1
|
Maier M, Powell D, Harrison C, Gordon J, Murchie P, Allan JL. Assessing Decision Fatigue in General Practitioners' Prescribing Decisions Using the Australian BEACH Data Set. Med Decis Making 2024; 44:627-640. [PMID: 39056336 DOI: 10.1177/0272989x241263823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
BACKGROUND General practitioners (GPs) make numerous care decisions throughout their workdays. Extended periods of decision making can result in decision fatigue, a gradual shift toward decisions that are less cognitively effortful. This study examines whether observed patterns in GPs' prescribing decisions are consistent with the decision fatigue phenomenon. We hypothesized that the likelihood of prescribing frequently overprescribed medications (antibiotics, benzodiazepines, opioids; less effortful to prescribe) will increase and the likelihood of prescribing frequently underprescribed medications (statins, osteoporosis medications; more effortful to prescribe) will decrease over the workday. METHODS This study used nationally representative primary care data on GP-patient encounters from the Bettering the Evaluation and Care of Health program from Australia. The association between prescribing decisions and order of patient encounters over a GP's workday was assessed with generalized linear mixed models accounting for clustering and adjusting for patient, provider, and encounter characteristics. RESULTS Among 262,456 encounters recorded by 2,909 GPs, the odds of prescribing antibiotics significantly increased by 8.7% with 15 additional patient encounters (odds ratio [OR] = 1.087; confidence interval [CI] = 1.059-1.116). The odds of prescribing decreased significantly with 15 additional patient encounters by 6.3% for benzodiazepines (OR = 0.937; CI = 0.893-0.983), 21.9% for statins (OR = 0.791; CI = 0.753-0.831), and 25.0% for osteoporosis medications (OR = 0.750; CI = 0.690-0.814). No significant effects were observed for opioids. All findings were replicated in confirmatory analyses except the effect of benzodiazepines. CONCLUSIONS GPs were increasingly likely to prescribe antibiotics and were less likely to prescribe statins and osteoporosis medications as the workday wore on, which was consistent with decision fatigue. There was no convincing evidence of decision fatigue effects in the prescribing of opioids or benzodiazepines. These findings establish decision fatigue as a promising target for optimizing prescribing behavior. HIGHLIGHTS We found that as general practitioners progress through their workday, they become more likely to prescribe antibiotics that are reportedly overprescribed and less likely to prescribe statins and osteoporosis medications that are reportedly underprescribed.This change in decision making over time is consistent with the decision fatigue phenomenon. Decision fatigue occurs when we make many decisions without taking a rest break. As we make those decisions, we become gradually more likely to make decisions that are less difficult.The findings of this study show that decision fatigue is a possible target for improving guideline-compliant prescribing of pharmacologic medications.
Collapse
Affiliation(s)
- Mona Maier
- Health Psychology, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Daniel Powell
- Health Psychology, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Julie Gordon
- School of Health Sciences, University of Sydney, Sydney, Australia
| | - Peter Murchie
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Julia L Allan
- Division of Psychology, University of Stirling, Stirling, UK
| |
Collapse
|
2
|
Matulis JC, Swanson K, McCoy R. The association between primary care appointment lengths and opioid prescribing for common pain conditions. BMC Health Serv Res 2024; 24:776. [PMID: 38956585 PMCID: PMC11220962 DOI: 10.1186/s12913-024-11215-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 06/18/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND While brief duration primary care appointments may improve access, they also limit the time clinicians spend evaluating painful conditions. This study aimed to evaluate whether 15-minute primary care appointments resulted in higher rates of opioid prescribing when compared to ≥ 30-minute appointments. METHODS We performed a retrospective cohort study using electronic health record (EHR), pharmacy, and administrative scheduling data from five primary care practices in Minnesota. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 scheduled for 15-minute appointments were propensity score matched to those scheduled for ≥ 30-minutes. Sub-groups were analyzed to include patients with acute and chronic pain conditions and prior opioid exposure. Multivariate logistic regression was performed to examine the effects of appointment length on the likelihood of an opioid being prescribed, adjusting for covariates including ethnicity, race, sex, marital status, and prior ED visits and hospitalizations for all conditions. RESULTS We identified 45,471 eligible acute primary care visits during the study period with 2.7% (N = 1233) of the visits scheduled for 15 min and 98.2% (N = 44,238) scheduled for 30 min or longer. Rates of opioid prescribing were significantly lower for opioid naive patients with acute pain scheduled in 15-minute appointments when compared to appointments of 30 min of longer (OR 0.55, 95% CI 0.35-0.84). There were no significant differences in opioid prescribing among other sub-groups. CONCLUSIONS For selected indications and for selected patients, shorter duration appointments may not result in greater rates of opioid prescribing for common painful conditions.
Collapse
Affiliation(s)
- John C Matulis
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Kristi Swanson
- Kern Center for the Science of Health Care Delivery, Mayo Clinic Robert D. and Patricia E, Rochester, MN, USA
| | - Rozalina McCoy
- Division of Endocrinology, Diabetes, & Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland Institute for Health Computing, Bethesda, MD, USA
- Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD, USA
| |
Collapse
|
3
|
Mukhopadhyay A, Reynolds HR, King WC, Phillips LM, Nagler AR, Szerencsy A, Saxena A, Klapheke N, Katz SD, Horwitz LI, Blecker S. Impact of Visit Volume on the Effectiveness of Electronic Tools to Improve Heart Failure Care. JACC. HEART FAILURE 2024; 12:665-674. [PMID: 38043045 DOI: 10.1016/j.jchf.2023.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Electronic health record (EHR) tools can improve prescribing of guideline-recommended therapies for heart failure with reduced ejection fraction (HFrEF), but their effectiveness may vary by physician workload. OBJECTIVES This paper aims to assess whether physician workload modifies the effectiveness of EHR tools for HFrEF. METHODS This was a prespecified subgroup analysis of the BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations for Heart Failure) cluster-randomized trial, which compared effectiveness of an alert vs message vs usual care on prescribing of mineralocorticoid antagonists (MRAs). The trial included adults with HFrEF seen in cardiology offices who were eligible for and not prescribed MRAs. Visit volume was defined at the cardiologist-level as number of visits per 6-month study period (high = upper tertile vs non-high = remaining). Analysis at the patient-level used likelihood ratio test for interaction with log-binomial models. RESULTS Among 2,211 patients seen by 174 cardiologists, 932 (42.2%) were seen by high-volume cardiologists (median: 1,853; Q1-Q3: 1,637-2,225 visits/6 mo; and median: 10; Q1-Q3: 9-12 visits/half-day). MRA was prescribed to 5.5% in the high-volume vs 14.8% in the non-high-volume groups in the usual care arm, 10.3% vs 19.6% in the message arm, and 31.2% vs 28.2% in the alert arm, respectively. Visit volume modified treatment effect (P for interaction = 0.02) such that the alert was more effective in the high-volume group (relative risk: 5.16; 95% CI: 2.57-10.4) than the non-high-volume group (relative risk: 1.93; 95% CI: 1.29-2.90). CONCLUSIONS An EHR-embedded alert increased prescribing by >5-fold among patients seen by high-volume cardiologists. Our findings support use of EHR alerts, especially in busy practice settings. (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations for Heart Failure [BETTER CARE-HF]; NCT05275920).
Collapse
Affiliation(s)
- Amrita Mukhopadhyay
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA.
| | - Harmony R Reynolds
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - William C King
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Lawrence M Phillips
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Arielle R Nagler
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA
| | - Adam Szerencsy
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA; Division of Hospital Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Archana Saxena
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA; Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Nathan Klapheke
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Leora I Horwitz
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Division of Hospital Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Saul Blecker
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| |
Collapse
|
4
|
Kim HM, Strominger J, Zivin K, Van T, Maust DT. Relationship between facility number of clinicians and prescribing intensity of psychotropic medications, opioids, and antibiotics in ambulatory practice. BMC Health Serv Res 2024; 24:217. [PMID: 38365679 PMCID: PMC10874022 DOI: 10.1186/s12913-024-10613-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 01/17/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Promoting appropriate pharmacotherapy requires understanding the factors that influence how clinicians prescribe medications. While prior work has focused on patient and clinician factors, features of the organizational setting have received less attention, though identifying sources of variation in prescribing may help identify opportunities to improve patient safety and outcomes. OBJECTIVE To evaluate the relationship between the number of clinicians who prescribe medications in a facility and facility prescribing intensity of six individual medication classes by clinician specialty: benzodiazepines, antipsychotics, antiepileptics, and antidepressants by psychiatrists and antibiotics, opioids, antiepileptics, and antidepressants by primary care clinicians (PCPs). DESIGN We used 2017 Veterans Health Administration (VHA) administrative data. SUBJECTS We included patient-clinician dyads of older patients (> 55 years) with an outpatient encounter with a clinician in 2017. Patient-clinician data from 140 VHA facilities were included (n = 13,347,658). Analysis was repeated for years 2014 to 2016. MAIN MEASURES For each medication, facility prescribing intensity measures were calculated as clinician prescribing intensity averaged over all clinicians at each facility. Clinician prescribing intensity measures included percentage of each clinician's patients prescribed the medication and mean number of days supply per patient among all patients of each clinician. KEY RESULTS As the number of prescribing clinicians in a facility increased, the intensity of prescribing decreased. Every increase of 10 facility clinicians was associated with a significant decline in prescribing intensity for both specialties for different medication classes: for psychiatrists, declines ranged from 6 to 11%, and for PCPs, from 2 to 3%. The pattern of more clinicians less prescribing was significant across all years. CONCLUSION Future work should explore the mechanisms that link the number of facility clinicians with prescribing intensity for benzodiazepines, antipsychotics, antiepileptics, antidepressants, antibiotics, and opioids. Facilities with fewer clinicians may need additional resources to avoid unwanted prescribing of potentially harmful or unnecessary medications.
