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Mold JW, Barton ED.
OAFP starts practice-based resource/research network. J
Mold JW, Cacy JR, Barton ED.
Patient-Physician E-Mail Communication.
J
Methods: 23 physicians from 14 OKPRN practices enrolled 25 consecutive
patients each on two separate days (total N=1068 patients).
Each patient answered 5 questions on the back of a postal card that was then
mailed to the OU DFPM.
Conclusions: A significant number of primary care patients have computer
and e-mail. Approximately half would
like to be able to use e-mail to communicate with their PCP.
Cacy J, Mold JW.
The Clinical Characteristics of Brown Recluse Spider Bites Treated by Family Physicians:
An OKPRN Study. The Journal of Family
Practice 1999. 48(7): 536-542.
Methods: Preprinted, postage-paid
cards of two types were given to physician members of the Oklahoma Physicians Research
Network. One card was used for recording
examination and treatment data, and the other was for tracking the progress of the
bite until it was completely healed.
For comparison, similar information was collected from the local poison control
center.
Results: From April 1996
to August 1998, the physicians recorded 149 bites.
Most of the victims were women aged 18 to 65 years, and most sought treatment
within 3 days. Pain was common but
not universal. Most bites were located
on the extremities. Erythema was always
present, but necrosis was present in only 40% of the bites.
Some systemic signs or symptoms were common.
The most frequent forms of treatment were systemic antibiotics (66% of cases)
and conservative wound management (56%).
Only 1 hospitalization occurred; 43% of the bites healed within 2 weeks; and only
13% resulted in scarring.
Conclusions:
The brown recluse
spider bite is a relatively common problem treated by family physicians in
Mold JW. Treatment of brown recluse spider bites by family physicians. Submitted to JABPF
(in press)
Methods: Same as for first brown recluse study.
Total N 256 bites.
Results: Predictors of longer healing time:Delay in seeking treatment. Diameter of erythema
when first seen. Diameter of necrosis when first seen. Diameter of necrosis when
first seenTreatment with dapsone, systemic steroids, or high dose Vitamin C. Predictors
of scarring: Diameter of necrosis when first seen. Diabetes mellitusDiameter
of necrosis when first seenDiabetes mellitusTreatment with dapsone or high dose
Vitamin C
Conclusions: None of the treatment approaches used by OKPRN physicians made
any difference in healing time or probability of scarring.
Fortunately most bites (80%) healed without scarring.
The median time to healing was 17 days.
Mold JW and Thompson DM.
Management of brown recluse spider bites in primary care.
JABPF September/October 2004,
17(5): 347-352.
Brown Recluse
Spiders
Unpublished
Background and Rationale: Little is known about the level of knowledge
and experience of Oklahomans with regard to brown recluse spider bites.
There may be a need for additional public education on this subject.
Methods: All adult (>18 y.o.) patients being seen in the waiting
rooms of the Family Medicine Center clinics and individuals shopping at a grocery
store in Edmond during predetermined periods of time were approached and asked to
answer a series of questions and to pick out a picture of a brown recluse spider
from among five pictures of spiders.
Results: 132 FMC patients and 90 shoppers completed the survey.
Although the mean ages (43.6 vs. 21.4) and gender distribution (67% female
vs. 50% female) of the two groups were different, their responses to the survey
were practically identical. 46% thought
they could identify a BR spider and 44% chose the correct picture.
Twenty-four percent had seen a BR spider in their home in the past year,
but only 2% had been bitten by one.
Conclusion: Brown recluse spiders are common in
Hulson TD, Mold JW, Scheid D, Aaron M, Aspy CB, Ballard NL,
Boren N, Gregory ME, Truong TC. Diagnosing
Influenza: The Value of Clinical Clues and Laboratory Tests.
The Journal of Family Practice 2001 December.
50(12): 1051-1056.
Methods:
Data were collected
during 3 consecutive influenza outbreaks over a 2-year period in one 5-man family
practice office in
Results:
Culture-positive
cases could not be reliably distinguished from those that were culture negative
using symptoms or vaccination status.
