Comanagement of Rashes by Primary Care Providers and Dermatologists: A Retrospective Study



 

Sangeeta Marwaha, MD1; Jennifer R Dusendang, MPH2; Stacey E Alexeeff, PhD2; Eileen Crowley, MD3; Michael Haiman, MD4; Ngoc Pham, MD5; Melanie J Tuerk, MD6; Danny Wudka, MIDS7; Michael Hartmann, MS, MA7; Lisa J Herrinton, PhD2

Perm J 2021;25:20.320

https://doi.org/10.7812/TPP/20.320

Background: There is a high demand for managing skin disease, and dermatologists are in short supply.

Objectives: To better understand how rashes and other specific skin conditions are co-managed by primary care providers (PCPs) and dermatologists, we estimated the frequency with which PCPs sought consultation with or referral to dermatology and the proportion of patients who had a follow-up dermatology office visit in the following 90 days.

Design and Setting: The retrospective longitudinal study included 106,459 patients with a skin condition diagnosed by 3,830 PCPs, from January 2017 to March 2017.

Methods: Comprehensive electronic medical record data with generalized linear mixed modeling accounted for patient factors including diagnosis and clustering by medical center and PCP.

Results: PCPs escalated 9% of patients to dermatology through consultation or referral, while 5% required a follow-up dermatology office visit within 90 days. Patients with bullous, hair, or pigment conditions or psoriasis were most likely to be escalated. Clustering of escalation and follow-up visits was minimal in relation to medical center (intraclass correlation, 0.04 for both outcomes) or PCP (escalation, intraclass correlation, 0.16; follow-up visits, 0.09).

Discussion: Improving primary care education in skin disease and, for certain skin conditions, standardizing approaches to workup, treatment, and escalation may further streamline care and reduce pressure on the dermatologist workforce.

Conclusion: PCPs managed 91% of rashes without consultation or referral to dermatology, and the frequency of patients scheduled for dermatology office visits after primary care was similar from one PCP to another.

INTRODUCTION

Skin rashes accounted for 13 million physician visits in the United States in 2016.1 Dermatologist care may be important for patients with lesions, rare or resistant rashes and other skin conditions, and for patient education. Nonetheless, many of these conditions are self-limiting and require simple treatments. These conditions can be managed by primary care providers (PCPs) to reduce overuse of dermatologists, which affects healthcare costs.2,3 Thus, co-management of skin conditions by PCPs and dermatologists is an important topic. We previously investigated presentation of rashes in the community setting, use of teledermatology to standardize management of these conditions, and co-management of skin cancer.4–6 In this study, we examined co-management of rashes, hypothesizing that the specific diagnosis was related to the likelihood of escalation and to the likelihood of a follow-up dermatology office visit. This information is important for designing clinical workflows that increase the efficient use of care.

METHODS

Setting

Kaiser Permanente Northern California provides prepaid, comprehensive, and integrated healthcare to 4.4 million members. Dermatological concerns are very common in the primary care setting, and primary care physicians can either treat conditions on their own or consult with a dermatologist through 1 of 3 workflows (roving dermatology, teledermatology, e-consult) (Figure 1). At several medical centers, PCPs seeking dermatology expertise can request an immediate visit with a “roving” dermatologist who works in the primary care clinic. The PCP calls the “rover” who, if available, arrives to evaluate the patient and treat them if needed equipment and supplies are available. Thus, roving involves the dermatologist coming to see the patient, offering the convenience of immediate management and the direct involvement of the dermatologist who explains the diagnosis and treatment. Roving dermatology is offered at medical centers where many primary care physicians work in the same or nearby buildings, making it convenient for a roving dermatologist to visit each practice. Store-and-forward teledermatology enables the primary care physician to take and transmit photographs with a patient history and is effective for general dermatology patients;8 however, a camera or mobile device is required, and in some settings, an assistant is needed to take the photograph. Also, after transmitting the photograph for the dermatologist’s review, it may be minutes to hours before the dermatologist’s advice comes back to the PCP, who then must provide the information to the patient. E-consult is a consultative system in which the PCP provides the patient’s history, usually without a photograph, with a request that the patient be seen in dermatology. It is commonly accepted in our organization that e-consult often leads to an appointment in a specialty department, although it can also be used to “ask the specialist” without expecting an appointment, as has been described in other settings. Patients referred to dermatology and those whose condition persists and who are scheduled for a follow-up visit in a dermatology office require an additional co-payment.

 tpj20320f1

Figure 1. Modalities used by primary care providers to escalate patients to dermatologists, Kaiser Permanente Northern California.

