American Diabetes Association
Jan 1, 2017; 35:5-26
Position Statements

American Diabetes Association
Apr 1, 2015; 33:97-111
Position Statements

Research suggests that the prevalence of obesity in children with autism spectrum disorder (ASD) is higher than in typically developing children. The US Preventive Services Task Force and the American Academy of Pediatrics (AAP) have endorsed screening children for overweight and obesity as part of the standard of care for physicians. However, the pediatric provider community has been inadequately prepared to address this issue in children with ASD. The Healthy Weight Research Network, a national research network of pediatric obesity and autism experts funded by the US Health Resources and Service Administration Maternal and Child Health Bureau, developed recommendations for managing overweight and obesity in children with ASD, which include adaptations to the AAP’s 2007 guidance. These recommendations were developed from extant scientific evidence in children with ASD, and when evidence was unavailable, consensus was established on the basis of clinical experience. It should be noted that these recommendations do not reflect official AAP policy. Many of the AAP recommendations remain appropriate for primary care practitioners to implement with their patients with ASD; however, the significant challenges experienced by this population in both dietary and physical activity domains, as well as the stress experienced by their families, require adaptations and modifications for both preventive and intervention efforts. These recommendations can assist pediatric providers in providing tailored guidance on weight management to children with ASD and their families.

CONTEXT:

Recommendations conflict regarding universal application of formal screening instruments in primary care (PC) and PC-like settings for autism spectrum disorder (ASD).

Recommendations in pediatrics call for general developmental screening of young children; however, research suggests social-emotional development, in particular, is important as an initial indicator of general well-being versus risk, and may warrant inclusion in screening protocols.

Via a social-emotional screening program, significant percentages of children can be identified as being at risk for social-emotional problems, and colocation of an early childhood psychologist promotes the ability to effectively address young children’s social-emotional development within their medical home. (Read the full article)

Clinic-based weight control treatments for youth have largely been designed for preadolescent children and their families by using family-based care, a strategy that may be less appealing to adolescents as they become increasingly motivated by peer acceptance rather than parental influence.

To our knowledge, this is the first study to demonstrate the efficacy of a primary care–based, multicomponent lifestyle intervention specifically tailored for overweight adolescent females and demonstrating a sustained effect (at 12 months) extending beyond the active 5-month intervention. (Read the full article)

There are known gaps in quality measures for children. More clinical effectiveness research is needed. The patient-centered medical home may serve as a model to guide the development of quality measures, particularly for children with complex medical conditions.

This study combined systematic literature review and the Rand/University of California Los Angeles appropriateness method to develop quality measures for children with complex medical conditions. These are valid and feasible quality measures based on the patient-centered medical home framework that may be used to assess care. (Read the full article)

Clinical decision support systems offer a way to help physicians use evidence-based guidelines for screening. Screening patients for common developmental, psychosocial, and behavioral issues informs the clinical decision-making process and may improve patient outcomes.

The Child Health Improvement through Computer Automation system, a clinical decision support system and an electronic medical record, is able to effectively screen patient families in the waiting room by using a tailored questionnaire. The study reveals positive screening rates for identifiable risks in a very large representative urban population by using Child Health Improvement through Computer Automation’s questionnaire. (Read the full article)

Primary care settings provide an important venue for early detection of substance use and intervention, but adolescent screening rates need improvement. Screening and brief interventions appear effective in reducing adult problem drinking but evidence for effectiveness among adolescents is needed.

A computer-facilitated system for screening, feedback, and provider brief advice for primary care can increase adolescent receipt of substance use screening across a variety of practice settings, and shows promise for reducing adolescents’ use of alcohol and cannabis. (Read the full article)

Overweight children are at risk for becoming obese adults, especially if they have an obese parent. Family-based behavioral interventions, largely implemented in specialized settings, have shown efficacy in weight control in youth aged ≥8 years.