Both WBC count and ZstatFlu results discriminated fairly well, and their combination
did somewhat better. Differential counts
were not helpful. WBC counts above
8,000 were associated with a low probability of influenza.
The sensitivity and specificity of the ZstatFlu were 65% and 83%, respectively.
Conclusions:
Our data suggest
that symptoms and vaccine status do not reliably identify patients with influenza. Use of WBC counts and the ZstatFlu test
can be helpful. The sequence, combination,
and criteria for use of these tests depend on tradeoffs between under-treatment
of influenza cases and the over-treatment of non-influenza cases, and cost and benefit
projections for individual patients.
Mold JW, Gregory ME.
Best Practices Research. Family Medicine
2003 February, 35(2): 131-134.
This is a description
of the “best practices research” method pioneered for use in practice-based research
networks by OKPRN. It is a method used
to identify effective methods for managing common primary care processes like lab
test results, prescription refills, no-shows, preventive services, etc.
The process of interest is first broken down into to its component parts. Values and acceptable standards are
then agreed upon for each part (to define “most effective”).
Finally, exemplars are sought and identified from within the network for
each part, their methods are studied, and the best methods are combined into a complete
“best” method.
Mold JW, Cacy DS, Dalbir DK.
Management of Laboratory Test Results in Family Practice.
An OKPRN Study. The Journal of
Family Practice, 2000 August.
49(8): 709-715.
Methods:
We used a questionnaire
guided by a literature review to identify a conceptual model, current practices,
and clinicians who reported having an effective method for at least one of 4 steps
in the process of managing laboratory test results.
Clinicians with differing methods were selected for each of the steps. Practice audits and patient surveys
were used to determine actual performance.
On the basis of these audits, we constructed a unified best method and conducted
time-motion studies to determine its cost.
Results:
After auditing
only 4 practices we were able to identify effective methods for 3 of the 4 steps
involved in the management of laboratory test results.
The unified best method costs approximately $5.19 per set of tests for an
individual patient.
Conclusions:
By identifying
effective practices within a family practice research network, an effective method
was identified for 3 or the 4 steps involved in the management of laboratory test
results in primary care settings.
Mold JW, Enright MM, Oehlert WH.
Improving the quality of care for diabetic patients using best practices
research and practice enhancement assistants.
In preparation.
Methods: Exemplars identified from previous OFMQ audits were interviewed
regarding their diabetes management methods.
Six common principles were discovered.
These principles were then taught to 20 OKPRN physicians who were also provided
with a practice enhancement assistant to help them make changes.
A PDA-based program was also available to use by choice.
Pre- and 3 mo. Post-intervention audits were done.
Conclusions: Use of the best practices research approach in combination
with a PEA resulted in significant short-term improvements in quality of diabetes
care.
Roberts M and Mold JW. Primary care network survey.
Presented at OKPRN Convocation 2/2003.
Methods: The PRINS surveys were designed by the Agency for Healthcare
Research and Quality and primary care practice-based research network directors. They were intended to capture information
on the clinicians and practices involved in primary care practice-based research
networks and a sample of their patient encounters, and to compare them to other
clinicians and practices using other available data sets.
Overall, 1500 PRINS 1 surveys were completed by clinicians in 19 networks
across the country, and PRINS 2 information was captured on 26,649 encounters. In OKPRN, a total of 248 clinicians,
including 98 faculty members, 100 second and third year residents, and 50 community
practitioners, completed the PRINS 1 survey (clinician and practice information),
and 40 faculty, 52 residents, and 26 community practitioners completed data on approximately
30 encounters each, capturing data on a total of 3535 encounters.
Results: PRINS 1: (OKPRN compared to Family Physicians nationally)Community Practitioners:
OKPRN practitioners were more likely to be younger, male, and Native American; they
were less likely to be Hispanic and black.