Collapse
Affiliation(s)
- Hyungjin Myra Kim
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, 915 E. Washington Street, Ann Arbor, Michigan, 48109-1070, USA.
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, 48105, USA.
| | - Julie Strominger
- Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, 40109, USA
| | - Kara Zivin
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, 48105, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, 40109, USA
| | - Tony Van
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, 48105, USA
| | - Donovan T Maust
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, 48105, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, 40109, USA
| |
Collapse
|
5
|
Pritchard KT, Baillargeon J, Lee WC, Doulatram G, Raji MA, Kuo YF. Inequitable access to nonpharmacologic pain treatment providers among cancer-free U.S. adults. Prev Med 2024; 178:107809. [PMID: 38072313 PMCID: PMC10872296 DOI: 10.1016/j.ypmed.2023.107809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 11/01/2023] [Accepted: 12/05/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE Using evidence-based nonpharmacologic pain treatments may prevent opioid overuse and associated adverse outcomes. There is limited data on the impact of access-promoting social determinants of health (SDoH: education, income, transportation) on use of nonpharmacologic pain treatments. Our objective was to examine the relationship between SDoH and use of nonpharmacologic pain treatment providers. Our goal was to understand policy-actionable factors contributing to inequity in pain treatment. METHODS Based on Andersen's Health Utilization Model, this cross-sectional analysis of 2016-2019 Medical Expenditure Panel Survey data evaluated whether use of outpatient nonpharmacologic pain treatment providers is driven by enabling (i.e., advantageous socioeconomic resources) or need (i.e., perceived disability and diagnosed disease) factors. The study sample (unweighted n = 28,188) represented a weighted N = 81,912,730 noninstitutionalized, cancer-free, U.S. adults with pain interference. The primary outcome measured use of nonpharmacologic providers relative to exclusive prescription opioid use or no treatment (i.e., neither opioids nor nonpharmacologic). To quantify equitable access, we compared the variance-between access-promoting enabling factors versus medical need factors-that explained utilization. RESULTS Compared to enabling factors, need factors explained twice the variance predicting pain treatment utilization. Still, the adjusted odds of using nonpharmacologic providers instead of opioids alone were 39% lower among respondents identifying as Black (95% Confidence Interval [CI], 0.49-0.76) and respondents residing in the U.S. South (95% CI, 0.51-0.74). Higher education (95% CI, 1.72-2.79) and income (95% CI, 1.68-2.42) both facilitated using nonpharmacologic providers instead of opioids. CONCLUSIONS These findings highlight the substantial influence access-promoting SDoH have on pain treatment utilization.
Collapse
Affiliation(s)
- Kevin T Pritchard
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Jacques Baillargeon
- Department of Epidemiology, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX, USA.
| | - Wei-Chen Lee
- Department of Family Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | - Gulshan Doulatram
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA.
| | - Mukaila A Raji
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | - Yong-Fang Kuo
- Department of Biostatistics and Data Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX, USA.
| |
Collapse
|
6
|
Vicente L, Matute H. Humans inherit artificial intelligence biases. Sci Rep 2023; 13:15737. [PMID: 37789032 PMCID: PMC10547752 DOI: 10.1038/s41598-023-42384-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/09/2023] [Indexed: 10/05/2023] Open
Abstract
Artificial intelligence recommendations are sometimes erroneous and biased. In our research, we hypothesized that people who perform a (simulated) medical diagnostic task assisted by a biased AI system will reproduce the model's bias in their own decisions, even when they move to a context without AI support. In three experiments, participants completed a medical-themed classification task with or without the help of a biased AI system. The biased recommendations by the AI influenced participants' decisions. Moreover, when those participants, assisted by the AI, moved on to perform the task without assistance, they made the same errors as the AI had made during the previous phase. Thus, participants' responses mimicked AI bias even when the AI was no longer making suggestions. These results provide evidence of human inheritance of AI bias.
Collapse
Affiliation(s)
- Lucía Vicente
- Department of Psychology, Deusto University, Avenida Universidades 24, 48007, Bilbao, Spain
| | - Helena Matute
- Department of Psychology, Deusto University, Avenida Universidades 24, 48007, Bilbao, Spain.
| |
Collapse
|
7
|
Foussell I, Negley M, Thompson A, Turner A, Wygal A, Devries A, Hilton C, Pritchard KT. Characteristics of Early Interventions for Pain and Function Following Lower Extremity Joint Replacement: Systematic Review. Occup Ther Health Care 2023; 37:627-647. [PMID: 35654087 PMCID: PMC9715835 DOI: 10.1080/07380577.2022.2066239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
Occupational therapy is beneficial among adults with chronic pain; however, occupational therapy interventions addressing earlier phases of pain have not been clearly explicated. This systematic review characterized acute and subacute interventions billable by occupational therapy after hip or knee replacement to improve pain and function. Seven articles met inclusion criteria. Six articles had a low risk of bias. Three intervention types were found: task-oriented exercise, water-based, and modalities. Only task-oriented interventions improved both pain and function one-year after surgery. There are long-term benefits to early task-oriented exercise. Further research is needed to contextualize occupational therapy's role in early pain interventions.
Collapse
Affiliation(s)
- Isabella Foussell
- Department of Occupational Therapy, School of Health
Professions, University of Texas Medical Branch, Galveston, TX, USA
| | - Marisa Negley
- Department of Occupational Therapy, School of Health
Professions, University of Texas Medical Branch, Galveston, TX, USA
| | - Abigail Thompson
- Department of Occupational Therapy, School of Health
Professions, University of Texas Medical Branch, Galveston, TX, USA
| | - Andrea Turner
- Department of Occupational Therapy, School of Health
Professions, University of Texas Medical Branch, Galveston, TX, USA
| | - Amanda Wygal
- Department of Occupational Therapy, School of Health
Professions, University of Texas Medical Branch, Galveston, TX, USA
| | - Alison Devries
- Moody Medical Library, University of Texas Medical Branch,
Galveston, TX, USA
| | - Claudia Hilton
- Department of Occupational Therapy, School of Health
Professions, University of Texas Medical Branch, Galveston, TX, USA
| | - Kevin T. Pritchard
- Department of Nutrition, Metabolism, and Rehabilitation
Sciences, School of Health Professions, University of Texas Medical Branch,
Galveston, TX, USA
| |
Collapse
|
8
|
Ginestra JC, Kohn R, Hubbard RA, Auriemma CL, Patel MS, Anesi GL, Kerlin MP, Weissman GE. Association of Time of Day with Delays in Antimicrobial Initiation among Ward Patients with Hospital-Onset Sepsis. Ann Am Thorac Soc 2023; 20:1299-1308. [PMID: 37166187 PMCID: PMC10502885 DOI: 10.1513/annalsats.202302-160oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/09/2023] [Indexed: 05/12/2023] Open
Abstract
Rationale: Although the mainstay of sepsis treatment is timely initiation of broad-spectrum antimicrobials, treatment delays are common, especially among patients who develop hospital-onset sepsis. The time of day has been associated with suboptimal clinical care in several contexts, but its association with treatment initiation among patients with hospital-onset sepsis is unknown. Objectives: Assess the association of time of day with antimicrobial initiation among ward patients with hospital-onset sepsis. Methods: This retrospective cohort study included ward patients who developed hospital-onset sepsis while admitted to five acute care hospitals in a single health system from July 2017 through December 2019. Hospital-onset sepsis was defined by the Centers for Disease Control and Prevention Adult Sepsis Event criteria. We estimated the association between the hour of day and antimicrobial initiation among patients with hospital-onset sepsis using a discrete-time time-to-event model, accounting for time elapsed from sepsis onset. In a secondary analysis, we fit a quantile regression model to estimate the association between the hour of day of sepsis onset and time to antimicrobial initiation. Results: Among 1,672 patients with hospital-onset sepsis, the probability of antimicrobial initiation at any given hour varied nearly fivefold throughout the day, ranging from 3.0% (95% confidence interval [CI], 1.8-4.1%) at 7 a.m. to 13.9% (95% CI, 11.3-16.5%) at 6 p.m., with nadirs at 7 a.m. and 7 p.m. and progressive decline throughout the night shift (13.4% [95% CI, 10.7-16.0%] at 9 p.m. to 3.2% [95% CI, 2.0-4.0] at 6 a.m.). The standardized predicted median time to antimicrobial initiation was 3.2 hours (interquartile range [IQR], 2.5-3.8 h) for sepsis onset during the day shift (7 a.m.-7 p.m.) and 12.9 hours (IQR, 10.9-14.9 h) during the night shift (7 p.m.-7 a.m.). Conclusions: The probability of antimicrobial initiation among patients with new hospital-onset sepsis declined at shift changes and overnight. Time to antimicrobial initiation for patients with sepsis onset overnight was four times longer than for patients with onset during the day. These findings indicate that time of day is associated with important care processes for ward patients with hospital-onset sepsis. Future work should validate these findings in other settings and elucidate underlying mechanisms to inform quality-enhancing interventions.
