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Satterwhite S, Nguyen MLT, Honcharov V, McDermott AM, Sarkar U. "Good Care Is Slow Enough to Be Able to Pay Attention": Primary Care Time Scarcity and Patient Safety. J Gen Intern Med 2024; 39:1575-1582. [PMID: 38360962 DOI: 10.1007/s11606-024-08658-1] [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: 10/23/2023] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND There is growing, widespread recognition that expectations of US primary care vastly exceed the time and resources allocated to it. Little research has directly examined how time scarcity contributes to harm or patient safety incidents not readily capturable by population-based quality metrics. OBJECTIVE To examine near-miss events identified by primary care physicians in which taking additional time improved patient care or prevented harm. DESIGN Qualitative study based on semi-structured interviews. PARTICIPANTS Twenty-five primary care physicians practicing in the USA. APPROACH Participants completed a survey that included demographic questions, the Ballard Organizational Temporality Scale and the Mini-Z scale, followed by a one hour qualitative interview over video-conference (Zoom). Iterative thematic qualitative data analysis was conducted. KEY RESULTS Primary care physicians identified several types of near-miss events in which taking extra time during visits changed their clinical management. These were evident in five types of patient care episodes: high-risk social situations, high-risk medication regimens requiring patient education, high acuity conditions requiring immediate workup or treatment, interactions of physical and mental health, and investigating more subtle clinical suspicions. These near-miss events highlight the ways in which unreasonably large patient panels and packed schedules impede adequate responses to patient care episodes that are time sensitive and intensive or require flexibility. CONCLUSIONS Primary care physicians identify and address patient safety issues and high-risk situations by spending more time than allotted for a given patient encounter. Current quality metrics do not account for this critical aspect of primary care work. Current healthcare policy and organization create time scarcity. Interventions to address time scarcity and to measure its prevalence and implications for care quality and safety are urgently needed.
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Affiliation(s)
- Shannon Satterwhite
- Department of Family and Community Medicine, UC Davis Health, Sacramento, CA, USA
| | - Michelle-Linh T Nguyen
- Division of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
- Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Vlad Honcharov
- Division of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
- Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Aoife M McDermott
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
- Aston University, Birmingham, UK
| | - Urmimala Sarkar
- Division of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
- UCSF Pride Hall, San Francisco, CA, USA.
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Richards S, Wang T, Abel ED, Linzer M, Romberger D. Sustainable. Am J Med 2024; 137:552-558. [PMID: 38492767 DOI: 10.1016/j.amjmed.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 03/01/2024] [Indexed: 03/18/2024]
Affiliation(s)
- Sarah Richards
- Department of Medicine, University of Nebraska Medical Center, Omaha
| | | | | | - Mark Linzer
- Department of Medicine, Hennepin Healthcare and University of Minnesota, Minneapolis.
| | - Debra Romberger
- Department of Medicine, University of Nebraska Medical Center, Omaha
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Adeyemi O, Walker L, Bermudez E, Cuthel AM, Zhao N, Siman N, Goldfeld K, Brody AA, Bouillon-Minois JB, DiMaggio C, Chodosh J, Grudzen CR. Emergency Nurses' Perceived Barriers and Solutions to Engaging Patients With Life-Limiting Illnesses in Serious Illness Conversations: A United States Multicenter Mixed-Method Analysis. J Emerg Nurs 2024; 50:225-242. [PMID: 37966418 PMCID: PMC10939973 DOI: 10.1016/j.jen.2023.09.010] [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: 09/22/2022] [Revised: 07/27/2023] [Accepted: 09/06/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION This study aimed to assess emergency nurses' perceived barriers toward engaging patients in serious illness conversations. METHODS Using a mixed-method (quant + QUAL) convergent design, we pooled data on the emergency nurses who underwent the End-of-Life Nursing Education Consortium training across 33 emergency departments. Data were extracted from the End-of-Life Nursing Education Consortium post-training questionnaire, comprising a 5-item survey and 1 open-ended question. Our quantitative analysis employed a cross-sectional design to assess the proportion of emergency nurses who report that they will encounter barriers in engaging seriously ill patients in serious illness conversations in the emergency department. Our qualitative analysis used conceptual content analysis to generate themes and meaning units of the perceived barriers and possible solutions toward having serious illness conversations in the emergency department. RESULTS A total of 2176 emergency nurses responded to the survey. Results from the quantitative analysis showed that 1473 (67.7%) emergency nurses reported that they will encounter barriers while engaging in serious illness conversations. Three thematic barriers-human factors, time constraints, and challenges in the emergency department work environment-emerged from the content analysis. Some of the subthemes included the perceived difficulty of serious illness conversations, delay in daily throughput, and lack of privacy in the emergency department. The potential solutions extracted included the need for continued training, the provision of dedicated emergency nurses to handle serious illness conversations, and the creation of dedicated spaces for serious illness conversations. DISCUSSION Emergency nurses may encounter barriers while engaging in serious illness conversations. Institutional-level policies may be required in creating a palliative care-friendly emergency department work environment.