Study Population

The retrospective cohort study included health plan members aged 0 to 89 years with an office or telephone encounter with a PCP for a rash or other new skin condition, other than a lesion, between January 2017 and March 2017. In order to ensure that the primary care physician’s actions and potential follow-up care were due to the current rash diagnosis and not another pre-existing skin condition or a new lesion diagnosis, we excluded patients who, in the year preceding their index encounter, had a diagnosis of a dermatological condition or a dermatologist visit. We also excluded patients who were diagnosed by the PCP or dermatologist with a second, non-rash dermatological condition on the same day as the index rash diagnosis.

Data Collection

Data were obtained from the electronic medical record. Diagnosis was treated as the exposure variable. The PCP’s process of care was defined as managing the patient alone or using 1 of 3 modalities (roving dermatology, teledermatology, e-consult) to escalate the patient to dermatology (ie, obtain advice or refer the patient for a visit). Escalation using roving dermatology, teledermatology, or e-consult was treated as a process variable. The outcome variable was defined as the occurrence (yes/no) of a follow-up dermatology office visit within 90 days of the primary care visit, excluding phototherapy visits. Ninety days was chosen to give patients enough time to try an initial treatment and schedule a follow-up appointment, if necessary, but to minimize the potential for other skin conditions to develop, which might lead to new visits in dermatology.

The diagnosis was categorized into 8 groups: acne and other follicular disorders (ICD-10 diagnostic code: L70-L73), bullous and other systemic disorders (L10-L14, L92-L95), alopecia and other hair disorders (L63-L68), viral infections of the skin (B00-B09, B35-B36, L00-L05, L08), inflammatory dermatoses (L20-L28, L30, L41-L44, L49-L53, R21), disorders of pigmentation (L80-L81), psoriasis (L40), and other conditions including pruritis, radiation-related conditions, and sweat disorders (L29, L55-L56, L58-L59, L74-L75, L83, L85-L91). Patients with multiple diagnoses were defined as such.

Patient-level covariables included age, sex, and race/ethnicity, using patient self-report when available. Past dermatological diagnoses were obtained for the 10 years preceding the initial visit date (recognizing that those with a diagnosis in the past year were excluded) and included diagnoses listed earlier as well as skin cancer (ICD-10 diagnostic code: C43-C44, C4A, D04, D22-D23, D48-D49), actinic keratoses (L57), and seborrheic keratoses (L82). History of a dermatological diagnosis was categorized as chronic (acne, inflammatory, psoriasis, skin cancer, actinic keratosis), acute (bullous, hair, infectious, pigmentation, other conditions, or seborrheic keratosis), or none, in that order.

Statistical Analysis

Preliminary data analysis was performed using frequencies and cross-tabulations. We estimated the adjusted odds ratio (OR) and 95% confidence interval (CI) for the association of current diagnosis with the two outcome variables, escalation and follow-up, using nested generalized linear mixed models with random intercepts for medical center and physician to account for the correlation induced among patients with the same PCP or the same medical center. These models adjusted for age, sex, race/ethnicity, and history of a dermatological diagnosis in the preceding 10 years, as well as the PCP who made the initial diagnosis and the medical center at which the initial diagnosis was made. Intraclass correlations (ICCs) for medical center and PCP were computed using the latent variable method assuming a standard logistic distribution with a mean of 0 and variance .8 Using this method, medical center ICC is the correlation between 2 patients at the same medical center with different PCPs and provider ICC is the correlation between 2 patients at the same medical center and with the same PCP, after accounting for patient-level covariates in the model. Higher ICC indicates more correlation between patients with the same PCP or at the same medical center, ie, that their care was influenced by the particular provider or medical center practices rather than by other covariates in the model.

The project was approved by the local Institutional Review Board (CN-17-2954).