Collapse
Affiliation(s)
- Jennifer C. Ginestra
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | - Rachel Kohn
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Catherine L. Auriemma
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | | | - George L. Anesi
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | - Meeta Prasad Kerlin
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | - Gary E. Weissman
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| |
Collapse
|
9
|
Huang Y, Aparasu RR, Varisco TJ. Outpatient opioid prescribing by Alzheimer's diagnosis among older adults with pain in United States. BMC Geriatr 2023; 23:465. [PMID: 37528367 PMCID: PMC10394812 DOI: 10.1186/s12877-023-04115-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/16/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVE To examine opioid prescribing practices for pain in older adults with and without Alzheimer's Disease and Related Dementias (ADRD). METHODS This cross-sectional study used National Ambulatory Medical Care Survey data (2014-2016, and 2018). Adults aged ≥ 50 years with pain were analyzed. Prescribing of opioid and concomitant sedative prescriptions (including benzodiazepines, Z-drugs, and barbiturates) were identified by the Multum lexicon code. Multivariable logistic regression evaluated the risk of opioid prescribing or co-prescribing of opioid and sedative associated with ADRD in older adults with pain. RESULTS There were 13,299 office visits in older adults with pain, representing 451.75 million visits. Opioid prescribing occurred in 27.19%; 30% involved co-prescribing of opioids and sedatives. ADRD was not associated with opioid prescribing or co-prescribing of opioid and sedative therapy. CONCLUSIONS Opioid and sedatives are commonly prescribed in older adults with pain. Longitudinal studies need to understand the etiology and chronicity of opioid use in older patients, specifically with ADRD.
Collapse
Affiliation(s)
- Yinan Huang
- Department of Pharmacy Administration, University of Mississippi College of Pharmacy, 235 Faser Hall, Oxford, Mississippi, 38677, USA.
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcome and Policy, University of Houston College of Pharmacy, Houston, USA
| | - Tyler J Varisco
- Department of Pharmaceutical Health Outcome and Policy, University of Houston College of Pharmacy, Houston, USA
- Prescription Drug Misuse Education and Research Center, University of Houston College of Pharmacy, Houston, USA
| |
Collapse
|
10
|
Derricks V, Gainsburg I, Shields C, Fiscella K, Epstein R, Yu V, Griggs JJ. Examining the effects of physician burnout on pain management for patients with advanced lung cancer. Support Care Cancer 2023; 31:469. [PMID: 37458824 DOI: 10.1007/s00520-023-07899-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/21/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE Physician burnout is generally associated with worse clinical outcomes. The purpose of this study is to examine the effects of physician burnout on the quality of physicians' pain assessment and opioid prescribing for patients with advanced lung cancer. Moreover, we test whether these relationships are moderated by patient-level factors, such as patient race and activation level, that have a demonstrated impact on clinical encounters. METHODS We conducted a secondary analysis of data from a multisite randomized field experiment. From 2012 to 2016, 96 primary care physicians and oncologists who treated solid tumors were recruited from hospitals and medical sites in three small metropolitan and rural areas in the USA. Physicians saw two unannounced standardized patients who presented with advanced lung cancer. Standardized patients varied across race (Black or White) and activation level (activated, typical). Visits were audio recorded and transcribed. Pain management was evaluated by the quality of pain assessment and opioid prescribing during these visits. RESULTS Mixed-effects linear regression and generalized mixed-effects modeling showed that higher levels of burnout were associated with a greater likelihood of prescribing an opioid and prescribing stronger opioid doses for patients. These effects were not moderated by patient race or activation level. CONCLUSION Findings from this work inform our understanding of physician-level factors that impact clinical decision-making in the context of cancer pain management. Specifically, this study identifies the role of physician burnout on the quality of prescribing for patients with advanced lung cancer.
Collapse
Affiliation(s)
- Veronica Derricks
- Department of Psychology, Indiana University-Purdue University Indianapolis, 402 N Blackford St., Indianapolis, IN, 46202, USA.
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA.
| | - Izzy Gainsburg
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
- John F. Kennedy School of Government, Harvard University, Cambridge, MA, USA
| | - Cleveland Shields
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
| | - Kevin Fiscella
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Ronald Epstein
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Veronica Yu
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Jennifer J Griggs
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
11
|
Parzuchowski A, Oronce C, Guo R, Tseng CH, Fendrick AM, Mafi JN. Evaluating the accessibility and value of U.S. ambulatory care among Medicaid expansion states and non-expansion states, 2012-2015. BMC Health Serv Res 2023; 23:723. [PMID: 37400793 PMCID: PMC10318663 DOI: 10.1186/s12913-023-09696-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 06/07/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND While the Affordable Care Act's Medicaid expansion improved healthcare coverage and access for millions of uninsured Americans, less is known about its effects on the overall accessibility and quality of care across all payers. Rapid volume increases of newly enrolled Medicaid patients might have unintentionally strained accessibility or quality of care. We assessed changes in physician office visits and high- and low-value care associated with Medicaid expansion across all payers. METHODS Prespecified, quasi-experimental, difference-in-differences analysis pre and post Medicaid expansion (2012-2015) in 8 states that did and 5 that did not choose to expand Medicaid. Physician office visits sampled from the National Ambulatory Medical Care Survey, standardized with U.S. Census population estimates. Outcomes included visit rates per state population and rates of high or low-value service composites of 10 high-value measures and 7 low-value care measures respectively, stratified by year and insurance. RESULTS We identified approximately 143 million adults utilizing 1.9 billion visits (mean age 56; 60% female) during 2012-2015. Medicaid visits increased in expansion states post-expansion compared to non-expansion states by 16.2 per 100 adults (p = 0.031 95% CI 1.5-31.0). New Medicaid visits increased by 3.1 per 100 adults (95% CI 0.9-5.3, p = 0.007). No changes were observed in Medicare or commercially-insured visit rates. High or low-value care did not change for any insurance type, except high-value care during new Medicaid visits, which increased by 4.3 services per 100 adults (95% CI 1.1-7.5, p = 0.009). CONCLUSIONS Following Medicaid expansion, the U.S. healthcare system increased access to care and use of high-value services for millions of Medicaid enrollees, without observable reductions in access or quality for those enrolled in other insurance types. Provision of low-value care continued at similar rates post-expansion, informing future federal policies designed to improve the value of care.
Collapse
Affiliation(s)
- Aaron Parzuchowski
- Department of Veteran Affairs, National Clinician Scholars Program, Ann Arbor, MI, USA
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Carlos Oronce
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Rong Guo
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - A Mark Fendrick
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA.
| |
Collapse
|
12
|
Mead M, Nanda U, Ibrahim AM. The Variable Impact of Clinical Risk-Adjustment Models to Evaluate Hospital Design. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2023; 16:146-155. [PMID: 37016837 DOI: 10.1177/19375867231154250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
OBJECTIVES To identify the impact of clinical risk adjustment models for evaluating pain medication consumption differences between private rooms and a multibed ward. BACKGROUND Views of nature are reported to reduce anxiety and pain for patients. This often leads to prioritizing large windows with views for patient rooms; however, it is not clear how other factors influencing pain (e.g., patient demographics) may confound evaluations of room design. METHODS We identified 1,284 patients at the University of Michigan undergoing thyroidectomy where patients recovered in one of the two locations: a private room with a view to nature or a multibed ward with no windows. We used pain medication data from the electronic medical record and risk adjustment models to evaluate pain medication consumption between the room types. RESULTS Private room patients did not use more pain medications when measured using unadjusted morphine milligram equivalents (18.3 vs. 15.3 mg, p = .06). Risk adjusting for age, gender, comorbidities, opioid history, and procedure subtype resulted in private room patients demonstrating higher consumption of morphine milliequivalents (17.5 vs. 15.5 mg, p < .01). In contrast, risk adjusting for age, gender, opioid history, and selected comorbidities estimated higher pain medication consumption for multibed ward patients relative to private rooms (16.27 vs. 15.51 mg, p < .05). CONCLUSION Estimated differences of pain medication consumption for patients in differently designed rooms varied depending on the risk adjustment model. These findings underscore the importance of understanding appropriate clinical measurement and risk adjustment strategies to accurately estimate the impact of design, before applying research into practice.