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Affiliation(s)
- Oluwaseun Adeyemi
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | | | | | - Allison M. Cuthel
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Nicole Zhao
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Renaissance School of Medicine, Stony Brook University, Stony Brook NY
| | - Nina Siman
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Keith Goldfeld
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
| | - Abraham A. Brody
- New York University Rory Meyers College of Nursing, New York, NY, USA; Hartford Institute for Geriatric Nursing, New York, NY, USA; Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jean-Baptiste Bouillon-Minois
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Emergency Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Charles DiMaggio
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
| | - Joshua Chodosh
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
- New York University Grossman School of Medicine, Department of Medicine, New York, New York, USA
| | - Corita R. Grudzen
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Charoensri S, Bashaw L, Dehmlow C, Ellies T, Wyckoff J, Turcu AF. Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening. JAMA Intern Med 2024; 184:174-182. [PMID: 38190155 PMCID: PMC10775078 DOI: 10.1001/jamainternmed.2023.7389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/10/2023] [Indexed: 01/09/2024]
Abstract
Importance Primary aldosteronism (PA) is a common cause of secondary hypertension and an independent risk factor for cardiovascular morbidity and mortality. Fewer than 2% to 4% of patients at risk are evaluated for PA. Objective To develop and evaluate an electronic health record best-practice advisory (BPA) that assists with PA screening. Design, Setting, and Participants This prospective quality improvement study was conducted at academic center outpatient clinics. Data analysis was performed between February and June 2023 and included adults with hypertension and at least 1 of the following: 4 or more current antihypertensive medications; hypokalemia; age younger than 35 years; or adrenal nodule(s). Patients previously tested for PA were excluded. Exposure A noninterruptive BPA was developed to trigger for PA screening candidates seen in outpatient setting by clinicians who treat hypertension. The BPA included an order set for PA screening and a link to results interpretation guidance. Main Outcomes and Measures (1) The number of PA screening candidates identified by the BPA between October 1, 2021, and December 31, 2022; (2) the rates of PA screening; and (3) the BPA use patterns, stratified by physician specialty were assessed. Results Over 15 months, the BPA identified 14 603 unique candidates (mean [SD] age, 65.5 [16.9] years; 7300 women [49.9%]; 371 [2.5%] Asian, 2383 [16.3%] Black, and 11 225 [76.9%] White individuals) for PA screening, including 7028 (48.1%) with treatment-resistant hypertension, 6351 (43.5%) with hypokalemia, 1537 (10.5%) younger than 35 years, and 445 (3.1%) with adrenal nodule(s). In total, 2040 patients (14.0%) received orders for PA screening. Of these, 1439 patients (70.5%) completed the recommended screening within the system, and 250 (17.4%) had positive screening results. Most screening orders were placed by internists (40.0%) and family medicine physicians (28.1%). Family practitioners (80.3%) and internists (68.9%) placed most orders via the embedded order set, while specialists placed most orders (83.0%-95.4%) outside the BPA. Patients who received screening were younger and included more women and Black patients than those not screened. The likelihood of screening was higher among patients with obesity and dyslipidemia and lower in those with chronic kidney disease and established cardiovascular complications. Conclusions and Relevance The study results suggest that noninterruptive BPAs are potentially promising PA screening-assistance tools, particularly among primary care physicians. Combined with artificial intelligence algorithms that optimize the detection yield, refined BPAs may contribute to personalized hypertension care.
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Affiliation(s)
- Suranut Charoensri
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Linda Bashaw
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Cheryl Dehmlow
- Health Information and Technology Systems, University of Michigan, Ann Arbor
| | - Tammy Ellies
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jennifer Wyckoff
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Adina F. Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
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Hepner KA, Sousa JL, Roth CP, Huilgol SS, Jean C, Schulson LB, Gandhi P, Malika N, Engel CC. Improving Pain Care for Service Members: Administrator, Provider, and Patient Perspectives on Treatment, Policies, and Opportunities for Change. RAND HEALTH QUARTERLY 2023; 11:3. [PMID: 38264313 PMCID: PMC10732241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Acute and chronic pain are common among service members, with musculoskeletal pain and injuries being the leading cause of nondeployability among active-duty service members. Given the significant implications for individual health and force readiness, providing high-quality pain care to service members is a priority of the Military Health System (MHS). Prior RAND research used administrative data to assess the quality and safety of pain care and opioid prescribing in the MHS, generated a set of quality measures that the MHS could adopt going forward, and identified strengths and opportunities for improvement in care provided to service members with pain conditions. In this study, authors document findings from interviews with MHS administrators, providers, and patients, providing valuable detail and context for those findings, along with on-the-ground perspectives on MHS pain care policies and guidance in practice. Staff and patients recommended prioritizing increases in treatment access and availability to improve pain care, and patients emphasized effective treatment and patient-centered care as the most important facilitators of high-quality pain care.
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6
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Layton AM, Alexis A, Baldwin H, Bettoli V, Del Rosso J, Dirschka T, Dréno B, Gold LS, Harper J, Ko JY, Al Nuaimi K, Oon HH, Rajagopalan M, Rocha M, See JA, Weiss J, Tan J. The Personalized Acne Treatment Tool - Recommendations to facilitate a patient-centered approach to acne management from the Personalizing Acne: Consensus of Experts. JAAD Int 2023; 12:60-69. [PMID: 37274381 PMCID: PMC10236180 DOI: 10.1016/j.jdin.2023.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 06/06/2023] Open
Abstract
Background Acne, a commonly treated skin disease, requires patient-centered management due to its varying presentations, chronicity, and impact on health-related quality of life. Despite this, evidence-based clinical guidelines focus primarily on clinical severity of facial acne, omitting important patient- and disease-related factors, including ongoing management. Objectives To generate recommendations to support patient-centered acne management, which incorporate priority and prognostic factors beyond conventional clinical severity, traditionally defined by grading the appearance and extent of visible lesions. Methods The Personalizing Acne: Consensus of Experts consisted of 17 dermatologists who used a modified Delphi approach to reach consensus on statements regarding patient- and treatment-related factors pertaining to patient-centered acne management. Consensus was defined as ≥75% voting "agree" or "strongly agree." Results Recommendations based on factors such as acne sequelae, location of acne, high burden of disease, and individual patient features were generated and incorporated into the Personalized Acne Treatment Tool. Limitations Recommendations are based on expert opinion, which may differ from patients' perspectives. Regional variations in healthcare systems may not be represented. Conclusions The Personalizing Acne: Consensus of Experts panel provided practical recommendations to facilitate individualized management of acne, based on patient features, which can be implemented to improve treatment outcomes, adherence, and patient satisfaction.