RESULTS

We identified 247,546 patients aged £ 89 years with a diagnosis for a non-lesion condition during an in-office (90%) or telephone encounter (10%) with a dermatologist or PCP between January 2017 and March 2017. We excluded 27,769 (11%) who started their care in dermatology, 103,959 (47%) with a diagnosis or dermatology encounter in the preceding year, 7,378 (6%) who had a lesion or other dermatological diagnosis on the same day, and 1,981 (2%) who did not have health plan membership on the day of their diagnosis, leaving 106,459 eligible for study. Because of the large number of exclusions of patients with a diagnosis or dermatology encounter in the preceding year, we compared patients who were included and excluded from the study. Patients excluded from the study were similar to those who were included except that they were more likely to be ³ 50 years of age (45% vs 28%), white (60% vs 53%), and have a psoriasis diagnosis (9% vs 2%) (all p < 0.0001 in this large study).

Use of modalities to escalate patients varied by medical center (shown in Figure 2), with only 9 medical centers offering roving dermatology (of which centers C and D use PCPs with additional dermatology training in this work-flow). PCPs escalated 9,167 (9%) of patients to dermatology. At the medical centers offering roving dermatology, 3,394 were escalated via roving, representing 3% of patients overall but 6% of patients seen at a roving medical center. In addition, 3,315 (3%) were escalated via teledermatology and 2,458 (2%) via e-consult. Teledermatology and e-consult patients were more likely to be children (Table 1). Roving dermatology and teledermatology patients were more likely to be diagnosed with an inflammatory condition, whereas e-consult patients were more likely to be diagnosed with acne, a hair condition, or psoriasis.

tpj20320f2

Figure 2. Utilization of escalation modalities for 106,459 patients with rash and other non-lesion conditions who presented to a primary care provider within Kaiser Permanente Northern California by medical center, January 2017 to March 2017. PCPs = primary care providers.

Table 1. Risk factors for escalation within 90 days of primary care visit using roving dermatology, teledermatology, or e-consult, of 106,459 Kaiser Permanente Northern California members, aged 0-89 years, presenting to primary care with rash, January 2017 to March 2017

      Modela and escalation modality
      Model 1 Model 2 Model 3
 

Patients without escalation

(N = 97,292)

 

Patients with

escalation (N = 9,167)

 

 

Roving (N = 3,394)

 

 

Teledermatology (N = 3,315)

 

 

E-consult (N = 2,458)

  % % OR 95% CI OR 95% CI OR 95% CI
Age, years                
0-17 29 14 0.2 0.2-0.3 0.4 0.4-0.5 0.6 0.5-0.7
18-29 16 21 1.0 Ref. 1.0 Ref. 1.0 Ref.
30-49 27 36 1.0 0.9-1.2 1.0 0.9-1.1 1.0 0.9-1.1
50-69 22 24 0.9 0.8-1.0 0.9 0.8-1.0 0.8 0.7-0.9
70-89 6 5 0.8 0.7-1.0 0.6 0.5-0.7 0.5 0.4-0.6
Sex                
Female 56 57 1.0 Ref. 1.0 Ref. 1.0 Ref.
Male 44 43 1.0 1.0-1.1 1.0 0.9-1.1 1.1 1.0-1.2
Race/ethnicity                
Asian American 21 23 0.9 0.8-1.0 0.8 0.7-0.9 0.9 0.8-1.0
African American 7 7 1.0 0.8-1.1 0.9 0.8-1.1 1.2 1.0-1.4
Hispanic 24 22 0.8 0.7-0.9 0.8 0.7-0.9 1.0 0.9-1.1
White 40 40 1.0 Ref. 1.0 Ref. 1.0 Ref.
Other/missing 9 8 0.9 0.8-1.1 0.8 0.7-1.0 1.0 0.9-1.2
History of dermatological diagnosisb                
Any chronic 10 13 1.1 1.0-1.2 1.0 0.9-1.2 1.2 1.1-1.4
Acute 3 4 1.1 0.9-1.4 1.1 0.9-1.4 0.9 0.7-1.2
No history 86 83 1.0 Ref. 1.0 Ref. 1.0 Ref.
Present diagnosis                
Acne 16 15 0.7 0.7-0.8 0.4 0.3-0.4 1.6 1.4-1.8
Bullous < 1 < 1 1.7 1.0-3.0 1.2 0.7-2.2 5.5 3.4-8.8
Hair 2 5 0.7 0.6-0.9 0.6 0.5-0.8 5.5 4.7-6.5
Infectious 26 7 0.3 0.2-0.3 0.1 0.1-0.1 0.3 0.3-0.4
Inflammatory 39 48 1.0 Ref. 1.0 Ref. 1.0 Ref.
Pigment 1 4 2.4 1.9-3.0 2.1 1.7-2.6 4.5 3.5-5.7
Psoriasis 2 4 1.1 0.9-1.3 0.5 0.4-0.7 5.1 4.3-6.0
Multiple 8 6 1.7 1.5-1.9 1.1 1.0-1.3 2.4 2.0-2.8
Other 5 11 0.5 0.4-0.6 0.2 0.2-0.3 1.8 1.6-2.1
Roving is available at medical center                
Yes 52 57 0.2 0.1-0.3 0.6 0.3-1.1
No 48 43 1.0 Ref. 1.0 Ref.