This study demonstrates the efficacy of a family-based behavioral weight control program translated to be implemented in the primary care setting. The work underscores the importance of pediatricians intervening early and shifting their focus from the child to the family. (Read the full article)

Filling a prescription is the first step in medication adherence. Unfilled prescriptions are a documented component of nonadherence in adult and pediatric emergency departments and family practices. No one has reported the proportion of unfilled prescriptions in pediatric primary care.

This study identifies the proportion of unfilled prescriptions in a large sample of primary care pediatric patients. It describes clinical and demographic factors associated with prescription filling and suggests that electronic prescribing may improve adherence. (Read the full article)

Practice characteristics, such as practice size, have been associated with the readiness of adult primary care practices for medical home certification. Little is known about how ready primary care practices for children are for medical home certification.

Primary care practices for children attained only 38% of the infrastructure required for medical home certification. Smaller practice size was significantly associated with lower infrastructure scores. Medical home programs need effective approaches to support practices with limited resources. (Read the full article)

Racial disparities in health care have been reported in multiple settings, but not thoroughly examined at the clinician level. The frequent occurrence of respiratory tract infections allows the evaluation of differences in the management of children seen by the same clinician.

Racial differences in the management of common pediatric infections occur among children treated by the same clinician. Given persistent concerns about nonjudicious antibiotic use, examining racial differences may inform our understanding of prescribing practices and identify opportunities for intervention. (Read the full article)

The incidence of permanent hearing loss doubles between birth and school age. Otoacoustic emissions screening has been used successfully in early childhood educational settings to identify children with losses not found through newborn screening.

Using otoacoustic emissions to screen the hearing of young children during routine health care visits is feasible and can lead to the identification of permanent hearing loss overlooked by providers relying solely on subjective methods. (Read the full article)

Internet, smartphones, and online social media offer new platforms for health promotion and disease management. Few studies have evaluated the use of digital technology among families receiving care in an urban pediatric primary care setting.

Caregivers in an urban pediatric primary care setting have access to and frequently use the Internet, smartphones, and online social media. These technologies may help reach a traditionally hard-to-reach population. (Read the full article)

Because of high costs of newer vaccines, financial risk to private vaccination providers has increased. Previous studies have shown general dissatisfaction with payment for the cost of vaccines and administration fees, with some providers considering no longer providing childhood vaccines.

We show that many providers are dissatisfied with payment for vaccine purchase and administration from all types of payers and that, for new vaccines, providers are using a variety of strategies with parents to handle uncertainty about insurance coverage. (Read the full article)

The Centers for Disease Control and Prevention recommends that health departments in all 50 states deliver AFIX (Assessment, Feedback, Incentives, and eXchange) consultations to 25% of federally funded vaccine providers each year. AFIX effectively raises vaccination coverage among young children.

AFIX consultations achieved short-term gains in coverage for 11- to 12-year-olds for vaccines in the adolescent platform. No gains occurred for older adolescents or over the long term. Consultations were equally effective when delivered in-person or by webinar. (Read the full article)

A substantial gap exists between what is recommended for effective primary care of children and what takes place. Patient-centered health information technologies have been used to gather information and counsel parents, however, have not been integrated directly with electronic health records nor been speech-based to improve decision-making at the point-of-care.

This study shows that a ubiquitous technology, the telephone, can be successfully used to automatically assess and counsel parents before pediatric primary care visits as well as inform their primary care clinicians in a way that is feasible and effective for multiple important issues. (Read the full article)

Childhood obesity rates in the United States remain at historic highs. The pediatric primary care office represents an important, underutilized source of intervention. There is a need to test the efficacy of motivational interviewing for pediatric obesity in primary care.

This is among the first large-scale randomized trials to show significant reductions in BMI and that motivational interviewing, delivered by trained providers in the primary care setting, can be an important and feasible part of addressing childhood obesity. (Read the full article)

More than a quarter of child deaths in the United Kingdom are estimated to have identifiable failures in care. Although children account for 40% of the family practice workload, little is known about iatrogenic harm to children in this setting.