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Affiliation(s)
- Alison M. Layton
- Skin Research Centre, York University, York, UK
- Harrogate and District NHS Foundation Trust, Harrogate, UK
| | | | - Hilary Baldwin
- Robert Wood Johnson Medical Center, New Brunswick, New Jersey
- The Acne Treatment and Research Center, Brooklyn, New York
| | - Vincenzo Bettoli
- Dermatology Unit – Teaching Hospital, Azienda Ospedaliera, University of Ferrara, Ferrara, Italy
| | - James Del Rosso
- Advanced Dermatology and Cosmetic Surgery, Maitland, Florida
- JDR Dermatology Research, Las Vegas, Nevada
| | | | | | | | - Julie Harper
- Dermatology and Skin Care Center of Birmingham, Birmingham, Alabama
| | - Joo Yeon Ko
- Department of Dermatology, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Khaled Al Nuaimi
- Faculty of Medicine, Sharjah University, Sharjah, United Arab Emirates
| | - Hazel H. Oon
- Division of Dermatology, National Skin Centre, Singapore
| | | | - Marco Rocha
- Federal University of São Paulo, São Paulo, Brazil
| | - Jo-Ann See
- Central Sydney Dermatology, Sydney, New South Wales, Australia
| | | | - Jerry Tan
- Windsor Clinical Research Inc, Windsor, Ontario, Canada
- Department of Medicine, University of Western Ontario, Windsor, Ontario, Canada
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7
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Leive A, David G, Candon M. On resource allocation in health care: The case of concierge medicine. JOURNAL OF HEALTH ECONOMICS 2023; 90:102776. [PMID: 37329669 DOI: 10.1016/j.jhealeco.2023.102776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 04/25/2023] [Accepted: 05/30/2023] [Indexed: 06/19/2023]
Abstract
Resource allocation generally involves a tension between efficiency and equity, particularly in health care. The growth in exclusive physician arrangements using non-linear prices is leading to consumer segmentation with theoretically ambiguous welfare implications. We study concierge medicine, in which physicians only provide care to patients paying a retainer fee. We find limited evidence of selection based on health and stronger evidence of selection based on income. Using a matching strategy that leverages the staggered adoption of concierge medicine, we find large spending increases and no average mortality effects for patients impacted by the switch to concierge medicine.
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Affiliation(s)
- Adam Leive
- Goldman School of Public Policy, University of California, Berkeley, United States.
| | - Guy David
- The Wharton School, University of Pennsylvania, United States
| | - Molly Candon
- Perelman School of Medicine, University of Pennsylvania, United States
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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: 8] [Impact Index Per Article: 8.0] [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.
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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
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Franco MI, Staab EM, Zhu M, Knitter A, Wan W, Gibbons R, Vinci L, Shah S, Yohanna D, Beckman N, Laiteerapong N. Pragmatic Clinical Trial of Population Health, Portal-Based Depression Screening: the PORTAL-Depression Study. J Gen Intern Med 2023; 38:857-864. [PMID: 36127535 PMCID: PMC9488885 DOI: 10.1007/s11606-022-07779-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/30/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND A population health approach to depression screening using patient portals may be a promising strategy to proactively engage and identify patients with depression. OBJECTIVE To determine whether a population health approach to depression screening is more effective than screening during clinic appointments alone for identifying patients with depression. DESIGN A pragmatic clinical trial at an adult outpatient internal medicine clinic at an urban, academic, tertiary care center. PATIENTS Eligible patients (n = 2713) were adults due for depression screening with active portal accounts. Patients with documented depression or bipolar disorder and those who had been screened in the year prior to the study were excluded. INTERVENTION Patients were randomly assigned to usual (n = 1372) or population healthcare (n = 1341). For usual care, patients were screened by medical assistants during clinic appointments. Population healthcare patients were sent letters through the portal inviting them to fill out an online screener regardless of whether they had a scheduled appointment. The same screening tool, the Computerized Adaptive Test for Mental Health (CAT-MH™), was used for clinic- and portal-based screening. MAIN MEASURES The primary outcome was the depression screening rate. KEY RESULTS The depression screening rate in the population healthcare arm was higher than that in the usual care arm (43% (n = 578) vs. 33% (n = 459), p < 0.0001). The rate of positive screens was also higher in the population healthcare arm compared to that in the usual care (10% (n = 58) vs. 4% (n = 17), p < 0.001). CONCLUSION Findings suggest depression screening via a portal as part of a population health approach can increase screening and case identification, compared to usual care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03832283.
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Affiliation(s)
| | - Erin M Staab
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mengqi Zhu
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Robert Gibbons
- Department of Medicine, University of Chicago, Chicago, IL, USA
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Lisa Vinci
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Sachin Shah
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Daniel Yohanna
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Nancy Beckman
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Neda Laiteerapong
- Department of Medicine, University of Chicago, Chicago, IL, USA.
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA.