Faculty: OKPRN faculty were more likely to be younger and female.Residents:
OKPRN resident members were younger, female, and Native American; they were less
likely to be African American.PRINS 2: (OKPRN compared to PCPs in the National
Ambulatory Medical Care Survey)Community Practitioners: On average, OKPRN
physicians see more Native Americans and Medicare patients, and fewer Hispanics,
Medicaid, and HMO patients. They do
less non-illness care and more ambulatory surgery.
Faculty: OKPRN faculty physicians see a higher percentage of female,
Native American, Medicaid, and HMO patients and fewer Hispanic patients.
They do less non-illness care and more ambulatory surgery than PCPs surveyed
for NAMCS.Residents: OKPRN residents see more female, Black, Native American,
Medicaid, self pay, and HMO patients and many fewer Caucasian and Medicare patients. They do more non-illness care than NAMCS
PCPs.
Conclusions: While OKPRN clinicians are similar to national samples, they
differ in several important ways. Within
OKPRN, residents see a very different spectrum of patients than faculty and particularly
community physicians do.
Mold JW, Mathew MK, Belgore S, DeHaven M.
Prevalence of night sweats in primary care patients.
An OKPRN and TAFP-Net collaborative study.
The Journal of Family Practice 2002 May, 51(5): 452- 456.
Methods:
Results:
Of the 2267 patients
who participated, 41% reported experiencing night sweats within the last month,
including 23% with pure night sweats and an additional 18% with day and night sweats. The prevalence of night sweats in both
men and women was highest in the group aged 41 years to 55 years.
In multivariate analyses, factors associated with pure night sweats in women
were hot flashes and panic attacks; in men, sleep problems.
Variables associated with night and day sweats in women were increased weight,
hot flashes, sleep disturbances and use of antihistamines, selective serotonin reuptake
inhibitors (SSRIs) and other (non-SSRI, non-tricyclic) antidepressants; in men,
increased weight, hot flashes, and greater alcohol use.
A majority of patients had not reported their night sweats to
their physicians, even when frequent and severe.
Conclusions: Night sweats
are common and under-reported. Pure
night sweats and night and day sweats may have different causes.
With regard to the etiologies of pure night sweats, panic attacks and sleep
disorders need further investigation.
Mold JW, Aboshady HM, and Roberts AM. Prevalence and predictors
of night sweats, day sweats, and hot flashes.
Annals of Family Medicine 2004
September/October, 2(5): 391-397
Methods: A cross-sectional
study of patients over 64 years old recruited from the practices of 23 family physicians. Variables included socio-demographic
information, health habits, chronic medical problems, symptoms, quality of life
(QOL), and the degree to which patients were bothered by night sweats, daytime sweating,
and hot flashes.
Results:
Among the 795 patients, 10% reported being bothered by night
sweats, 9% day sweats, and 8% hot flashes.
Eighteen percent reported at least one of these symptoms.
The three symptoms were strongly correlated.
Factors associated with night sweats in the multivariate models were age
(O.R.0.94/yr; C.I.: 95%: 0.89, 0.98), fever (O.R. 12.60; C.I. 95%:
6.58, 24.14), muscle cramps (0.R. 2.84; C.I. 95%: 1.53, 5.24), numbness
of hands and/or feet (O.R. 3.34; C.I. 95%: 1.92, 5.81), impaired vision
(O.R. 2.45; C.I. 95%: 1.41, 4.27), and hearing loss (O.R.1.84; C.I.
95%: 1.03, 3.27). Day sweats
were associated with fever (O.R. 4.10; C.I. 95%: 2.14, 7.87), restless
legs (O.R. 3.22; C.I. 95%: 1.76, 5.89), lightheadedness (O.R. 2.24; C.I.
95%: 1.30, 3.88), and diabetes (O.R. 2.19; C.I. 95%: 1.22,
3.92). Hot flashes were associated
with non-Caucasian race (O.R. 3.10; C.I. 95%: 1.60, 5.98), fever (O.R.
