms.

BackgroundMost patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits.ObjectiveTo test the hypothesis that a “Pre-Visit Prioritization” secure email message could improve visit communication and glycemic control among patients with type 2 diabetes.DesignWe conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system.ParticipantsEligible patients had at least 1 year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c)?>?=?8.0%, and were registered users of the KPNC online patient portal.InterventionsPatients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care.Main MeasuresGlycemic control; change in HbA1c 6 and 12 months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences.Key ResultsDuring the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n?=?457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p?=?0.048) and being given treatment choices to consider (81% vs 73%, p?=?0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56%?±?1.45%), with no significant differences between arms.ConclusionsA “light touch” email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation.Trial RegistryNCT02375932

Despite policy and practice support to develop and test interventions designed to increase access to quality care among high-need patients, many of these interventions fail to meet expectations once deployed in real-life clinical settings. One example is the Patient-Centered Medical Home (PCMH) model, designed to deliver coordinated care. A meta-analysis of PCMH initiatives found mixed evidence of impacts on service access, quality, and costs. Conceptualizing PCMH as a complex health intervention can generate insights into the mechanisms by which this model achieves its effects. It can also address heterogeneity by distinguishing PCMH core functions (the intervention’s basic purposes) from forms (the strategies used to meet each function). We conducted a scoping review to identify core functions and forms documented in published PCMH models from 2007 to 2017. We analyzed and summarized the data to develop a PCMH Function and Form Matrix. The matrix contributes to the development of an explicit theory-based depiction of how an intervention achieves its effects, and can guide decision-support tools in the field. This innovative approach can support transformations of clinical settings and implementation efforts by building on a clear understanding of the intervention’s standard core functions and the forms adapted to local contexts’ characteristics.