This is the first analysis of nationally collected pediatric safety incident reports from family practice. To mitigate harm to children, priority areas requiring improvement include medication provision, referral of unwell children, provision of evidence-based treatment, and adequate diagnosis and assessment. (Read the full article)

NEW CASTLE (Jan. 2, 2019) – The number of full-time equivalent primary care physicians providing direct patient care in Delaware in 2018 declined about 6 percent from 2013, a trend that resulted in a slightly lower percentage of physicians statewide who are accepting new patients, according to a new University of Delaware study of the […]

NEW CASTLE (October 9, 2019) – The Department of Health and Social Services (DHSS) is seeking applications from Delaware health care providers for one-time, health information exchange (HIE) support mini-grants to adopt the full range of health information exchange tools offered by the Delaware Health Information Network (DHIN). DHIN is Delaware’s Health Information Exchange (HIE) […]

DEPARTMENT OF INSURANCE: Office of the Commissioner

Title: U.S. Primary Care Docs Unprepared for Surge in Alzheimer's Cases
Category: Health News
Created: 3/11/2020 12:00:00 AM
Last Editorial Review: 3/11/2020 12:00:00 AM

Title: The Doctor Gap: In Areas of Greatest Need, Primary Care Is a Team Effort
Category: Health News
Created: 3/19/2020 12:00:00 AM
Last Editorial Review: 3/20/2020 12:00:00 AM

Despite advances in oral health care, inequalities in oral health outcomes persist due to problems in access. With proper training, primary care providers can mitigate this inequality by providing oral health education, screening, and referral to advanced dental treatment. Diverging sets of oral health competencies and guidelines have been released or endorsed by multiple primary care disciplines. The aim of this study was to transform multiple sets of competencies into Entrustable Professional Activities (EPAs) for oral health integration into primary care training. A scoping review of the literature between January 2000 and December 2016 was conducted according to PRISMA methodology to identify all existing sets of competencies. The following primary care disciplines were included in the search: allopathic/osteopathic medical schools and residency programs in family medicine, internal medicine, and pediatrics; physician assistant programs; and nurse practitioner programs. Competencies were compared using the Health Resources and Services Administration Integration of Oral Health and Primary Care Practice competencies as the foundational set and translated into EPAs. The resulting EPAs were tested with a reactor panel. The scoping review produced 1,466 references, of which 114 were selected for full text review. Fourteen competencies were identified as being central to the integration of oral health into primary care. These were converted to seven EPAs for oral health integration into primary care and were mapped onto Accreditation Council for Graduate Medical Education residency competency domains as well to the Association of American Medical Colleges EPAs for graduating medical students. The resulting EPAs delineate the essential, observable work required of primary care providers to ensure that oral health is treated as a critical determinant of overall health.

Background:

Patient identification is an important step for advance care planning (ACP) discussions.

Purpose:

Clinical evidence shows minimal benefit to vitamin D screening and subsequent treatment in the general population. This study aims to assess the effectiveness of 2 light-touch interventions on reducing vitamin D test orders.

Therapeutic inertia is a prevalent problem in people with type 2 diabetes in primary care and affects clinical outcomes. It arises from a complex interplay of patient-, clinician-, and health system–related factors. Ultimately, clinical practice guidelines have not made an impact on improving glycemic targets over the past decade. A more proactive approach, including focusing on optimal combination agents for early glycemic durability, may reduce therapeutic inertia and improve clinical outcomes.

BackgroundAutistic people are at increased risk of developing mental health problems. To reduce the negative impact of living with autism in a non-autistic world, efforts to improve take-up and access to care, and support in early years, which will typically start with a GP appointment, must be grounded in the accounts of autistic young adults.AimTo explore how autistic young adults understand and manage mental health problems; and to consider help seeking as a focus.Design and settingA cross-sectional, qualitative study. Autistic participants were purposively selected to represent a range of mental health conditions including anxiety and depression. A subsample were recruited from a population cohort screened for autism in childhood. The study concerns access to primary care.MethodNineteen autistic young adults without learning disabilities, aged 23 or 24 years, were recruited. In-depth, semi-structured interviews explored how they understood and managed mental health problems. Data were analysed thematically.ResultsYoung adults preferred self-management strategies. Multiple factors contributed to a focus on self-management, including: beliefs about the aetiology of mental health difficulties and increased vulnerability with the context of a diagnosis of autism, knowledge of self-management, and a view that formal support was unavailable or inadequate. Families had limited awareness of professional support.ConclusionYoung autistic adults without learning disabilities, and their families, may hold erroneous beliefs about autism and mental health. This may affect help seeking and contribute to an exacerbation of symptoms. GPs need to be alert to the fact that autistic young adults in their care may be experiencing mental health difficulties but may not recognise them as such.