3.98; C.I. 95%: 1.97, 8.04), bone pain (O.R. 2.31; C.I. 95%:
1.30, 4.08), impaired vision (O.R. 2.12; C.I. 95%: 1.19, 3.79), and nervous
spells (O.R. 1.87; C.I. 95%: 1.01, 3.46).
All three symptoms were associated with reduced QOL.
Conclusions:
Night sweats,
day sweats, and hot flashes are reasonable common symptoms in elderly primary care
patients. Presumably related to autonomic
reactions to emotional or physical distress, they are, no doubt, more noticeable
and distressing to some than to others.
Though relatively non-specific, their presence should probably prompt additional
questions about febrile illnesses, diabetes, anxiety, depression, somatic and visceral
pain, sensory deficits, and restless legs syndrome in addition to standard, recommended
evaluations for uncommon serious diseases such as tuberculosis and malignancies.
Mold JW, Wooley J, and Nagykaldi Z. Associations between night
sweats and sleep disturbances. In Press,
Annals of Family Medicine
METHODS:
Cross-sectional
study of consecutive adult patients seen in 10 primary care physicians’ offices. Data collected and transmitted by PDA
included demographic variables, height, weight, and blood pressure, occurrence of
a variety of sleep-related symptoms, and occurrence and severity of night sweats,
day sweats, and hot flashes in the past month.
For women, information about menstrual status was also obtained.
RESULTS: Thirty-four percent
of the 363 patients interviewed reported night sweats, half of whom reported saturating
their bed clothes. In the multivariate
model, night sweats were associated with daytime tiredness (O.R.: 1.99; C.I.95%:
1.12 – 3.53), waking up with a bitter taste in the mouth (O.R.: 1.94; C.I.95%:
1.19 – 3.18), legs jerking during sleep (O.R.: 1.78; C.I.95%: 1.05 –
3.00), and awakening with pain in the night (O.R.: 1.87; C.I.95%: 1.16
– 2.99).
CONCLUSIONS: Night sweats are associated with several sleep symptoms. Both night sweats and sleep disturbances
are commonly experienced by adult primary care patients.
Patients complaining of night sweats should be asked about sleep quality
and sleep-related symptoms.
Mold JW, Vesely S, Schenk, J, Keyl B, and Roberts AM.
The prevalence, predictors, and consequences of peripheral sensory neuropathy
in older patients.
JABFP September-October 2004, 17(5): 309-318.
Methods:
Results: The prevalence of at least one bilateral peripheral neurological
deficit rose from 26% in the 65-74 year old age group to 54% for those 85 and older. Only 28% of those with a deficit had
a history of a disease known to cause peripheral neuropathy.
In those who did, the prevalence was substantially higher overall (45% vs.
26%), and the prevalence did not increase with increasing age.
The most common deficit was loss of ankle reflex followed by loss of fine
touch sensation. After controlling
for other relevant variables, the predictors of neurological deficits included:
age (O.R.: 1.08/year), income less than $15,000 (O.R.: 1.94), a history of military
service (O.R.: 1.77), body mass index (O.R.: 1.06/unit), a history of diabetes mellitus
(O.R.: 2.50), Vitamin B12 deficiency (O.R.: 2.42), or rheumatoid arthritis (O.R.:
2.95), and the absence of hypertension (O.R.: 0.64).
The presence of neurological deficits was associated with numbness, pain,
restless legs, trouble with walking and balance, and reduced quality of life but
not with reported falls.
Conclusions: Bilateral sensory deficits are exceedingly common in the elderly.
In most cases, there is no history of a disease known to cause peripheral neuropathy.
While their significance requires further elucidation, it appears that this problem
is not as benign as generally supposed.
Mold JW, Fryer GE. When do older patients change primary care
doctors? JABFP January 2005
17: 453-460.
Methods: Same as for the other OKLAHOMA Studies projects except that
some data from years two and three were used.