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Da Silva T, Lokhandwala A, Al Kaabi N, Semenchuk J, Goobie GC, Camacho E, Reid WD, Fisher JH, Ryerson CJ, Rozenberg D. Characterization and reliability of internet resources on pulmonary rehabilitation for individuals with chronic lung disease. Chron Respir Dis 2023; 20:14799731231158119. [PMID: 36790021 PMCID: PMC9936390 DOI: 10.1177/14799731231158119] [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: 02/16/2023] Open
Abstract
BACKGROUND Individuals with lung disease commonly use the internet as a source of health information on pulmonary rehabilitation (PR). The objective of this study was to characterize internet resources on PR, and to assess the content, readability, and quality of patient-directed PR resources. METHODS The first 200 websites for the search term 'pulmonary rehabilitation resources and exercise' were analyzed on Google, Yahoo, and Bing. Website content was assessed based on 30 key components of PR from the 2013 and 2021 international consensus statements. Website quality was determined using DISCERN, JAMA benchmarks, and Global Quality Scale (GQS). RESULTS 66 unique PR websites were identified with the two most common categories being scientific resources (39%) and foundation/advocacy organizations (33%). The average reading level of websites was 11 ± 3. PR content varied significantly across websites (mean range 13.4-21.5). Median DISCERN total score and GQS score were 4 (IQR 3-4) and 3.5 (IQR 2-4), respectively, representing moderate-good quality. Foundation/advocacy websites had higher DISCERN and GQS scores compared to other websites. CONCLUSION Foundation/advocacy websites had the highest quality and reliability metrics; however, the higher-than-recommended reading levels may compromise patient comprehension and utilization. This study provides critical insight on the current state of online PR health-related information.
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Affiliation(s)
- Tania Da Silva
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Ashira Lokhandwala
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Noor Al Kaabi
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Julie Semenchuk
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Gillian C Goobie
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Encarna Camacho
- Division of Respirology, Temerty Faculty of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - W Darlene Reid
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada,Interdepartmental Division of Critical Care Medicine, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Jolene H Fisher
- Division of Respirology, Temerty Faculty of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Christopher J Ryerson
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada,Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, BC, Canada
| | - Dmitry Rozenberg
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada,Division of Respirology, Temerty Faculty of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada,Dmitry Rozenberg, Toronto General Hospital Research Institute, 200 Elizabeth Street, 13 EN-229, Toronto, ON M5G 2C4, Canada.
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11
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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.
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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
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12
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Niendam TA, Loewy R, Savill M, Delucchi KL, Lesh TA, Ragland JD, Bolden K, Skymba HV, Gobrial S, Meyer MS, Pierce KM, Rosenthal A, Fedechko TL, Tully LM, Tryon VL, Goldman H, Cress RD, Kravitz RL, Carter CS. Effect of Technology-Enhanced Screening in Addition to Standard Targeted Clinician Education on the Duration of Untreated Psychosis: A Cluster Randomized Clinical Trial. JAMA Psychiatry 2023; 80:119-126. [PMID: 36598770 PMCID: PMC9857799 DOI: 10.1001/jamapsychiatry.2022.4436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 11/02/2022] [Indexed: 01/05/2023]
Abstract
Importance Reducing the duration of untreated psychosis (DUP) is essential to improving outcomes for people with first-episode psychosis (FEP). Current US approaches are insufficient to reduce DUP to international standards of less than 90 days. Objective To determine whether population-based electronic screening in addition to standard targeted clinician education increases early detection of psychosis and decreases DUP, compared with clinician education alone. Design, Setting, and Participants This cluster randomized clinical trial included individuals aged 12 to 30 years presenting for services between March 2015 and September 2017 at participating sites that included community mental health clinics and school support and special education services. Eligible participants were referred to the Early Diagnosis and Preventative Treatment (EDAPT) Clinic. Data analyses were performed in September and October 2019 for the primary and secondary analyses, with the exploratory subgroup analyses completed in May 2021. Interventions All sites in both groups received targeted education about early psychosis for health care professionals. In the active screening group, clients also completed the Prodromal Questionnaire-Brief using tablets at intake; referrals were based on those scores and clinical judgment. In the group receiving treatment as usual (TAU), referrals were based on clinical judgment alone. Main Outcomes and Measures Primary outcomes included DUP, defined as the period from full psychosis onset to the date of the EDAPT diagnostic telephone interview, and the number of individuals identified with FEP or a psychosis spectrum disorder. Exploratory analyses examined differences by site type, completion rates between conditions, and days from service entry to telephone interview. Results Twenty-four sites agreed to participate, and 12 sites were randomized to either the active screening or TAU group. However, only 10 community clinics and 4 school sites were able to fully implement population screening and were included in the final analysis. The total potentially eligible population size within each study group was similar, with 2432 individuals entering at active screening group sites and 2455 at TAU group sites. A total of 303 diagnostic telephone interviews were completed (178 [58.7%] female individuals; mean [SD] age, 17.09 years [4.57]). Active screening sites reported a significantly higher detection rate of psychosis spectrum disorders (136 cases [5.6%], relative to 65 [2.6%]; P < .001) and referred a higher proportion of individuals with FEP and DUP less than 90 days (13 cases, relative to 4; odds ratio, 0.30; 95% CI, 0.10-0.93; P = .03). There was no difference in mean (SD) DUP between groups (active screening group, 239.0 days [207.4]; TAU group 262.3 days [170.2]). Conclusions and Relevance In this cluster trial, population-based technology-enhanced screening across community settings detected more than twice as many individuals with psychosis spectrum disorders compared with clinical judgment alone but did not reduce DUP. Screening could identify people undetected in US mental health services. Significant DUP reduction may require interventions to reduce time to the first mental health contact. Trial Registration ClinicalTrials.gov Identifier: NCT02841956.