Collapse
Affiliation(s)
- Mitchell Mead
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Taubman College of Architecture & Urban Planning, University of Michigan, Ann Arbor, MI, USA
| | - Upali Nanda
- Taubman College of Architecture & Urban Planning, University of Michigan, Ann Arbor, MI, USA
- HKS, Detroit, MI, USA
| | - Andrew M Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Taubman College of Architecture & Urban Planning, University of Michigan, Ann Arbor, MI, USA
- HOK, Chicago, IL, USA
| |
Collapse
|
13
|
Neprash HT, Mulcahy JF, Cross DA, Gaugler JE, Golberstein E, Ganguli I. Association of Primary Care Visit Length With Potentially Inappropriate Prescribing. JAMA HEALTH FORUM 2023; 4:e230052. [PMID: 36897582 PMCID: PMC10249052 DOI: 10.1001/jamahealthforum.2023.0052] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Importance Time is a valuable resource in primary care, and physicians and patients consistently raise concerns about inadequate time during visits. However, there is little evidence on whether shorter visits translate into lower-quality care. Objective To investigate variations in primary care visit length and quantify the association between visit length and potentially inappropriate prescribing decisions by primary care physicians. Design, Setting, and Participants This cross-sectional study used data from electronic health record systems in primary care offices across the US to analyze adult primary care visits occurring in calendar year 2017. Analysis was conducted from March 2022 through January 2023. Main Outcomes and Measures Regression analyses quantified the association between patient visit characteristics and visit length (measured using time stamp data) and the association between visit length and potentially inappropriate prescribing decisions, including inappropriate antibiotic prescriptions for upper respiratory tract infections, coprescribing of opioids and benzodiazepines for painful conditions, and prescriptions that were potentially inappropriate for older adults (based on the Beers criteria). All rates were estimated using physician fixed effects and were adjusted for patient and visit characteristics. Results This study included 8 119 161 primary care visits by 4 360 445 patients (56.6% women) with 8091 primary care physicians; 7.7% of patients were Hispanic, 10.4% were non-Hispanic Black, 68.2% were non-Hispanic White, 5.5% were other race and ethnicity, and 8.3% had missing race and ethnicity. Longer visits were more complex (ie, more diagnoses recorded and/or more chronic conditions coded). After controlling for scheduled visit duration and measures of visit complexity, younger, publicly insured, Hispanic, and non-Hispanic Black patients had shorter visits. For each additional minute of visit length, the likelihood that a visit resulted in an inappropriate antibiotic prescription changed by -0.11 percentage points (95% CI, -0.14 to -0.09 percentage points) and the likelihood of opioid and benzodiazepine coprescribing changed by -0.01 percentage points (95% CI, -0.01 to -0.009 percentage points). Visit length had a positive association with potentially inappropriate prescribing among older adults (0.004 percentage points; 95% CI, 0.003-0.006 percentage points). Conclusions and Relevance In this cross-sectional study, shorter visit length was associated with a higher likelihood of inappropriate antibiotic prescribing for patients with upper respiratory tract infections and coprescribing of opioids and benzodiazepines for patients with painful conditions. These findings suggest opportunities for additional research and operational improvements to visit scheduling and quality of prescribing decisions in primary care.
Collapse
Affiliation(s)
- Hannah T Neprash
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - John F Mulcahy
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Dori A Cross
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Joseph E Gaugler
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Ezra Golberstein
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
14
|
Linzer M, Sullivan EE, Olson APJ, Khazen M, Mirica M, Schiff GD. Improving diagnosis: adding context to cognition. Diagnosis (Berl) 2023; 10:4-8. [PMID: 35985033 DOI: 10.1515/dx-2022-0058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/26/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The environment in which clinicians provide care and think about their patients is a crucial and undervalued component of the diagnostic process. CONTENT In this paper, we propose a new conceptual model that links work conditions to clinician responses such as stress and burnout, which in turn impacts the quality of the diagnostic process and finally patient diagnostic outcomes. The mechanism for these interactions critically depends on the relationship between working memory (WM) and long-term memory (LTM), and ways WM and LTM interactions are affected by working conditions. SUMMARY We propose a conceptual model to guide interventions to improve work conditions, clinician reactions and ultimately diagnostic process, accuracy and outcomes. OUTLOOK Improving diagnosis can be accomplished if we are able to understand, measure and increase our knowledge of the context of care.
Collapse
Affiliation(s)
- Mark Linzer
- Department of Medicine and the Institute for Professional Worklife, Hennepin Healthcare and University of Minnesota Medical School, Minneapolis, MN, USA
| | - Erin E Sullivan
- Harvard Medical School, Center for Primary Care, Harvard University, Boston, MA, USA.,Sawyer School of Business, Suffolk University, Boston, MA, USA
| | - Andrew P J Olson
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Maram Khazen
- Harvard Medical School, Center for Primary Care, Harvard University, Boston, MA, USA.,Brigham and Women's Hospital, Center for Patient Safety Research, Boston, MA, USA.,School of Public Health, Haifa University, Haifa, Israel
| | - Maria Mirica
- Brigham and Women's Hospital, Center for Patient Safety Research, Boston, MA, USA
| | - Gordon D Schiff
- Harvard Medical School, Center for Primary Care, Harvard University, Boston, MA, USA.,Brigham and Women's Hospital, Center for Patient Safety Research, Boston, MA, USA
| |
Collapse
|
15
|
Kolla L, Chen J, Parikh RB. Time of Clinic Appointment and Serious Illness Communication in Oncology. Cancer Control 2023; 30:10732748231170488. [PMID: 37071969 PMCID: PMC10126780 DOI: 10.1177/10732748231170488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
INTRODUCTION Serious illness communication in oncology increases goal concordant care. Factors associated with the frequency of serious illness conversations are not well understood. Given prior evidence of the association between suboptimal decision-making and clinic time, we aimed to investigate the relationship between appointment time and the likelihood of serious illness conversations in oncology. METHODS We conducted a retrospective study of electronic health record data from 55 367 patient encounters between June 2019 to April 2020, using generalized estimating equations to model the likelihood of a serious illness conversation across clinic time. RESULTS Documentation rate decreased from 2.1 to 1.5% in the morning clinic session (8am-12pm) and from 1.2% to .9% in the afternoon clinic session (1pm-4pm). Adjusted odds ratios for Serious illness conversations documentation rates were significantly lower for all hours of each session after the earliest hour (adjusted odds ratios .91 [95% CI, .84-.97], P = .006 for overall linear trend). CONCLUSIONS Serious illness conversations between oncologists and patients decrease considerably through the clinic day, and proactive strategies to avoid missed conversations should be investigated.
Collapse
Affiliation(s)
- Likhitha Kolla
- Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jinbo Chen
- Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ravi B Parikh
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| |
Collapse
|
16
|
Bell LV, Fitzgerald SF, Flusk D, Poulin PA, Rash JA. Healthcare provider knowledge, beliefs, and attitudes regarding opioids for chronic non-cancer pain in North America prior to the emergence of COVID-19: A systematic review of qualitative research. Can J Pain 2023; 7:2156331. [PMID: 36874229 PMCID: PMC9980668 DOI: 10.1080/24740527.2022.2156331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Balance between benefits and harms of using opioids for the management of chronic noncancer pain (CNCP) must be carefully considered on a case-by-case basis. There is no one-size-fits-all approach that can be executed by prescribers and clinicians when considering this therapy. Aim The aim of this study was to identify barriers and facilitators for prescribing opioids for CNCP through a systematic review of qualitative literature. Methods Six databases were searched from inception to June 2019 for qualitative studies reporting on provider knowledge, attitudes, beliefs, or practices pertaining to prescribing opioids for CNCP in North America. Data were extracted, risk of bias was rated, and confidence in evidence was graded. Results Twenty-seven studies reporting data from 599 health care providers were included. Ten themes emerged that influenced clinical decision making when prescribing opioids. Providers were more comfortable to prescribe opioids when (1) patients were actively engaged in pain self-management, (2) clear institutional prescribing policies were present and prescription drug monitoring programs were used, (3) long-standing relationships and strong therapeutic alliance were present, and (4) interprofessional supports were available. Factors that reduced likelihood of prescribing opioids included (1) uncertainty toward subjectivity of pain and efficacy of opioids, (2) concern for the patient (e.g., adverse effects) and community (i.e., diversion), (3) previous negative experiences (e.g., receiving threats), (4) difficulty enacting guidelines, and (5) organizational barriers (e.g., insufficient appointment duration and lengthy documentation). Conclusions Understanding barriers and facilitators that influence opioid-prescribing practices offers insight into modifiable targets for interventions that can support providers in delivering care consistent with practice guidelines.