a Each of the 3 models also accounted for clustering by medical center and primary care provider. Only patients seen at medical centers that offer roving dermatology (N = 55,606) were included in the model of roving.

b History of dermatological diagnosis was categorized as chronic (acne, inflammatory, psoriasis, skin cancer, actinic keratosis); acute (bullous, hair, infectious, pigmentation, other conditions, or seborrheic keratosis); or none, in that order.

— = not estimated; CI = confidence interval; OR = odds ratio; Ref. = reference.

The 3 models analyzing escalation (vs no escalation) are shown in Table 2. Models for teledermatology and e-consult accounted for the presence of roving dermatology at the medical center. Medical centers that offered roving dermatology had one-fifth the use of teledermatology (OR 0.2; 95% CI 0.1-0.3). Patients escalated using roving dermatology or teledermatology were similar to each other with respect to demographic characteristics, history of dermato- logic diagnosis, and present diagnosis. Medical centers that offered roving dermatology had 40% lower use of e-consult (OR, 0.6; 95% CI 0.3-1.1), although this result may have been due to chance. Patients escalated using e-consult had different diagnoses than those escalated using roving derma- tology or teledermatology. Compared to patients with an inflammatory condition, those with an infectious condition were less likely to be escalated using any modality (ORs: roving, 0.3; teledermatology, 0.1; e-consult, 0.3). Those with a pigment or bullous disorder, or with multiple disorders, were more likely to be escalated using roving dermatology or teledermatology. In contrast, those with any diagnosis other than an infectious or inflammatory condition were more likely to be escalated using e-consult. Children and adults aged ³ 70 years were more likely than younger adults to be escalated using any modality. Patients with acne, of whom 9% were escalated, were most likely to be escalated using e-consult.

Table 2. Adjusteda odds ratio and 95% confidence interval of a follow-up dermatology office visit within 90 days of primary care visit, January 2017 to March 2017

  Follow-up dermatology office visit
Percent with outcome (N = 106,459) Adjusted OR
OR 95% CI
Age, years      
0-17 3 0.6 0.6-0.7
18-29 6 1.0 Ref
30-49 6 1.0 1.0-1.1
50-69 6 1.1 1.0-1.2
70-89 6 1.0 0.9-1.1
Sex      
Female 6 1.0 Ref
Male 5 1.0 1.0-1.1
Race/ethnicity      
Asian American 5 0.8 0.7-0.9
African American 5 1.0 0.9-1.1
Hispanic 5 0.8 0.7-0.9
White 6 1.0 Ref
Other/missing 5 0.9 0.8-1.0
History of dermatological diagnosisb      
Any chronic 8 1.5 1.4-1.6
Acute 7 1.2 1.1-1.4
No history 5 1.0 Ref
Present diagnosis      
Acne 5 0.9 0.8-1.0
Bullous 11 1.9 1.3-2.7
Hair 16 3.0 2.6-3.3
Infectious 2 0.4 0.3-0.4
Inflammatory 6 1.0 Ref
Pigment 11 2.1 1.8-2.6
Psoriasis 13 2.2 1.9-2.4
Multiple 9 1.5 1.4-1.7
Other 6 1.0 0.9-1.1

a The model also accounted for clustering by medical center and primary care provider.

b History of dermatological diagnosis was categorized as chronic (acne, inflammatory, psoriasis, skin cancer, actinic keratosis); acute (bullous, hair, infectious, pigmentation, other conditions, or seborrheic keratosis); or none, in that order.