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Affiliation(s)
- Tara A Niendam
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - Rachel Loewy
- Department of Psychiatry, University of California, San Francisco
- UCSF Weill Institute for Neurosciences, San Francisco, California
| | - Mark Savill
- Department of Psychiatry, University of California, San Francisco
- UCSF Weill Institute for Neurosciences, San Francisco, California
| | - Kevin L Delucchi
- Department of Psychiatry, University of California, San Francisco
- UCSF Weill Institute for Neurosciences, San Francisco, California
| | - Tyler A Lesh
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - J Daniel Ragland
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - Khalima Bolden
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - Haley V Skymba
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - Sarah Gobrial
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - Monet S Meyer
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - Katherine M Pierce
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - Adi Rosenthal
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - Taylor L Fedechko
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | - Laura M Tully
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
| | | | - Howard Goldman
- Department of Psychiatry, University of Maryland, Baltimore
| | - Rosemary D Cress
- Department of Public Health Sciences, University of California, Davis, Sacramento
| | - Richard L Kravitz
- Department of General Medicine, Geriatrics, and Bioethics, University of California, Davis, Sacramento
| | - Cameron S Carter
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento
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13
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Schein J, Cloutier M, Gauthier-Loiselle M, Bungay R, Guerin A, Childress A. Symptoms associated with ADHD/treatment-related adverse side effects and their impact on quality of life and work productivity in adults with ADHD. Curr Med Res Opin 2023; 39:149-159. [PMID: 36082503 DOI: 10.1080/03007995.2022.2122228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Describe symptoms associated with ADHD/treatment-related adverse side effects among adults with ADHD in the US and assess their impact on quality of life (QoL) and work productivity. METHODS An online survey among adults receiving ADHD medications in the US was conducted to collect information relating to symptoms associated with ADHD/treatment-related adverse side effects. Participants were recruited from the panel of a well-established market research firm, Dynata, from 26 July to 30 July 2021 and were included in the study if they met the eligibility criteria and were willing to participate in the survey. Correlations between symptoms and key outcomes (QoL/employment/work impairment) were estimated using linear regression analyses. RESULTS Of 585 participants, 95.2% experienced ≥1 symptom associated with ADHD/treatment-related adverse side effects in the past month (average = 5.8 symptoms). The number of symptoms was significantly correlated with reduced QoL, reduced probability of being employed, and increased work/activity impairment. Among subgroups with insomnia/other sleep disturbances and emotional impulsivity/mood lability, 50.4% and 44.7% reported their symptoms had "a lot" or "extremely" negative impact on their overall well-being, respectively. CONCLUSIONS Symptoms associated with ADHD/treatment-related adverse side effects are common and have a substantial negative impact on QoL and reduces patients' probability of employment. Improved management of ADHD/treatment-related adverse side effects and more tolerable treatment options have the potential to improve QoL and work productivity among adults with ADHD.
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Affiliation(s)
- Jeff Schein
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA
| | | | | | | | | | - Ann Childress
- Center for Psychiatry and Behavioral Medicine, Las Vegas, NV, USA
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14
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Fante-Coleman T, Wilson CL, Cameron R, Coleman T, Travers R. ‘Getting shut down and shut out’: Exploring ACB patient perceptions on healthcare access at the physician-patient level in Canada. Int J Qual Stud Health Well-being 2022; 17:2075531. [PMID: 35585792 PMCID: PMC9132487 DOI: 10.1080/17482631.2022.2075531] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Purpose The experiences of African, Caribbean and Black (ACB) Canadians are seldom explored in the Canadian context. Family physicians act as a gateway to the rest of the healthcare system and are necessary to provide proper patient care. However, Canada’s history with colonialism may impact the socio-cultural context in which patients receive care. Method 41 participants from Waterloo Region, Ontario, were engaged in eight focus groups to discuss their experiences in the healthcare system. Data were analysed following thematic analysis. Results Style of care, racism and discrimination and a lack of cultural competence hindered access. oor Inadequate cultural competence was attributed to western and biomedical approaches, poor understanding of patients’ context, physicians failing to address specific health concerns, and racism and discrimination. Participants highlighted that the two facilitators to care were having an ACB family physician and fostering positive relationships with physicians. Conclusion Participants predominantly expressed dissatisfaction in physicians’ approaches to care, which were compounded by experiences of racism and discrimination. Findings demonstrate how ACB patients are marginalized and excluded from the healthcare syste Iimplications for better access to care included utilizing community healthcare centres, increasing physicians’ capacity around culturally inclusive care, and increasing access to ACB physicians.
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Affiliation(s)
- Tiyondah Fante-Coleman
- Access and Equity Research Lab1, Department of Psychology2, Department of Health Sciences4 Wilfrid Laurier University, Waterloo, Ontario, Canada
- Dalla Lana School of Public Health5 University of Toronto, Toronto, Ontario, Canada
- Black Health Alliance, Toronto, Ontario, Canada
| | - Ciann L. Wilson
- Access and Equity Research Lab1, Department of Psychology2, Department of Health Sciences4 Wilfrid Laurier University, Waterloo, Ontario, Canada
- Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Ruth Cameron
- Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, Canada
- AIDS Committee of Cambridge, Kitchener, Waterloo and Area, Kitchener, Ontario, Canada
| | - Todd Coleman
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Robb Travers
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
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15
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Nguyen MLT, Schotland SV, Howell JD. From Individualized Interactions to Standardized Schedules: A History of Time Organization in U.S. Outpatient Medicine. Ann Intern Med 2022; 175:1468-1474. [PMID: 36037467 DOI: 10.7326/m22-1575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Many outpatient physicians and patients feel that current scheduling systems do not afford enough time for direct patient-physician interaction, leaving patients feeling unheard and physicians feeling demoralized. This dissatisfaction degrades patients' trust in the health care system and contributes to workforce moral injury and burnout. In the hopes of understanding the roots of this time stress and helping to guide future decisions about how to organize physicians' time, this article describes changes in the organization of U.S. outpatient physicians' time, starting from care at home in the late 19th century. It discusses the origins of the appointment system, which was invented to be highly personalized, with assistants adjusting appointment durations to accommodate clinical activities, specific patient needs, and individual physician proclivities. The article then describes how centralization of appointment scheduling became more common as U.S. medicine became increasingly consolidated into larger and larger groups and health systems. This distanced schedulers from the people and care they were organizing and necessitated standardized appointment durations, which did not accommodate individual patient and physician needs. With the rise of managerialism, schedulers became increasingly accountable to administrators rather than patients and physicians. Whereas early appointment systems depended on personal connection between schedulers and the physicians and patients they supported, today's schedulers have few such interactions. The widespread shift to centralized scheduling and standardized time slots has contributed to misalignment among time allocation, patient care, and health care workforce well-being and is likely exacerbating ongoing tensions among patients, physicians, and administrators.