Collapse
Affiliation(s)
- Louise V Bell
- Department of Psychology, University of New Brunswick, Fredericton, New Brunswick, Canada
| | - Sarah F Fitzgerald
- Department of Psychology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - David Flusk
- Discipline of Anesthesia, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Patricia A Poulin
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Psychology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua A Rash
- Department of Psychology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| |
Collapse
|
17
|
Cross DA, Adler-Milstein J, Holmgren AJ. Management Opportunities and Challenges After Achieving Widespread Health System Digitization. Adv Health Care Manag 2022; 21:67-87. [PMID: 36437617 DOI: 10.1108/s1474-823120220000021004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The adoption of electronic health records (EHRs) and digitization of health data over the past decade is ushering in the next generation of digital health tools that leverage artificial intelligence (AI) to improve varied aspects of health system performance. The decade ahead is therefore shaping up to be one in which digital health becomes even more at the forefront of health care delivery - demanding the time, attention, and resources of health care leaders and frontline staff, and becoming inextricably linked with all dimensions of health care delivery. In this chapter, we look back and look ahead. There are substantive lessons learned from the first era of large-scale adoption of enterprise EHRs and ongoing challenges that organizations are wrestling with - particularly related to the tension between standardization and flexibility/customization of EHR systems and the processes they support. Managing this tension during efforts to implement and optimize enterprise systems is perhaps the core challenge of the past decade, and one that has impeded consistent realization of value from initial EHR investments. We describe these challenges, how they manifest, and organizational strategies to address them, with a specific focus on alignment with broader value-based care transformation. We then look ahead to the AI wave - the massive number of applications of AI to health care delivery, the expected benefits, the risks and challenges, and approaches that health systems can consider to realize the benefits while avoiding the risks.
Collapse
|
18
|
Narayan S, Rizzardo S, Hamilton MA, Cooper I, Maclure M, McCracken RK, Klimas J. Development and pilot evaluation of an educational session to support sparing opioid prescriptions to opioid naïve patients in a Canadian primary care setting. Fam Pract 2022; 39:1024-1030. [PMID: 35543305 PMCID: PMC9680661 DOI: 10.1093/fampra/cmac044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prescribing rates of some analgesics decreased during the public health crisis. Yet, up to a quarter of opioid-naïve persons prescribed opioids for noncancer pain develop prescription opioid use disorder. We, therefore, sought to evaluate a pilot educational session to support primary care-based sparing of opioid analgesics for noncancer pain among opioid-naïve patients in British Columbia (BC). METHODS Therapeutics Initiative in BC has launched an audit and feedback intervention. Individual prescribing portraits were mailed to opioid prescribers, followed by academic detailing webinars. The webinars' learning outcomes included defining the terms opioid naïve and opioid sparing, and educating attendees on the (lack of) evidence for opioid analgesics to treat noncancer pain. The primary outcome was change in knowledge measured by four multiple-choice questions at the outset and conclusion of the webinar. RESULTS Two hundred participants attended four webinars; 124 (62%) responded to the knowledge questions. Community-based primary care professionals (80/65%) from mostly urban settings (77/62%) self-identified as family physicians (46/37%), residents (22/18%), nurse practitioners (24/19%), and others (32/26%). Twelve participants (10%) recalled receiving the individualized portraits. While the correct identification of opioid naïve definitions increased by 23%, the correct identification of opioid sparing declined by 7%. Knowledge of the gaps in high-quality evidence supporting opioid analgesics and risk tools increased by 26% and 35%, respectively. CONCLUSION The educational session outlined in this pilot yielded mixed results but appeared acceptable to learners and may need further refinement to become a feasible way to train professionals to help tackle the current toxic drugs crisis.
Collapse
Affiliation(s)
- Shawna Narayan
- Department of Family Practice, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
| | - Stefania Rizzardo
- School of Occupational and Public Health, Ryerson University, 350 Victoria Street, Toronto, ON, M5B 2K3, Canada
| | - Michee-Ana Hamilton
- Department of Family Practice, Innovation Support Unit, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
| | - Ian Cooper
- Department of Family Practice, Innovation Support Unit, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, Therapeutics Initiative, University of British Columbia, Vancouver, BC, V6T 2A1, Canada
| | - Rita K McCracken
- Department of Family Practice, Innovation Support Unit, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
| | - Jan Klimas
- Department of Family Practice, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
| |
Collapse
|
19
|
How are Patient Order and Shift Timing Associated With Imaging Choices in the Emergency Department? Evidence From Niagara Health Administrative Data. Ann Emerg Med 2022; 80:392-400. [PMID: 35953385 DOI: 10.1016/j.annemergmed.2022.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE We assessed whether the timing and order of patients over emergency shifts are associated with receiving diagnostic imaging in the emergency department and characterized whether changes in imaging are associated with changes in patients returning to the ED. METHODS In this retrospective study, we used multivariate and instrumental variable regressions to examine how the timing and order of patients are associated with the use of diagnostic imaging. Outcomes include whether a patient receives a radiograph, a computed tomography (CT) scan, an ultrasound, and 7-day bouncebacks to the ED. The variables of interest are time and order during a physician's shift in which a patient is seen. RESULTS A total of 841,683 ED visits were examined from an administrative database of all ED visits to Niagara Health. Relative to the first patient, the probability of receiving a radiograph, CT, and ultrasound decreases by 6.4%, 9.1%, and 3.8% if a patient is the 15th patient seen during a shift. Relative to the first minute, the probability of receiving a radiograph, CT, or ultrasound increases by 1.9%, 2.7%, and 1.1% if a patient is seen in the 180th minute. Seven-day bounceback rates are not consistently associated with patient order or timing in a shift and imaging orders. CONCLUSION Imaging in the ED is associated with shift length and especially patient order, suggesting that physicians make different imaging decisions over the course of their shifts. Additional imaging does not translate into reductions in subsequent bouncebacks to the hospital.
Collapse
|
20
|
Agarwal I, Joseph JW, Sanchez LD. Time on shift in the emergency department and decision to prescribe opioids to patients without chronic opioid use. Clin Exp Emerg Med 2022; 9:108-113. [PMID: 35843610 PMCID: PMC9288880 DOI: 10.15441/ceem.22.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/26/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To study the effect of time on shift on the opioid prescribing practices of emergency physicians among patients without chronic opioid use.Methods We analyzed pain-related visits for five painful conditions from 2010 to 2017 at a single academic hospital in Boston. Visits were categorized according to national guidelines as conditions for which opioids are “sometimes indicated” (fracture and renal colic) or “usually not indicated” (headache, low back pain, and fibromyalgia). Using conditional logistic regression with fixed effects for clinicians, we estimated the probability of opioid prescribing for pain-related visits as a function of shift hour at discharge, time of day, and patient-level confounders (age, sex, and pain score).Results Among 16,115 visits for which opioids were sometimes indicated, opioid prescribing increased over the course of a shift (28% in the first hour compared with 40% in the last hour; adjusted odds ratio, 1.06; 95% confidence interval, 1.02–1.10; adjusted P-trend <0.01). However, among visits for which opioids are usually not indicated, relative to the first hour, opioid prescriptions progressively fell (40% in the first hour compared with 23% in the last hour; adjusted odds ratio, 0.93; 95% confidence interval, 0.91–0.96; adjusted P-trend <0.01).Conclusion As shift hour progressed, emergency physicians became more likely to prescribe opioids for conditions that are sometimes indicated, and less likely to prescribe opioids for nonindicated conditions. Our study suggests that clinical decision making in the emergency department can be substantially influenced by external factors such as clinician shift hour.
Collapse
|
21
|
Allen KS, Danielson EC, Downs SM, Mazurenko O, Diiulio J, Salloum RG, Mamlin BW, Harle CA. Evaluating a Prototype Clinical Decision Support Tool for Chronic Pain Treatment in Primary Care. Appl Clin Inform 2022; 13:602-611. [PMID: 35649500 DOI: 10.1055/s-0042-1749332] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES The Chronic Pain Treatment Tracker (Tx Tracker) is a prototype decision support tool to aid primary care clinicians when caring for patients with chronic noncancer pain. This study evaluated clinicians' perceived utility of Tx Tracker in meeting information needs and identifying treatment options, and preferences for visual design. METHODS We conducted 12 semi-structured interviews with primary care clinicians from four health systems in Indiana. The interviews were conducted in two waves, with prototype and interview guide revisions after the first six interviews. The interviews included exploration of Tx Tracker using a think-aloud approach and a clinical scenario. Clinicians were presented with a patient scenario and asked to use Tx Tracker to make a treatment recommendation. Last, participants answered several evaluation questions. Detailed field notes were collected, coded, and thematically analyzed by four analysts. RESULTS We identified several themes: the need for clinicians to be presented with a comprehensive patient history, the usefulness of Tx Tracker in patient discussions about treatment planning, potential usefulness of Tx Tracker for patients with high uncertainty or risk, potential usefulness of Tx Tracker in aggregating scattered information, variability in expectations about workflows, skepticism about underlying electronic health record data quality, interest in using Tx Tracker to annotate or update information, interest in using Tx Tracker to translate information to clinical action, desire for interface with visual cues for risks, warnings, or treatment options, and desire for interactive functionality. CONCLUSION Tools like Tx Tracker, by aggregating key information about past, current, and potential future treatments, may help clinicians collaborate with their patients in choosing the best pain treatments. Still, the use and usefulness of Tx Tracker likely relies on continued improvement of its functionality, accurate and complete underlying data, and tailored integration with varying workflows, care team roles, and user preferences.