CI = confidence interval; OR = odds ratio; Ref. = reference.

Escalation of patients clustered minimally by medical center (ICC 0.04) but somewhat more by PCP (ICC 0.16). A follow-up dermatology office visit was used by 5% of all patients (N = 5,694) of which 3% were not initially escalated by their PCP, ie, were escalated later by their PCP or sought out a dermatology visit on their own. A follow-up dermatology office visit was used by 13% (N = 444) for those who were escalated via roving dermatology, 24% (N = 787) for teledermatology, and 73% (N = 1,794) for e-consult. Adults were more likely than children to need a follow-up dermatology office visit within 90 days, as were those with a history of a chronic dermatological diagnosis and those presently diagnosed with a bullous, hair, or pigment condition; psoriasis; or multiple diagnoses (Table 2). A present infectious diagnosis was associated with lower odds of needing a visit. Receiving a follow-up dermatology office visit clustered minimally by medical center (ICC 0.04) and PCP (ICC 0.09).

DISCUSSION

We conducted a retrospective cohort study of 106,459 primary care patients to gain insight into the utilization of dermatologists in the management of rash and other non-lesion skin conditions. In our capitated system, 89% of patients began in primary care, of whom 91% were managed by PCP without consultation from dermatology. Children were less likely than adults to be escalated. In contrast, those with a chronic dermatological diagnosis or being presently diagnosed with a bullous, hair, or pigment condition, psoriasis, or multiple diagnoses were more likely to be escalated. At medical centers that offered a roving dermatologist, it appeared that PCPs preferentially escalated via roving dermatology over teledermatology, and the frequency of escalation was increased. Roving dermatology may be preferred by the patient and PCP because it is immediate and offers direct dermatology care. However, a robust roving dermatology system is costly, particularly at smaller centers, as it requires the dermatologist to maintain their full practice within the primary care buildings, which may not escalate enough patients to justify having a full-time roving dermatologist. Additionally, while the roving dermatologist is being called in to assist on primary care cases, they are unable to perform higher-level care such as necessary biopsies. In contrast, teledermatology offers greater cost efficiency, as it enables the dermatologist to see more cases per day.

Strengths of this study included the large, diverse, well- characterized, community-based population with excellent follow-up and comprehensive medical information. A key limitation was lack of information on severity including the extent of distribution and degree of symptoms, because this information was not recorded in a structured manner in clinic notes. If escalation was related strictly to challenges in diagnosis and treatment, one would expect patients in the same medical center and with the same PCP to be minimally correlated. In contrast, if escalation were related to the preference of the PCP, one would expect patients with the same PCP to be highly correlated. Indeed, in our setting, clustering of escalation (medical center ICC, 0.04; provider ICC, 0.16) and follow-up dermatology visits (0.04 and 0.09, respectively) were low. Because escalation and follow-up dermatology visits were associated with patient characteristics and present diagnoses, but were minimally correlated by PCP or medical center, the decision to escalate or follow-up is likely due to disease severity or complexity and not individual provider preferences—suggesting standardized care. A second limitation is that we did not account for referrals in which the patient failed to show. A third limitation relates to generalizability. Kaiser Permanente’s level of integration and coordination is greater than at many other settings, although the Veterans Administration and systems outside the United States also offer integrated care. We were also unable to separate e-consult requests that were only to “ask the specialist” rather than to initiate a referral to dermatology; although, in our setting, this is less common due to the prevalence of teledermatology modalities that allow for photographs to be forwarded to dermatology.

This study observed that the pattern of care was quite different for e-consult patients than for roving dermatology and teledermatology patients. E-consult was used for only 2.3% of patients, with diagnoses of bullous, hair, and pigment conditions, as well as psoriasis and acne being strongly related to escalation, and with 73% of patients needing a follow-up visit to the dermatology office. Similar to other settings,9–12 patients escalated using e-consult may have had cosmetic concerns and a greater desire to see a dermatologist in person. The diagnoses related to e-consult tend to require additional visit time for counseling. Alopecia areata is treated with in-office injections, thus requiring an in-office visit. Although, in our setting, we expect PCPs to treat mild plaque psoriasis with topical therapies, psoriasis often requires life-long treatment, and as topical therapy is exhausted, patients may require dermatologist-prescribed treatments for systemic medications and phototherapy, although we did not count phototherapy visits unless they included time with a dermatologist. Acne is also a chronic disease that may be severe and disfiguring, with past studies reporting success with protocolized treatment.12 Initial acne treatment options are available for PCPs to prescribe and monitor; however, dermatology is often needed for more severe cases.