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Affiliation(s)
- Michelle-Linh T Nguyen
- National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies, and Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, California (M.T.N.)
| | - Samuel V Schotland
- School of Medicine, University of Michigan, Ann Arbor, Michigan, and Program in the History of Science and Medicine, Yale University, New Haven, Connecticut (S.V.S.)
| | - Joel D Howell
- Department of Internal Medicine, Department of History, and Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan (J.D.H.)
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16
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Zikusooka M, Hanna R, Malaj A, Ertem M, Elci OC. Factors affecting patient satisfaction in refugee health centers in Turkey. PLoS One 2022; 17:e0274316. [PMID: 36112570 PMCID: PMC9480993 DOI: 10.1371/journal.pone.0274316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Turkey hosts an estimated 3.7 million Syrian refugees. Syrian refugees have access to free primary care provided through Refugee Health Centers(RHC). We aimed to determine factors that influence patient satisfaction in refugee health centers. METHODS The study was a cross-sectional quantitative study. A patient survey was administered among 4548 patients attending services in selected 16 provinces in Turkey. A quantitative questionnaire was used to collect information on patient satisfaction and experience in the healthcare facility. Information on "overall satisfaction with health services" was collected on a 5-point Likert scale and dichotomized for analysis. Logistic regression was conducted to identify factors that influenced patient satisfaction. RESULTS We found that 78.2% of the participants were satisfied with the health services they received. Factors related to service quality and communication were significant determinants of patient satisfaction. The strongest predictors of satisfaction were having a sufficient consultation time (AOR: 2.37; 95% CI: 1.76-3.21; p< 0.0001), receiving a comprehensive examination (AOR: 2.01; 95% CI: 1.49-2.70; p < 0.0001) and being treated with respect by the nurse (AOR: 2.08; 95% CI: 1.52-2.85; p< 0.0001). CONCLUSION Providing integrated, culturally and linguistically sensitive health services is important in refugee settings. The quality of service and communication with patients influence patient satisfaction in refugee health centers. As such, improvements in aspects such as consultation time and the quality of physician-patient interaction are recommended for patient satisfaction.
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Affiliation(s)
- Monica Zikusooka
- Refugee Health Programme, WHO Country Office in Turkey, WHO Regional Office for Europe, Turkey
| | - Radysh Hanna
- Refugee Health Programme, WHO Country Office in Turkey, WHO Regional Office for Europe, Turkey
| | - Altin Malaj
- Refugee Health Programme, WHO Country Office in Turkey, WHO Regional Office for Europe, Turkey
| | | | - Omur Cinar Elci
- Refugee Health Programme, WHO Country Office in Turkey, WHO Regional Office for Europe, Turkey
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17
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Miksanek TJ, Edwards ST, Weyer G, Laiteerapong N. Association of Time-Based Billing With Evaluation and Management Revenue for Outpatient Visits. JAMA Netw Open 2022; 5:e2229504. [PMID: 36044213 PMCID: PMC9434360 DOI: 10.1001/jamanetworkopen.2022.29504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Time-based billing options for physicians have expanded, enabling many physicians to bill according to time spent instead of medical decision-making (MDM) level for fee-for-service outpatient visits. However, no study to date has estimated the revenue changes associated with time-based billing. OBJECTIVE To compare evaluation and management (E/M) reimbursement for physicians using time-based billing vs MDM-based billing for outpatient visits of varying lengths. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation used 2019 billing data for outpatient E/M codes and 2021 reimbursement rates from the Centers for Medicare & Medicaid Services. Modeling of generic clinic templates was performed to estimate expected yearly E/M revenues for a single full-time physician working in an outpatient clinic using fee-for-service billing. MAIN OUTCOMES AND MEASURES Yearly E/M revenues for different patient visit templates were modeled. The standardized length of return patient visits was 10 to 45 minutes, and new patient visits were twice as long in duration. RESULTS Under MDM-based billing, increased visit length was associated with decreased E/M revenue ($564 188 for 30-minute new patient visit/15-minute return patient visit vs $423 137 for 40-minute new patient visit/20-minute return patient visit). Under time-based billing, yearly E/M revenue remained similar across increasing visit lengths ($400 432 for 30-minute new patient visit/15-minute return patient visit vs $458 718 for 40-minute new patient visit/20-minute return patient visit). Compared with time-based billing, MDM-based billing was associated with higher E/M revenue for 10- to 15-minute return patient visits ($400 432 vs $564 188). Time-based billing was associated with higher E/M revenue for return patient visits lasting 20 minutes or longer. The highest modeled E/M revenue of $846 273 occurred for 10-minute return patient visits under MDM-based billing. CONCLUSIONS AND RELEVANCE Results of this study showed that the relative economic benefits of MDM-based billing and time-based billing differed and were associated with the length of patient visits. Physicians with longer patient visits were more likely to experience revenue increases from using time-based billing than physicians with shorter patient visits.