Results: The mean, median, and range of duration of relationship between
participants and their primary care providers were 10.27, 8, and 1 – 40 years. Just over 47% had seen the same PCP
for 10 or more years. After controlling
for other relevant variables, duration of the relationship was positively associated
with patient age (p<0.01), income (P<0.01), and education (p=0.03), and with
the number of PCP office visits during the past year (p=0.03).
Patients with longer relationships rated their PCP higher on all eight subscales
of the Components of Primary Care Index (CPCI).
Longer duration of current PCP relationship was associated with a greater
likelihood that the participant last changed PCPs involuntarily (p=0.002).
Those who had changed PCPs more recently were much more likely to have changed
because of change of insurance (p<0.001).
Conclusions: Older patients tend to stick with their PCP until they are
forced to change because of change of insurance, doctor retirement, change of location,
or death, patient change of location or death, or increased problems with transportation.
Nagykaldi Z, Mold JW, Aspy CB.
“Practice Facilitator: A Review of the Literature. Family Medicine 2005;37(8):581-8.
Methods: We searched four electronic databases from 1966 through the
present, reviewing all articles pertaining to PFs in an effort to understand the
history, training, financing, roles, methods, and impact of PFs.
Results: Since the early
1980s, PFs have worked with individual practices on relationship building, education,
and quality improvement (QI), particularly in the area of prevention.
A number of publications provide information on the roles of PFs in primary
care and methods they use to enhance practices.
Many prospective, uncontrolled studies and a few randomized, controlled trials
have documented the effectiveness of PFs but usually in combination with other interventions. A number of primary care PBRNs in the
Conclusions: The PF concept seems to be a useful practice enhancement approach
in primary care.
Mold JW and
Peterson K. “Primary Care Practice-Based
Research Networks: Working at the Interface Between Research and Quality Improvement.”
Annals of Family Medicine 2005;3(Suppl 1)S12-S15.
Methods: We gathered information from the published literature discussions
with PBRN leaders, case examples, and our own personal experience to describe a
role for PBRNs that comfortably bridges
the gap between research and QI, discovery and application, academicians and practitioners
- a role that may lead to the establishment of true learning communities.
We provide specific recommendations for network directors, network clinicians,
and other potential stakeholders.
Results:
PBRNs function
at the interface between research and QI, and interface called TRIP by some members
of the research community. In doing
so, PBRNs are inappropriate disconnect between discovery and implementation, research
and practice. Participatory models
are emerging in which stakeholders agree on their goals; apply their collective
knowledge, skills, and resources to accomplish these goals; and use research and
QI methods when appropriate.
Conclusions:
PBRNs
appear to be evolving from clinical laboratories into learning communities, proving
grounds for generalizable solutions to clinical problems, and engines for improvement
of primary care delivery systems.
Nagykaldi Z, Mold JW.
Diabetes Patient Tracker, a Personal Digital Assistant-Based Diabetes Management
System for Primary Care Practices in
Methods:
The Diabetes Patient
Tracker (DPT) was developed as a part of an OKPRN best practices research and development
project aimed at improving documentation and delivery of medical services for diabetic
patients. Participants were introduced
to the principles learned from exemplar physicians and supplied with a Diabetes
Toolkit that contained findings and resources for implementation.
Following the chart audits, consultations were held with physicians and the
office staff. They were taught how
to use the PDA and DPT handheld application. After and average of 4 months, patient
charts in participating physician offices were audited by OFMQ to determine the
post-intervention rates of delivering and documenting services.
Results:
Eighty percent
(20 of 25) of the physicians implemented the PDA-based electronic registry in their
practices, and 76% (19 of 25) had regular Practice Enhancement Assistant visits
to help them with the implementation of guidelines and the handheld system. Statistical analysis, by patient, demonstrated
a significant improvement (p<.05) in nine of the 10 measures included in the
audit (HgbA1c measurement within 1 year, urine for protein within 1 year, lipid
panel within 1 year, retinal examination within 1 year – both ordered and documented,
foot examination within 1 year, use of angiotensin converting enzyme inhibitor for
proteinuria, flu shot within 1 year, and Pneumovax ever).
