Our purpose in this article is to describe and illustrate the application of cluster analysis to identify clinically relevant multimorbidity groups. Multimorbidity is the co-occurrence of 2 or more illnesses within a single person, which raises the question whether consistent, clinically useful multimorbidity groups exist among sets of chronic illnesses. Our purpose in this article is to describe and illustrate the application of cluster analysis to identify clinically relevant multimorbidity groups. Application of cluster analysis involves a sequence of critical methodological and analytic decisions that influence the quality and meaning of the clusters produced. We illustrate the application of cluster analysis to identify multimorbidity clusters in a set of 45 chronic illnesses in primary care patients (N = 1,327,328), with 2 or more chronic conditions, served by the Veterans Health Administration. Six clinically useful multimorbidity clusters were identified: a Metabolic Cluster, an Obesity Cluster, a Liver Cluster, a Neurovascular Cluster, a Stress Cluster and a Dual Diagnosis Cluster. Cluster analysis appears to be a useful technique for identifying multiple disease clusters and patterns of multimorbidity.

Medicare beneficiaries in fair or poor health are more likely to experience a potentially preventable hospitalization if they live in a county designated as a primary care shortage area. Provision of Medicare coverage alone may not be enough to prevent poor ambulatory health care outcomes such as preventable hospitalizations. Improving health care outcomes for vulnerable elderly patients may require structural changes to the primary care ambulatory delivery system in the United States, especially in designated shortage areas.

Handheld computers are widely used in family practice residency programs in the United States. Although handheld computers were designed as electronic organizers, in family practice residencies they are used as medication reference tools, electronic textbooks, and clinical computational programs and to track activities that were previously associated with desktop database applications.

Background: Patients with schizophrenia have difficulty managing their medical healthcare needs, possibly resulting in delayed treatment and poor outcomes. We analyzed whether patients reduced primary care use over time, differentially by diagnosis with schizophrenia, diabetes, or both schizophrenia and diabetes. We also assessed whether such patterns of primary care use were a significant predictor of mortality over a 4-year period.

PURPOSE We wanted to examine the relationships between quality of diabetes care delivered, the type and length of encounter, and time to the next follow-up encounter. METHODSThe content of the physician-patient encounter was directly observed in 20 primary care clinics for 211 patients with type 2 diabetes mellitus. The quality of diabetes care was measured as the percentage of the 5 following services delivered during the encounter if they had not been offered in the previous year: foot examination, referral for an eye examination, a glycosylated hemoglobin (HbA 1c ) measurement, a lipid panel, and a urine microalbumin test. RESULTSAll indicated services were performed in 33% of encounters. Compared with encounters for an acute illness, patients visiting for chronic disease followup were 4.8 (95% CI, 1.95%-12.01%) times more likely to receive 100% of all indicated services. Length of encounter was associated with percentage of services delivered, but only during chronic disease follow-up encounters (P = .02). Encounters during which 100% of all indicated services were delivered had a mean length of 19.4 minutes. The time to the next scheduled encounter was shorter if fewer services were delivered during the observed encounter (P = .009). CONCLUSIONSCompeting demands during primary care encounters require patient and physician to prioritize services delivered and defer indicated services to subsequent visits. Current models of patient care in primary care settings are inadequate to address the multitude of tasks facing clinicians, especially among patients with complex chronic illnesses. Innovative approaches and new models are needed to improve the quality of diabetes care.

Stakeholders' recommendations suggest health care redesigns that incorporate patients' health priorities into care decisions and realign relationships across patients and clinicians.

Objective To measure the incidence of treatment failure and associated costs in patients with methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTIs). Methods This was a prospective, observational study in 13 primary care clinics. Primary care providers collected clinical data, wound swabs, and 90-day follow-up information. Patients were considered to have “moderate or complicated” SSTIs if they had a lesion ≥ 5 cm in diameter or diabetes mellitus. Treatment failure was evaluated within 90 days of the initial visit. Cost estimates were obtained from federal sources. Results Overall, treatment failure occurred in 21% of patients (n=21/98) at a mean additional cost of $1,933.71 per patient. Treatment failure occurred in 27% of patients in the moderate or complicated group and 11% of patients in the mild or uncomplicated group (p = 0.08). In a subgroup analysis of patients who received I&D, patients with moderate or complicated SSTIs had higher rates of treatment failure than patients with mild or uncomplicated SSTIs (36% vs. 10%; p = 0.04). Conclusions One in five patients presenting to a primary care clinic for a MRSA SSTI will likely require additional interventions as a result of treatment failure at an associated cost of almost $2,000 per patient. Baseline risk stratification and new treatment approaches are needed to reduce treatment failures and costs in the primary care setting.

OBJECTIVES Quantify the prevalence, measure the severity, and describe treatment patterns in patients who present to medical clinics in Texas with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft-tissue infections (SSTI). METHODS Ten primary care clinics participated in this prospective, community-based study. Clinicians consented patients and collected clinical information, pictures, and wound swabs; data were processed centrally. MRSASelect™ was used for identification. Susceptibilities were determined via Etest®. RESULTS Overall, 73/119 (61%) patients presenting with SSTIs meeting eligibility requirements had CA-MRSA. Among these, 49% were male, 79% were Hispanic, and 30% had diabetes. Half (56%) of the lesions were ≥ 5 cm in diameter. Most patients had abscesses (82%) and many reported pain scores of ≥ 7/10 (67%). Many presented with erythema (85%) or drainage (56%). Most received incision and drainage (I&D) plus an antibiotic (64%). Antibiotic monotherapy was frequently prescribed: trimethoprim-sulfamethoxazole (TMP-SMX) (78%), clindamycin (4%), doxycycline (2%), and mupirocin (2%). The rest received TMP-SMX in combination with other antibiotics. TMP-SMX was frequently administered as one double-strength tablet twice daily. Isolates were 93% susceptible to clindamycin and 100% susceptible to TMP-SMX, doxycycline, vancomycin, and linezolid. CONCLUSIONS We report a predominance of CA-MRSA SSTIs, favorable antibiotic susceptibilities, and frequent use of TMP-SMX in primary care clinics.