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Affiliation(s)
- Tyler J. Miksanek
- Biological Sciences Division, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Samuel T. Edwards
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - George Weyer
- Biological Sciences Division, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Neda Laiteerapong
- Biological Sciences Division, Department of Medicine, University of Chicago, Chicago, Illinois
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18
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Chalmer R, Ayers E, Weiss EF, Malik R, Ehrlich A, Wang C, Zwerling J, Ansari A, Possin KL, Verghese J. The 5-Cog paradigm to improve detection of cognitive impairment and dementia: clinical trial protocol. Neurodegener Dis Manag 2022; 12:171-184. [PMID: 35603666 PMCID: PMC9245592 DOI: 10.2217/nmt-2021-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/05/2022] [Indexed: 11/21/2022] Open
Abstract
Cognitive impairment related to dementia is under-diagnosed in primary care despite availability of numerous cognitive assessment tools; under-diagnosis is more prevalent for members of racial and ethnic minority groups. Clinical decision-support systems may improve rates of primary care providers responding to positive cognitive assessments with appropriate follow-up. The 5-Cog study is a randomized controlled trial in 1200 predominantly Black and Hispanic older adults from an urban underserved community who are presenting to primary care with cognitive concerns. The study will validate a novel 5-minute cognitive assessment coupled with an electronic medical record-embedded decision tree to overcome the barriers of current cognitive assessment paradigms in primary care and facilitate improved dementia care.
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Affiliation(s)
- Rachel Chalmer
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Emmeline Ayers
- Department of Neurology, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Erica F Weiss
- Department of Neurology, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Rubina Malik
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Amy Ehrlich
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Cuiling Wang
- Department of Epidemiology & Population Health, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Jessica Zwerling
- Department of Neurology, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Asif Ansari
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Katherine L Possin
- Department of Neurology, Memory & Aging Center, University of California San Francisco, San Francisco, CA 94158, USA
| | - Joe Verghese
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
- Department of Neurology, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Cadena DS, Chaudhri A, Scott C. Contraceptive Care Using Reproductive Justice Principles: Beyond Access. Am J Public Health 2022; 112:S494-S499. [PMID: 35767782 PMCID: PMC10461485 DOI: 10.2105/ajph.2022.306915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Denicia Sam Cadena
- Denicia Sam Cadena is policy director at Bold Futures in Albuquerque, New Mexico, and a board member of SisterReach. Aisha Chaudhri is the reproductive autonomy manager at EverThrive Illinois in Chicago, the co-chair of the board of directors of the Illinois Caucus for Adolescent Health in Chicago, and a steering committee member of the American Society for Emergency Contraception, Cambridge, MA. Cherisse Scott is founder and CEO at SisterReach, Memphis, TN
| | - Aisha Chaudhri
- Denicia Sam Cadena is policy director at Bold Futures in Albuquerque, New Mexico, and a board member of SisterReach. Aisha Chaudhri is the reproductive autonomy manager at EverThrive Illinois in Chicago, the co-chair of the board of directors of the Illinois Caucus for Adolescent Health in Chicago, and a steering committee member of the American Society for Emergency Contraception, Cambridge, MA. Cherisse Scott is founder and CEO at SisterReach, Memphis, TN
| | - Cherisse Scott
- Denicia Sam Cadena is policy director at Bold Futures in Albuquerque, New Mexico, and a board member of SisterReach. Aisha Chaudhri is the reproductive autonomy manager at EverThrive Illinois in Chicago, the co-chair of the board of directors of the Illinois Caucus for Adolescent Health in Chicago, and a steering committee member of the American Society for Emergency Contraception, Cambridge, MA. Cherisse Scott is founder and CEO at SisterReach, Memphis, TN
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20
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Linzer M, Rogers EA, Eton DT. Reducing the Burden of Treatment: Addressing How Our Patients Feel About What We Ask of Them: A "Less Is More" Perspective. Mayo Clin Proc 2022; 97:826-829. [PMID: 35414438 PMCID: PMC9081254 DOI: 10.1016/j.mayocp.2022.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 12/01/2021] [Accepted: 01/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Mark Linzer
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN.
| | - Elizabeth A Rogers
- Division of General Internal Medicine, University of Minnesota, Minneapolis
| | - David T Eton
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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21
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Pestka DL, Paterson NL, Brummel AR, Norman JA, White KM. Barriers and facilitators to implementing pharmacist-provided comprehensive medication management in primary care transformation. Am J Health Syst Pharm 2022; 79:1255-1265. [PMID: 35390120 PMCID: PMC9305504 DOI: 10.1093/ajhp/zxac104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE How to effectively integrate pharmacists into team-based models of care to maximize the benefit they bring to patients and care teams, especially during times of primary care transformation (PCT), remains unknown. The objective of this study was to identify barriers and facilitators when integrating pharmacist-provided comprehensive medication management (CMM) services into a health system's team-based PCT using the Consolidated Framework for Implementation Research (CFIR). METHODS Semistructured qualitative interviews were carried out with 22 care team members regarding their perceptions of the implementation of CMM in the PCT. Transcripts were coded to identify CMM implementation barriers and facilitators, and resulting codes were mapped to corresponding CFIR domains and constructs. RESULTS Fifteen codes emerged that were labeled as either a barrier or a facilitator to implementing CMM in the PCT. Facilitators were the perception of CMM as an invaluable resource, precharting, tailored appointment lengths, insurance coverage, increased pharmacy presence, enhanced team-based care, location of CMM, and identification of CMM advocates. Barriers included limited clinic leadership involvement, a need for additional resources, CMM pharmacists not always feeling part of the core team, understanding of and training around CMM's role in the PCT, changing mindsets to utilize resources such as CMM more frequently, underutilization of CMM, and CMM scheduling. CONCLUSION Clinical pharmacists providing CMM represent a valuable interdisciplinary care team member who can help improve healthcare quality and access to primary care. Identifying and addressing implementation barriers and facilitators early during PCT rollout is critical to the success of team-based services such as CMM and becoming a learning health system.