Collapse
Affiliation(s)
- Katie S Allen
- Health Policy and Management, Richard M. Fairbanks School of Public Health, IUPUI, Indianapolis, Indiana, United States.,Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, Indiana, United States
| | - Elizabeth C Danielson
- Center for Education in Health Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Sarah M Downs
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Olena Mazurenko
- Health Policy and Management, Richard M. Fairbanks School of Public Health, IUPUI, Indianapolis, Indiana, United States
| | - Julie Diiulio
- Health Outcomes and Biomedical Informatics, Applied Decision Science, LLC, Dayton, Ohio, United States
| | | | - Burke W Mamlin
- Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, Indiana, United States.,Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Christopher A Harle
- Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, Indiana, United States.,University of Florida, Gainesville, Florida, United States
| |
Collapse
|
22
|
Havlik JL, Mercurio MR, Hull SC. The Case for Ethical Efficiency: A System That Has Run Out of Time. Hastings Cent Rep 2022; 52:14-20. [PMID: 35476354 DOI: 10.1002/hast.1351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The American health care system increasingly conflates physician "productivity" with true clinical efficiency. In reality, inordinate time pressure on physicians compromises quality of care, decreases patient satisfaction, increases clinician burnout, and costs the health care system a great deal in the long term even if it is financially expedient in the short term. Inadequate time to deliver care thereby conflicts with the core principles of biomedical ethics, including autonomy, beneficence, nonmaleficence, and justice. We propose that the health care system adjust its focus to recognize the nonmonetary value of physician time while still realizing the need to deploy resources as effectively as possible, a concept we describe as "ethical efficiency."
Collapse
|
23
|
Allen T, Gyrd-Hansen D, Kristensen SR, Oxholm AS, Pedersen LB, Pezzino M. Physicians under Pressure: Evidence from Antibiotics Prescribing in England. Med Decis Making 2022; 42:303-312. [PMID: 35021900 PMCID: PMC8918864 DOI: 10.1177/0272989x211069931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Many physicians are experiencing increasing demands from both their patients and society. Evidence is scarce on the consequences of the pressure on physicians' decision making. We present a theoretical framework and predict that increasing pressure may make physicians disregard societal welfare when treating patients. SETTING We test our prediction on general practitioners' antibiotic-prescribing choices. Because prescribing broad-spectrum antibiotics does not require microbiological testing, it can be performed more quickly than prescribing for narrow-spectrum antibiotics and is therefore often preferred by the patient. In contrast, from a societal perspective, inappropriate prescribing of broad-spectrum antibiotics should be minimized as it may contribute to antimicrobial resistance in the general population. METHODS We combine longitudinal survey data and administrative data from 2010 to 2017 to create a balanced panel of up to 1072 English general practitioners (GPs). Using a series of linear models with GP fixed effects, we estimate the importance of different sources of pressure for GPs' prescribing. RESULTS We find that the percentage of broad-spectrum antibiotics prescribed increases by 6.4% as pressure increases on English GPs. The link between pressure and prescribing holds for different sources of pressure. CONCLUSIONS Our findings suggest that there may be societal costs of physicians working under pressure. Policy makers need to take these costs into account when evaluating existing policies as well as when introducing new policies affecting physicians' work pressure. An important avenue for further research is also to determine the underlying mechanisms related to the different sources of pressure.JEL-code: I11, J28, J45. HIGHLIGHTS Many physicians are working under increasing pressure.We test the importance of pressure on physicians' prescribing of antibiotics.The prescribed rate of broad-spectrum antibiotics increases with pressure.Policy makers should be aware of the societal costs of pressured physicians.[Formula: see text].
Collapse
Affiliation(s)
- Thomas Allen
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK.,Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, J.B., Odense C, Denmark
| | - Dorte Gyrd-Hansen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, J.B., Odense C, Denmark
| | - Søren Rud Kristensen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, J.B., Odense C, Denmark.,Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Anne Sophie Oxholm
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, J.B., Odense C, Denmark
| | - Line Bjørnskov Pedersen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, J.B., Odense C, Denmark.,Research Unit for General Practice, University of Southern Denmark, J..B, Odense C, Denmark
| | - Mario Pezzino
- School of Social Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
24
|
Barash M, Nanchal RS. Enhancing Analytical Reasoning in the Intensive Care Unit. Crit Care Clin 2021; 38:51-67. [PMID: 34794631 DOI: 10.1016/j.ccc.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clinical reasoning is prone to errors in judgment. Error is comprised of 2 components-bias and noise; each has an equally important role in the promulgation of error. Biases or systematic errors in reasoning are the product of misconceptions of probability and statistics. Biases arise because clinicians frequently rely on mental shortcuts or heuristics to make judgments. The most frequently used heuristics are representativeness, availability, and anchoring/adjustment which lead to the common biases of base rate neglect, misconceptions of regression, insensitivities to sample size, and fallacies of conjunctive, and disjunctive events. Bayesian reasoning is the framework within which posterior probabilities of events is identified. Familiarity with these mathematical concepts will likely enhance clinical reasoning. Noise is defined as inter or intraobserver variability in judgment that should be identical. Guidelines in medicine are a technique to reduce noise.
Collapse
Affiliation(s)
- Mark Barash
- Division of Pulmonary and Critical Care Medicine, Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, 8th Floor, Milwaukee, WI 53226, USA
| | - Rahul S Nanchal
- Division of Pulmonary and Critical Care Medicine, Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, 8th Floor, Milwaukee, WI 53226, USA.
| |
Collapse
|
25
|
Rhon DI, Mayhew RJ, Greenlee TA, Fritz JM. The influence of a MOBile-based video Instruction for Low back pain (MOBIL) on initial care decisions made by primary care providers: a randomized controlled trial. BMC FAMILY PRACTICE 2021; 22:200. [PMID: 34627152 PMCID: PMC8502287 DOI: 10.1186/s12875-021-01549-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks. OBJECTIVE Assess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups. METHODS This was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs. RESULTS Of 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention. CONCLUSION Factors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process. TRIAL REGISTRATION clinicaltrials.gov NCT02777983 .
Collapse
Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA. .,Uniformed Services University of the Health Sciences , Bethesda, MD, USA.
| | - Rachel J Mayhew
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
| | | |
Collapse
|
26
|
Keister LA, Stecher C, Aronson B, McConnell W, Hustedt J, Moody JW. Provider Bias in prescribing opioid analgesics: a study of electronic medical Records at a Hospital Emergency Department. BMC Public Health 2021; 21:1518. [PMID: 34362330 PMCID: PMC8344207 DOI: 10.1186/s12889-021-11551-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Physicians do not prescribe opioid analgesics for pain treatment equally across groups, and such disparities may pose significant public health concerns. Although research suggests that institutional constraints and cultural stereotypes influence doctors’ treatment of pain, prior quantitative evidence is mixed. The objective of this secondary analysis is therefore to clarify which institutional constraints and patient demographics bias provider prescribing of opioid analgesics. Methods We used electronic medical record data from an emergency department of a large U.S hospital during years 2008–2014. We ran multi-level logistic regression models to estimate factors associated with providing an opioid prescription during a given visit while controlling for ICD-9 diagnosis codes and between-patient heterogeneity. Results A total of 180,829 patient visits for 63,513 unique patients were recorded during the period of analysis. Overall, providers were significantly less likely to prescribe opioids to the same individual patient when the visit occurred during higher rates of emergency department crowding, later times of day, earlier in the week, later years in our sample, and when the patient had received fewer previous opioid prescriptions. Across all patients, providers were significantly more likely to prescribe opioids to patients who were middle-aged, white, and married. We found no bias towards women and no interaction effects between race and crowding or between race and sex. Conclusions Providers tend to prescribe fewer opioids during constrained diagnostic situations and undertreat pain for patients from high-risk and marginalized demographic groups. Potential harms resulting from previous treatment decisions may accumulate by informing future treatment decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11551-9.
