MacLaughlin, Kathy L.

Because of the complexity of cervical cancer prevention guidelines, clinicians often fail to follow best-practice recommendations. Moreover, existing clinical decision support (CDS) systems generally recommend a cervical cytology every three years for all female patients, which is inappropriate for patients with abnormal findings that require surveillance at shorter intervals. To address this problem, we developed a decision tree-based CDS system that integrates national guidelines to provide comprehensive guidance to clinicians. Validation was performed in several iterations by comparing recommendations generated by the system with those of clinicians for 333 patients. The CDS system extracted relevant patient information from the electronic health record and applied the guideline model with an overall accuracy of 87%. Providers without CDS assistance needed an average of 1 minute 39 seconds to decide on recommendations for management of abnormal findings. Overall, our work demonstrates the feasibility and potential utility of automated recommendation system for cervical cancer screening and surveillance.

The value of pelvic examination for healthy asymptomatic women has been called into question given the lack of benefit for ovarian and endometrial cancer screening, the ability to screen for sexually transmitted infections without a pelvic examination, and the uncoupling of the procurement of contraception with a pelvic examination. Still, there are indications for performing pelvic examinations in symptomatic women and in some high risk women. How do we as clinicians apply current evidence and expert opinion to our medical practice? Our recommendation to consider a pelvic examination at 3-5-year intervals with cervical cancer screening to elicit gynecologic and sexual health concerns offers a compromise between continuation of unnecessary annual pelvic examinations and complete elimination of these examinations.

Depression symptoms contribute to significant morbidity and health care utilization. The aim of this study was to determine the impact of symptom improvement (to remission) on outpatient clinical visits by depressed primary care patients. This study was a retrospective chart review analysis of 1733 primary care patients enrolled into collaborative care management (CCM) or usual care (UC) with 6-month follow-up data. Baseline data (including demographic information, clinical diagnosis, and depression severity) and 6-month follow-up data (Patient Health Questionnaire scores and the number of outpatient visits utilized) were included in the data set. To control for individual patient complexity and pattern of usage, the number of outpatient visits for 6 months prior to enrollment also was measured as was the presence of medical comorbidities. Multiple logistic regression analysis demonstrated that clinical remission at 6 months was an independent predictor of outpatient visit outlier status (>8 visits) (odds ratio [OR] 0.609, confidence interval (CI) 0.460–0.805, P <0.01) when controlling for all other independent variables including enrollment into CCM or UC. The OR of those patients not in remission at 6 months having outpatient visit outlier status was the inverse of this at 1.643 (CI 1.243–2.173). The most predictive variable for determining increased outpatient visit counts after diagnosis of depression was increased outpatient visits prior to diagnosis (OR 4.892, CI 3.655–6.548, P <0.01). In primary care patients treated for depression, successful treatment to remission at 6 months decreased the likelihood of the patient having more than 8 visits during the 6 months after diagnosis. ( Population Health Management 2014;17:180–184)

AbstractAims and objectivesThe aim of this study was to assess the impact of historical screening compliance with the effectiveness of patient reminder letters on cervical cancer screening rates.MethodUsing population‐based informatics systems, women with no cervical cancer screening in the prior 3 years were identified in two primary care clinics, Mayo Family Clinic Northeast (NE; n = 1613) and Northwest (NW; n = 1088). Patients were divided into two compliance groups: overdue/unknown screening status at study start or previously compliant. The NE Clinic sent reminder letters over a 6 months window to patients eligible for screening at the study start or during the study that were also identified as employees/dependents (E/D). There were 795 intervention (NE Clinic E/D patients) and 1906 control subjects. Using an intent‐to‐treat analysis, differences in screening rates were assessed.ResultsA higher unadjusted screening rate was observed for the E/D group than the non‐E/D group at both sites (32.7 versus 18.2% at NW, P < 0.001; 39.0 versus 14.7% at NE, P < 0.001). For the historically compliant group, unadjusted screening rates were higher for those who received letters (E/D subjects at NE) versus those who did not (E/D subjects at NW; 56.1 versus 44.5%, P = 0.01). No difference was observed between E/D subjects at NE (received letters) and NW (no letters) for the overdue/unknown group (27.4 versus 25.9%, P = 0.62). There was no difference in screening rates for non‐E/D subjects at NE versus at NW (none of whom received letters) for both the compliant (24.2 versus 30.6%, P = 0.18) and the overdue/unknown groups (11.9 versus 13.0%, P = 0.59). Multivariate logistic regression models showed a significant overall effect of E/D status (P = 0.006), compliance group (P < 0.001), and the interaction between clinic site and E/D status (P = 0.04).ConclusionAmong insured women, reminder letters appear to improve cervical cancer screening rates for those with a history of screening compliance. Reminder letters appear insufficient to motivate women if screening is overdue. Further investigation of the cohort of women overdue for screening is needed to develop interventions to successfully target this group.

As retail clinics provide a less costly alternative for health care, it would be reasonable to expect an increase in multiple (repeat) retail visits by those patients who may have expenses for receiving primary care. If costs were not a significant factor, then repeat visits should not be significantly different between these patients and those with coverage for primary care visits. The hypothesis for this study was that patients with the potential for out-of-pocket expenses would have a higher frequency of repeat retail clinic visits within 180 days compared to those with primary care coverage. A retrospective chart review was conducted of 5703 patients utilizing a retail clinic in Rochester, Minnesota from January 1, 2009 through June 30, 2009. The first visit to the retail clinic was considered the index visit and the chart was reviewed for repeat retail clinic visits within the next 180 days. Using a multiple logistic regression model, the odds of a pediatric patient ( N =2344) having a repeat retail visit within 180 days of the index visit were not significantly impacted by insurance coverage ( P =0.4209). Of the 3359 adult patients, those with unknown coverage had a 25.6% higher odds ratio of repeat retail clinic visits than those with insurance coverage (odds ratio 1.2557, confidence interval 1.0421–1.5131). This study suggested that when cost is an issue, the adult patient may favor retail clinics for episodic, low-acuity health care. In contrast, the pediatric population did not, suggesting that other factors, such as convenience, may play more of a role in the choice of episodic health care for this age group. ( Population Health Management 2012;15:358–361)

In 2008, the Institute for Clinical Systems Improvement (ICSI) in Minnesota implemented a model of collaborative care management (CCM) for treatment of depression in primary care. This resulted in significant improvements on both clinical response and remission over usual care, although an increase in utilization metrics has been observed. Mental health comorbidities have previously been significantly associated with an increased likelihood of not responding to initial treatment. This retrospective study hypothesized that patients with mental health comorbidities are more likely to be associated with patients who were readmitted into CCM with recurrent depression. A total of 145 patients who had completed CCM were studied; of these, 32 were diagnosed with recurrent depression and were readmitted to CCM, and 113 were in remission for at least 4 months. There were no statistically significant demographic differences between the 2 groups. The initial screening GAD-7 score for anxiety was significantly increased in the readmission group (12.81 vs 9.20, P = .001) as was the average length of treatment from initial diagnosis to remission (168.09 vs 120.99 days, P = .002). All other initial screening tests were not different between the groups. When controlling for the independent variables by multiple logistic regression, the odds ratio for GAD-7 was 1.1156 (CI = 1.0.192 to 1.2212, P = .0177) and for days of treatment in CCM was 1.0123 (CI = 1.0041 to 1.0206, P = .0033). Patients who are readmitted to CCM for recurrent depression have a statistically increased risk of associated anxiety and a longer treatment course than those who have remained in remission for at least 4 months.