BackgroundA brief intervention whereby GPs opportunistically facilitate an NHS-funded referral to a weight loss programme is clinically and cost-effective.AimTo test the acceptability of a brief intervention and attendance at a weight loss programme when GPs facilitate a referral that requires patients to pay for the service.Design and settingAn observational study of the effect of a GP encouraging attendance at a weight loss programme requiring self-payment in the West Midlands from 16 October 2018 to 30 November 2018, to compare with a previous trial in England in which the service was NHS-funded.MethodSixty patients with obesity who consecutively attended primary care appointments received an opportunistic brief intervention by a GP to endorse and offer a referral to a weight loss programme at the patient’s own expense. Participants were randomised to GPs who either stated the weekly monetary cost of the programme (basic cost) or who compared the weekly cost to an everyday discretionary item (cost comparison). Participants were subsequently asked to report whether they had attended a weight loss programme.ResultsOverall, 47% of participants (n = 28) accepted the referral; 50% (n = 15) in the basic cost group and 43% (n = 13) in the cost comparison group. This was significantly less than in a previous study when the programme was NHS-funded (77%, n = 722/940; P<0.0001). Most participants reported the intervention to be helpful/very helpful and appropriate/very appropriate (78%, n = 46/59 and 85%, n = 50/59, respectively) but scores were significantly lower than when the programme was NHS-funded (92% n = 851/922 and 88% n = 813/922, respectively; P = 0.004). One person (2%) attended the weight loss programme, which is significantly lower than the 40% of participants who attended when the programme was NHS-funded (P<0.0001).ConclusionGP referral to a weight loss programme that requires patients to pay rather than offering an NHS-funded programme is acceptable; however, it results in almost no attendance.

BackgroundAwareness of the importance of shared decision making (SDM) is widespread; however, little research has focused on discussions surrounding investigations, despite increasing laboratory testing in primary care.AimTo explore the discussion of blood tests in routine primary care consultations.Design and settingA secondary analysis of 50 video-recorded routine primary care consultations, linked surveys, and records data (all from the One in a Million [OiaM] archive). The consultations were taken by 22 GPs across 12 practices.MethodA coding scheme was developed, using qualitative content analysis, to explore discussion of blood tests in transcripts of recorded consultations. Codes focused on instigating testing, the extent of SDM, and how results were explained. Survey data were used to compare patients’ pre-visit expectations with consultation content. Medical records were reviewed to compare tests discussed with those ordered.ResultsIn 36 out of 50 consultations that discussed ordering blood tests, 11 patients (31%) hinted that they wanted a blood test; however, none asked explicitly. Only four patients (11%) were offered alternative options. In 29 cases (81%) the GP gave some explanation of the indication, but only in six cases (17%) were the limitations of testing explained. Only 10 out of 31 patients (32%) were informed about all blood tests ordered. Of the 23 out of 50 consultations in which results were conveyed, the GP gave no explanation of the results in six cases (26%). Thirteen patients (57%) were only informed of an assessment of the results (for example, ‘normal’), rather than the actual results.ConclusionA lack of information dissemination and SDM exists around ordering tests and conveying results. Promoting SDM could reduce unnecessary testing and improve patient-centred care.