Collapse
Affiliation(s)
- Lisa A Keister
- Department of Sociology, Duke Network Analysis, Sanford School of Public Policy, Duke University, Durham, NC, 27705, USA.
| | - Chad Stecher
- College of Health Solutions, Arizona State University, Phoenix, AZ, 85004, USA
| | - Brian Aronson
- The Adecco Group, 10151 Deerwood Park Blvd bldg 200 ste 101, Jacksonville, FL, 32256, USA
| | - William McConnell
- Department of Sociology, Florida Atlantic University, 777 Glades Road
- CU 97 Rm 253, Boca Raton, FL, 33431, USA
| | - Joshua Hustedt
- Department of Orthopedics, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, 85004, USA
| | - James W Moody
- Department of Sociology, Duke Network Analysis, Duke University, Durham, NC, 27705, USA
| |
Collapse
|
27
|
Sanghavi P, McWilliams JM, Schwartz AL, Zaslavsky AM. Association of Low-Value Care Exposure With Health Care Experience Ratings Among Patient Panels. JAMA Intern Med 2021; 181:941-948. [PMID: 34047761 PMCID: PMC8261613 DOI: 10.1001/jamainternmed.2021.1974] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
IMPORTANCE Patient reviews of health care experiences are increasingly used for public reporting and alternative payment models. Critics have argued that this incentivizes physicians to provide more care, including low-value care, undermining efforts to reduce wasteful practices. OBJECTIVE To assess associations between rates of low-value service provision to a primary care professional (PCP) patient panel and patients' ratings of their health care experiences. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study used Medicare fee-for-service claims from January 1, 2007, to December 31, 2014, for a random 20% sample of beneficiaries to identify beneficiaries for whom each of 8 low-value services could be ordered but would be considered unnecessary. The study also used health care experience reports from independently sampled beneficiaries who responded to the 2010-2015 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare fee-for-service survey. Statistical analysis was performed from January 1, 2019, to December 9, 2020. MAIN OUTCOMES AND MEASURES The main outcomes were health care experience ratings from Medicare beneficiaries who responded to the CAHPS survey from 2 domains, namely "Your Health Care in the Last 6 Months" (overall health care, office wait time, timely access to nonurgent care, and timely access to urgent care) and "Your Personal Doctor" (overall personal physician and a composite score for interactions with personal physician). Beneficiaries in both samples were attributed to the PCP with whom they had the most spending. For each PCP, a composite score of low-value service exposure was constructed using the 20% sample; this score represented the adjusted relative propensity of the PCP patient panel to receive low-value care. The association between low-value service exposure and health care experience ratings reported by the CAHPS respondents in the PCP patient panel was estimated using regression analysis. RESULTS The final sample had 100 743 PCPs, with a mean of approximately 258 patients per PCP. Only 1 notable association was found; more low-value care exposure was associated with more frequent reports of having to wait more than 15 minutes after the scheduled time of an appointment (a mean of 0.448 points lower CAHPS score on a 10-point scale for PCP patient panels who received the most low-value care vs the least low-value care). Although some other associations were statistically significant, their magnitudes were substantially smaller than those typically considered meaningful in other CAHPS literature and were inconsistent in direction across levels of low-value service exposure. CONCLUSIONS AND RELEVANCE This quality improvement study found that more low-value care exposure for a PCP patient panel was not associated with more favorable patient ratings of their health care experiences.
Collapse
Affiliation(s)
- Prachi Sanghavi
- Biological Sciences Division, Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - J Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Aaron L Schwartz
- Division of General Internal Medicine, Department of Medical Ethics and Health Policy, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
28
|
Hunt TC, Ambrose JP, Haaland B, Kawamoto K, Dechet CB, Lowrance WT, Hanson HA, O'Neil BB. Decision fatigue in low-value prostate cancer screening. Cancer 2021; 127:3343-3353. [PMID: 34043813 DOI: 10.1002/cncr.33644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/22/2021] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Low-value prostate-specific antigen (PSA) testing is common yet contributes substantial waste and downstream patient harm. Decision fatigue may represent an actionable target to reduce low-value urologic care. The objective of this study was to determine whether low-value PSA testing patterns by outpatient clinicians are consistent with decision fatigue. METHODS Outpatient appointments for adult men without prostate cancer were identified at a large academic health system from 2011 through 2018. The authors assessed the association of appointment time with the likelihood of PSA testing, stratified by patient age and appropriateness of testing based on clinical guidelines. Appointments included those scheduled between 8:00 am and 4:59 pm, with noon omitted. Urologists were examined separately from other clinicians. RESULTS In 1,581,826 outpatient appointments identified, the median patient age was 54 years (interquartile range, 37-66 years), 1,256,152 participants (79.4%) were White, and 133,693 (8.5%) had family history of prostate cancer. PSA testing would have been appropriate in 36.8% of appointments. Clinicians ordered testing in 3.6% of appropriate appointments and in 1.8% of low-value appointments. Appropriate testing was most likely at 8:00 am (reference group). PSA testing declined through 11:00 am (odds ratio [OR], 0.57; 95% CI, 0.50-0.64) and remained depressed through 4:00 pm (P < .001). Low-value testing was overall less likely (P < .001) and followed a similar trend, declining steadily from 8:00 am (OR, 0.48; 95% CI, 0.42-0.56) through 4:00 pm (P < .001; OR, 0.23; 95% CI, 0.18-0.30). Testing patterns in urologists were noticeably different. CONCLUSIONS Among most clinicians, outpatient PSA testing behaviors appear to be consistent with decision fatigue. These findings establish decision fatigue as a promising, actionable target for reducing wasteful and low-value practices in routine urologic care. LAY SUMMARY Decision fatigue causes poorer choices to be made with repetitive decision making. This study used medical records to investigate whether decision fatigue influenced clinicians' likelihood of ordering a low-value screening test (prostate-specific antigen [PSA]) for prostate cancer. In more than 1.5 million outpatient appointments by adult men without prostate cancer, the chances of both appropriate and low-value PSA testing declined as the clinic day progressed, with a larger decline for appropriate testing. Testing patterns in urologists were different from those reported by other clinicians. The authors conclude that outpatient PSA testing behaviors appear to be consistent with decision fatigue among most clinicians, and interventions may reduce wasteful testing and downstream patient harms.
Collapse
Affiliation(s)
- Trevor C Hunt
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jacob P Ambrose
- Population Sciences, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Benjamin Haaland
- Division of Biostatistics, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Christopher B Dechet
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - William T Lowrance
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Heidi A Hanson
- Population Sciences, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Brock B O'Neil
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| |
Collapse
|
29
|
Freedman S, Golberstein E, Huang TY, Satin DJ, Smith LB. Docs with their eyes on the clock? The effect of time pressures on primary care productivity. JOURNAL OF HEALTH ECONOMICS 2021; 77:102442. [PMID: 33684849 PMCID: PMC8122046 DOI: 10.1016/j.jhealeco.2021.102442] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 12/17/2020] [Accepted: 02/19/2021] [Indexed: 05/20/2023]
Abstract
This paper examines how time pressure, an important constraint faced by medical care providers, affects productivity in primary care. We generate empirical predictions by incorporating time pressure into a model of physician behavior by Tai-Seale and McGuire (2012). We use data from the electronic health records of a large integrated delivery system and leverage unexpected schedule changes as variation in time pressure. We find that greater time pressure reduces the number of diagnoses recorded during a visit and increases both scheduled and unscheduled follow-up care. We also find some evidence of increased low-value care, decreased preventive care, and decreased opioid prescribing.
Collapse
|
30
|
Oakes AH, Patel MS. Time to address disparities in care by appointment time. Healthcare (Basel) 2021; 9:100507. [DOI: 10.1016/j.hjdsi.2020.100507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/24/2020] [Accepted: 12/05/2020] [Indexed: 11/29/2022] Open
|
31
|
Association of Occupational and Physical Therapy With Duration of Prescription Opioid Use After Hip or Knee Arthroplasty: A Retrospective Cohort Study of Medicare Enrollees. Arch Phys Med Rehabil 2021; 102:1257-1266. [PMID: 33617862 DOI: 10.1016/j.apmr.2021.01.086] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To establish whether nonpharmacologic interventions, such as occupational and physical therapy, were associated with a shorter duration of prescription opioid use after hip or knee arthroplasty. DESIGN This retrospective cohort study used data from a national 5% Medicare sample database between January 1, 2010 and December 31, 2015. SETTING Home health or outpatient. PARTICIPANTS Adults 66 years or older with an inpatient total hip (n=4272) or knee (n=9796) arthroplasty (N=14,068). INTERVENTIONS We dichotomized patients according to whether they had received any nonpharmacologic pain intervention within 1 year after hospital discharge (eg, occupational or physical therapy evaluation). Using Cox proportional hazards, we treated exposure to nonpharmacologic interventions as time dependent to determine if skilled therapy was associated with duration of opioid use. MAIN OUTCOME MEASURES Duration of prescription opioid use. RESULTS Median time to begin nonpharmacologic interventions was 91 days (95% confidence interval [CI], 74-118d) for hip and 27 days (95% CI, 27-28d) for knee arthroplasty. Median time to discontinue prescription opioids was 16 days (hip: 95% CI, 15-16d) and 30 days (knee: 95% CI, 29-31d). Nonpharmacologic interventions delivered with home health increased the likelihood of discontinuing opioids after hip (hazard ratio [HR], 1.15; 95% CI, 1.01-1.30) and knee (HR, 1.10; 95% CI, 1.03-1.17) arthroplasty. A sensitivity analysis found these estimates to be robust and conservative. CONCLUSIONS Occupational and physical therapy with home health was associated with a shorter duration of prescription opioid use after hip and knee arthroplasty. Occupational and physical therapy can address pain and sociobehavioral factors associated with postsurgical opioid use.