Past studies of the effectiveness of co-management of dermatologic conditions using various workflows and technologies often combine lesions, rashes, and other skin conditions, obscuring differences across conditions that are important to driving the effectiveness of care.13–16 Other studies have focused strictly on severe conditions such as psoriasis.17 We are aware of a UK study of eczema, in which utilization of dermatologists represented 4% of the utilization of PCPs for this common condition, but not other more common and less severe conditions.18

Skin rashes and other non-lesion conditions are highly prevalent, and rapid, effective, and affordable pathways are needed for their management.19,20 Many of these conditions can be effectively diagnosed and treated in the primary care setting because they resolve on their own or are easily treated using anti-inflammatory and anti-infective medications that have a low risk of adverse side effects.12 Although PCPs manage most patients with rash and other non-lesion conditions in our setting, face-to-face visits with a dermatologist are important for making uncommon diagnoses, providing patient education, managing more challenging cases, and managing treatments that are not commonly used in primary care. Although dermatologists are in short supply, this study supports standardized management by PCPs in our integrated setting based on the patient’s complexity and not the PCPs practice preferences. Improving primary care education in skin disease may further improve care and reduce pressure on the dermatologist workforce. In addition, for certain skin conditions, such as acne, hair and pigmentation disorders, and psoriasis, use of protocols and other standardized approaches to workup, treatment, and escalation may further streamline and improve care. Various care pathways can be used to enable effective use of PCPs and dermatologists in managing skin disease, and further research will improve the matching of patients’ needs with clinical workflows.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Funding Statement

This research was funded solely by The Permanente Medical Group, Rapid Analytics Unit.

Author Affiliations

1Dermatology, Kaiser Permanente, Sacramento, CA

2Division of Research, Kaiser Permanente, Oakland, CA

3Dermatology, Kaiser Permanente, Vallejo, CA

4Dermatology, Kaiser Permanente, Santa Rosa, CA

5Dermatology, Kaiser Permanente, Santa Clara, CA

6Dermatology, Kaiser Permanente, Walnut Creek, CA

7The Permanente Medical Group, Quality and Operations Support, Kaiser Permanente, Oakland, CA

Corresponding Author

Lisa J Herrinton, PhD (Lisa.Herrinton@kp.org)

Author Contributions

Sangeeta Marwaha, MD, contributed to the study conception and design, interpretation of the data, and drafting the manuscript and critical revision; Jennifer R Dusendang, MPH, contributed to data acquisition, data analysis, and drafting of the manuscript; Stacey E Alexeeff, PhD, contributed to data analysis, data interpretation, and critical revision; Eileen Crowley, MD, contributed to data interpretation and critical revision; Michael Haiman, MD, contributed to data interpretation and critical revision; Ngoc Pham, MD, contributed to data interpretation and critical revision; Melanie J Tuerk, MD, contributed to data interpretation and critical revision; Danny Wudka contributed to data acquisition and critical revision; Michael Hartmann contributed to data acquisition and critical revision; Lisa Herrinton, PhD, contributed to study conception, study design, data analysis, drafting of the manuscript, and critical revision. All authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

Statement of Ethics

This project was approved by the Kaiser Permanente Northern California Institutional Review Board.

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19. Zakaria A, Miclau TA, Maurer T, Leslie KS, Amerson E. Cost minimization analysis of a teledermatology triage system in a managed care setting. JAMA Dermatol 2021 Jan; 157(1):52–8. DOI: https://doi.org/10.1001/jamadermatol.2020.4066

20. Zakaria A, Maurer T, Su G, Amerson E. Impact of teledermatology on the accessibility and efficiency of dermatology care in an urban safety-net hospital: A pre-post analysis. J Am Acad Dermatol 2019 Dec;81(6):1446–52. DOI: https://doi.org/10.1016/j.jaad.2019.08.016

Keywords: systems analysis; telemedicine; primary care providers, dermatologists; epidemiology; dermatology organization and administration

AbbreviationsCI = confidence interval; ICC = intraclass correlation; OR = odds ratio; PCP = primary care provider

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