BackgroundUrinary tract infections (UTIs) are one of the most common bacterial infections managed in general practice. Many women with symptoms of uncomplicated UTI may not benefit meaningfully from antibiotic treatment, but the evidence base is complex and there is no suitable shared decision-making resource to guide antibiotic treatment and symptomatic care for use in general practice consultations.AimTo develop an evidence-based, shared decision-making intervention leaflet to optimise management of uncomplicated UTI for women aged <65 years in the primary care setting.Design and settingQualitative telephone interviews with GPs and patient focus group interviews.MethodIn-depth interviews were conducted to explore how consultation discussions around diagnosis, antibiotic use, self-care, safety netting, and prevention of UTI could be improved. Interview schedules were based on the Theoretical Domains Framework.ResultsBarriers to an effective joint consultation and appropriate prescribing included: lack of GP time, misunderstanding of depth of knowledge and miscommunication between the patient and the GP, nature of the consults (such as telephone consultations), and a history of previous antibiotic therapy.ConclusionConsultation time pressures combined with late symptom presentation are a challenge for even the most experienced of GPs: however, it is clear that enhanced patient–clinician shared decision making is urgently required when it comes to UTIs. This communication should incorporate the provision of self-care, safety netting, and preventive advice to help guide patients when to consult. A shared decision-making information leaflet was iteratively co-produced with patients, clinicians, and researchers at Public Health England using study data.

BackgroundIn the context of a variable condition such as asthma, patient recognition of deteriorating control and knowing what prompt action to take is crucial. Yet, implementation of recommended self-management strategies remains poor.AimTo explore how patients with asthma and parents/carers of children with asthma develop and establish recommended self-management strategies for living with asthma, and how clinicians can best support the process.Design and settingA qualitative study in UK primary care.MethodPatients with asthma and parents/carers of children with asthma from 10 general practices were purposively sampled (using age, sex, and duration of asthma) to participate in focus groups or interviews between May 2016 and August 2016. Participants’ experiences of health care, management of asthma, and views on supported self-management were explored. Interviews and focus group sessions were audio-recorded and transcribed verbatim. Iterative thematic analysis was conducted, guided by the research questions and drawing on habit theory in discussion with a multidisciplinary research team.ResultsA total of 49 participants (45 patients; 4 parents/carers) took part in 32 interviews and five focus groups. Of these, 11 reported using an action plan. Patients learnt how to self-manage over time, building knowledge from personal experience and other sources, such as the internet. Some regular actions, for example, taking medication, became habitual. Dealing with new or unexpected scenarios required reflective abilities, which may be supported by a tailored action plan.ConclusionPatients reported learning intuitively how to self-manage. Some regular actions became habitual; dealing with the unexpected required more reflective cognitive skills. In order to support implementation of optimal asthma self- management, clinicians should consider both these aspects of self-management and support, and educate patients proactively.

PURPOSE

Operational failures are system-level errors in the supply of information, equipment, and materials to health care personnel. We aimed to review and synthesize the research literature to determine how operational failures in primary care affect the work of primary care physicians.

PURPOSE

The prognosis of older patients with dizziness in primary care is unknown. Our objective was to determine the prognosis and survival of patients with different subtypes and causes of dizziness.

Background:

Unnecessary antibiotic use in the community in Canada is not well defined. Our objective was to quantify unnecessary antibiotic prescribing in a Canadian primary care setting.

Background:

It is unclear how patient-reported access to primary care differs by physician payment model and participation in team-based care. We examined the association between timely and after-hours access to primary care and physician payment model and participation in team-based care, and sought to assess how access varied by patient characteristics.

Background:

Incentive payments for chronic diseases in British Columbia were intended to support primary care physicians in providing more comprehensive care, but research shows that not all physicians bill incentives and not all eligible patients have them billed on their behalf. We investigated patient and physician characteristics associated with billing incentives for chronic diseases in BC.

People with type 1 diabetes may receive a significant portion of their care from primary care providers (PCPs). To understand the involvement of PCPs in delivering type 1 diabetes care, we performed surveys in California and Florida, two of the most populous and diverse states in the United States. PCPs fill insulin prescriptions but report low confidence in providing type 1 diabetes care and difficulty accessing specialty referrals to endocrinologists.