Collapse
|
32
|
Variation in Cardiologist Statin Prescribing by Clinic Appointment Time. J Am Coll Cardiol 2021; 77:661-662. [PMID: 33538261 DOI: 10.1016/j.jacc.2020.11.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/22/2020] [Accepted: 11/17/2020] [Indexed: 11/22/2022]
|
33
|
Reducing burnout and enhancing work engagement among clinicians: The Minnesota experience. Health Care Manage Rev 2020; 47:49-57. [PMID: 33298803 DOI: 10.1097/hmr.0000000000000298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Minnesota Hospital Association (MHA) recognized the impact that burnout and disengagement had on the clinician population. A clinician task force developed a conceptual framework, followed by annual surveys and a series of interventions. Features of the job demands-resources model were used as the conceptual underpinning to this analysis. PURPOSE The aim of this study was to assess the applicability of a clinician-driven conceptual model in understanding burnout and work engagement in the state of Minnesota. METHODOLOGY Four thousand nine hundred ninety clinicians from 94 MHA member hospitals/systems responded to a 2018 survey using a brief instrument adapted, in part, from previously validated measures. RESULTS As hypothesized, job demands were strongly related to burnout, whereas resources were most related to work engagement. Variables from the MHA model explained 40% of variability in burnout and 24% of variability in work engagement. Variables related to burnout with the highest beta weights included having sufficient time for work (-0.266), values alignment with leaders (-0.176), and teamwork efficiency (-0.123), all ps < .001. Variables most associated with engagement included values alignment (0.196), feeling appreciated (0.163), and autonomy (0.093), ps < .001. CONCLUSION Findings support the basic premises of the proposed conceptual model. Remediable work-life conditions, such as having sufficient time to do the job, values alignment with leadership, teamwork efficiency, feeling appreciated, and clinician autonomy, manifested the strongest associations with burnout and work engagement. PRACTICE IMPLICATIONS Interventions reducing job demands and strengthening resources such as values alignment, teamwork efficiency, and clinician autonomy are seen as having the greatest potential efficacy.
Collapse
|
34
|
Abstract
OBJECTIVE To determine whether patient mortality after surgery differs between surgeries performed on surgeons' birthdays compared with other days of the year. DESIGN Retrospective observational study. SETTING US acute care and critical access hospitals. PARTICIPANTS 100% fee-for-service Medicare beneficiaries aged 65 to 99 years who underwent one of 17 common emergency surgical procedures in 2011-14. MAIN OUTCOME MEASURES Patient postoperative 30 day mortality, defined as death within 30 days after surgery, with adjustment for patient characteristics and surgeon fixed effects. RESULTS 980 876 procedures performed by 47 489 surgeons were analyzed. 2064 (0.2%) of the procedures were performed on surgeons' birthdays. Patient characteristics, including severity of illness, were similar between patients who underwent surgery on a surgeon's birthday and those who underwent surgery on other days. The overall unadjusted 30 day mortality on the operating surgeon's birthday was 7.0% (145/2064) and that on other days was 5.6% (54 824/978 812). After adjusting for patient characteristics and surgeon fixed effects (effectively comparing outcomes of patients treated by the same surgeon on different days), patients who underwent surgery on a surgeon's birthday exhibited higher mortality compared with patients who underwent surgery on other days (adjusted mortality rate, 6.9% v 5.6%; adjusted difference 1.3%, 95% confidence interval 0.1% to 2.5%; P=0.03). Event study analysis of patient mortality by day of surgery relative to a surgeon's birthday found similar results. CONCLUSIONS Among Medicare beneficiaries who underwent common emergency surgeries, those who received surgery on the surgeon's birthday experienced higher mortality compared with patients who underwent surgery on other days. These findings suggest that surgeons might be distracted by life events that are not directly related to work.
Collapse
Affiliation(s)
- Hirotaka Kato
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 1100 Glendon Avenue Suite 850, Los Angeles, CA, 90024, USA
- Graduate School of Business Administration, Keio University, Yokohama, Japan
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- USC Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 1100 Glendon Avenue Suite 850, Los Angeles, CA, 90024, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| |
Collapse
|
35
|
Haenssgen MJ, Charoenboon N, Xayavong T, Althaus T. Precarity and clinical determinants of healthcare-seeking behaviour and antibiotic use in rural Laos and Thailand. BMJ Glob Health 2020; 5:e003779. [PMID: 33298471 PMCID: PMC7733127 DOI: 10.1136/bmjgh-2020-003779] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The social determinants of health are a decisive yet persistently understudied area for tackling global health challenges like antimicrobial resistance (AMR). Precarity is one determinant whose importance is increasingly recognised, which we define here as 'a form of pernicious self-dependence that undermines individuals' control over their own lives and limits their ability to flexibly respond to crises'. We aimed to assess the relationship between precarity, other forms of deprivation and healthcare-seeking behaviour by asking, 'What is the impact of precarity, marginalisation and clinical presentation on healthcare-seeking behaviour?' and 'Do patients experiencing precarious livelihoods have clinically less advisable healthcare-seeking behaviour?' METHODS We used healthcare-seeking behaviour census survey data from rural Thailand and Laos, wherein five rural communities were surveyed two times over a period of 3 months (2-month recall period). Using descriptive statistical and multivariate logistic regression analysis on the illness level, we studied precarity alongside clinical presentation, marginalisation and facilitating solutions during an illness (eg, health-related phone use) as determinants of healthcare-seeking behaviour in the form of healthcare access and antibiotic use. RESULTS The data included 1421 illness episodes from 2066 villagers. Patients in precarious circumstances were up to 44.9 percentage points more likely to misuse antibiotics in the presence of situational facilitators (predicted antibiotic misuse: 6.2% (95% CI: 0.9% to 11.4%) vs 51.1% (95% CI: 16.6% to 85.5%) for precarious circumstances with/without facilitation). Marginalisation was linked to lower antibiotic use, but this did not translate into clinically more advisable behaviour. Clinical presentation played only a minor role in determining healthcare access and antibiotic use. CONCLUSIONS This study underlines the importance of context and local livelihoods in tackling drug resistance. While supporting the growing emphasis on AMR-sensitive development policy, we call for future research to study systematically the healthcare-seeking behaviour impact of precarious livelihoods, social policy and community development initiatives. TRIAL REGISTRATION NUMBER NCT03241316.
Collapse
Affiliation(s)
- Marco J Haenssgen
- Global Sustainable Development, University of Warwick, Coventry, West Midlands, UK
- Institute of Advanced Study, University of Warwick, Coventry, West Midlands, UK
| | - Nutcha Charoenboon
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Thipphaphone Xayavong
- Jacobs, Cordova & Associates, Vientiane, Vientiane Capital, Lao People's Democratic Republic
| | - Thomas Althaus
- Centre for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
- Mathematical and Economic Modelling, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| |
Collapse
|
36
|
Priest CR, Kenney BC, Brummett CM, Waljee JF, Englesbe MJ, Nalliah RP. Increased opioid prescription fills after dental procedures performed before weekends and holidays. J Am Dent Assoc 2020; 151:388-398.e1. [PMID: 32450977 DOI: 10.1016/j.adaj.2020.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/02/2020] [Accepted: 03/15/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Excess opioid prescriptions place patients and communities at risk of experiencing opioid-related morbidity. The authors designed a study to test the hypothesis that opioid prescription fills would be more common after dental procedures performed the day before a weekend or holiday than other weekdays. METHODS The authors performed a retrospective cohort study of 2,060,317 people, integrating Truven Health MarketScan insurance claims to evaluate variation in opioid fills for dental procedures performed the day before a weekend or holiday compared with other weekdays. Opioid-naïve people, aged 13 through 64 years, with eligible procedures from 2013 through 2017 were included. The primary outcome measure was a prescription opioid fill on the same date as the dental procedure. RESULTS Multivariable logistic regression results showed significantly higher odds of filling an opioid prescription for patients with procedures the day before weekends and holidays (adjusted odds ratio, 1.27; 95% confidence interval, 1.26 to 1.28) than for patients with procedures on other weekdays. In addition, the youngest age category, 13 through 29 years, had the highest odds of filling an opioid prescription compared with other age categories (reference category: patients aged 50-64 years, adjusted odds ratio, 1.43; 95% confidence interval, 1.41 to 1.44). CONCLUSIONS Outpatient dental procedures performed the day before a weekend or holiday were associated with a 27% increased adjusted odds of filling a prescription for an opioid. PRACTICAL IMPLICATIONS Although patients and dentists might be concerned about the challenges of unmanaged pain on weekends and holidays, opioids are not warranted for most dental procedures and should be replaced with patient education and nonopioid analgesics. Oral health care professionals concerned about postprocedural pain control should consider scheduling complex procedures earlier in the week, when emergency care is available to reduce unwarranted preemptive prescribing of opioids, which might be driving increased opioid fills before weekends and holidays.
Collapse
|