These improvements correspond with previous reports on the effectiveness
of electronic systems to improve disease management.
Project Title: “Smoke-Free Families”
Principal Investigator: James W. Mold, M.D., M.P.H.
Project Dates: 01/01/03-11/30/05
Sponsor: Robert Wood Johnson Foundation through the
Annual Direct Costs: $79,094
The University of Oklahoma Health Sciences Center, Oklahoma Physicians Research/ Resource Network, and Oklahoma State Medical Association were collaborating for the implementation of a Smoke Free Families project to assist pregnant women to stop smoking and evaluate the implementation of Smoke Free Families Best Practice Intervention in private physicians’ offices.
Ferrell CW, Aspy CB, Mold JW. Management of prescription refills in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. Journal of the American Board of Family Medicine: JABFM. 19(1):31-8, 2006 Jan-Feb. Background: Management of prescription refills is a significant challenge for primary care practices, but little information exists on the best way to do it. Methods: Using the "best practices research" method within a primary care practice-based research network, we delineated steps involved in the process and the most important requirements for each step. We identified potential exemplary practices for each step and conducted practice audits and patient surveys to document actual performance. Methods with the highest performance ratings for the predetermined requirements for the steps were combined into a "best" unified approach. Results: Half of the surveyed practices were satisfied with at least one step in their current refill management process, but only 9% (3 practices) were satisfied with all 5 steps. Practice audits identified acceptable methods for each step. The best combined method involves teaching patients to call the pharmacy first for prescription refills, accepting only fax requests from the pharmacy, allowing a nurse or medical assistant to make most refill decisions, documenting them in the chart immediately, responding back to the pharmacy by fax, and relying on the pharmacy to notify the patient when the refill is ready. Patient satisfaction with this method was reasonably good. The cost per refill was approximately $0.25 excluding overhead associated with office equipment and utilities. Conclusions: A satisfactory method for managing prescription refills in primary care practices was identified using the best practices research method.
Cotton A, Aspy CB, Mold JW, Stein H. Clinical decision-making in blood pressure management of patients with diabetes mellitus: an Oklahoma Physicians Resource/Research Network (OKPRN) Study. Journal of the American Board of Family Medicine: JABFM. 19(3):232-9, 2006 May-Jun. Background: Outcomes can be improved when the blood pressure (BP) is kept below 130/80 in patients with diabetes mellitus. However, physicians and patients achieve this target less than 50% of the time. The purpose of this study was to determine the reasons for this apparent quality deficit from the perspective of a small random sample of family physicians. Methods: Nine family physicians completed interviews about encounters with diabetic patients with BP >or=130/80 for whom no change in management was recorded. Four investigators analyzed the transcribed interviews to identify and categorize reasons for failure to intervene. Results: Ninety-eight (62%) of 159 patients had BP >or=130/80 at the index visit. No change in management was recorded in 73 (74%). Physicians gave 175 reasons for nonintervention in 3 broad categories, physician-related, patient-related, and information/measurement-related reasons, and 10 subcategories. In most cases they gave more than one reason (mean 2.4) per case. The most frequent subcategories were limited treatment options (47/73; 64%), inadequate information on which to intervene (43/73; 59%), and patient nonadherence (27/73; 37%). Competing demands were mentioned in 10 cases (13.7%). Physicians differed with regard to the kinds of reasons given. Conclusions: Physicians have a variety of clinical reasons for not responding to elevated BP in diabetic patients. Some might be addressed with better technology (eg, more reliable BP measurements) or health care system reforms (eg, less expensive medications). Others (eg, patient nonadherence) are more challenging. Methods for measuring quality must be robust enough to account for legitimate clinical reasons for not achieving BP targets. Physician-based interventions will need to take into account different physician personalities and practice styles.
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