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Affiliation(s)
- Deborah L Pestka
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | | | | | | | - Katie M White
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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22
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Borghmans F. The radical and requisite openness of viable systems: Implications for healthcare strategy and practice. J Eval Clin Pract 2022; 28:324-331. [PMID: 33977559 DOI: 10.1111/jep.13576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/18/2021] [Indexed: 11/29/2022]
Abstract
This paper addresses an ontological question about the nature of health and challenges some underpinning assumptions in western healthcare. In its analysis, health in its various statuses, is framed as a naturally occurring complex adaptive system made up of dynamically interacting subsystems that include the physiological, psychological, and social realms. Furthermore, openness in complex systems such as health, is necessary for the exchange of energy, information, and resources. Yet, within healthcare much effort is invested in constraining systems' behaviours, whether they be systems of knowledge, health, healthcare, and more. This paper draws on the complexity sciences and Levinasian philosophy to explicate the essential role of system openness in individual, population, and systemic viability. It highlights holism to be "not whole-ism", and system openness to be, not just a reality, but a critical feature of viability. Hence requisite openness is advocated as essential to efficacious and ethical healthcare practice and strategy, and vital for health.
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Affiliation(s)
- Felice Borghmans
- Faculty of Education, Monash University, Wellington Road, Clayton, Victoria, 3800, Australia
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23
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Swanson KM, Matulis JC, McCoy RG. Association between primary care appointment lengths and subsequent ambulatory reassessment, emergency department care, and hospitalization: a cohort study. BMC PRIMARY CARE 2022; 23:39. [PMID: 35249539 PMCID: PMC8900401 DOI: 10.1186/s12875-022-01644-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 02/08/2022] [Indexed: 12/18/2022]
Abstract
Background To meet increasing demand, healthcare systems may leverage shorter appointment lengths to compensate for a limited supply of primary care providers (PCPs). Limiting the time spent with patients when evaluating acute health needs may adversely affect quality of care and increase subsequent healthcare utilization; however, the impact of brief duration appointments on healthcare utilization in the United States has not been examined. This study aimed to assess for potential inferiority of shorter (15-min) primary care appointments compare to longer (≥ 30-min appointments) with respect to downstream healthcare utilization within 7 days of the initial appointment. Methods We performed a retrospective cohort study using electronic health record (EHR), billing, and administrative scheduling data from five primary care practices in Midwest United States. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 were included. Patients scheduled for 15-min appointments were propensity score matched to those scheduled for ≥ 30-min. Multivariate regression models examined the effects of appointment length on repeat primary care visits, emergency department (ED) visits, hospitalizations, and diagnostic services within 7 days following the visit. Models were adjusted for baseline patient, visit, and provider characteristics. A non-inferiority approach was employed. Results We identified 173,758 total index visits (6.5% 15-min, 93.5% ≥ 30-min). 11,222 15-min appointments were matched to a comparable ≥ 30-min visit. Longer appointments were more frequent among trainee physicians, patients with limited English proficiency, and patients with more comorbidities. There was no significant effect of scheduled appointment length on the incidence of repeat primary care visits (OR = 0.983, CI: 0.873, 1.106) or ED visits (OR = 0.856, CI: 0.700, 1.047). Shorter appointments were associated with lower rates of subsequent hospitalizations (OR = 0.689, CI: 0.504, 0.941), laboratory services (OR = 0.682, CI: 0.643, 0.724), and diagnostic imaging services (OR = 0.499, CI: 0.466, 0.534). None of the non-inferiority thresholds were exceeded. Conclusions For select indications and select low risk patients, shorter duration appointments may be a non-inferior option for scheduling of patient care that will not result in greater downstream healthcare utilization. These findings can help inform healthcare delivery models and triage processes as health systems and payers re-examine how to best deliver care to growing patient populations. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01644-8.
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Affiliation(s)
- Kristi M Swanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, USA.
| | - John C Matulis
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, USA
| | - Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, USA.,Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, USA
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Pestka DL, White KM, DeRoche KK, Benson BJ, Beebe TJ. 'Trying to fly the plane while we were building it'. Applying a learning health systems approach to evaluate early-stage barriers and facilitators to implementing primary care transformation: a qualitative study. BMJ Open 2022; 12:e053209. [PMID: 34980618 PMCID: PMC8724704 DOI: 10.1136/bmjopen-2021-053209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE A learning health system (LHS) uses data to generate evidence and answer questions required to continually improve system performance and patient care. Given the complexities of practice transformation, an area where LHS is particularly important is the study of primary care transformation (PCT) as PCT generates several practice-level questions that require study where the findings can be readily implemented. In May 2019, a large integrated health delivery system in Minnesota began implementation of a population management PCT in two of its 40 primary care clinics. In this model of care, patients are grouped into one of five service bundles based on their complexity of care; patient appointment lengths and services provided are then tailored to each service bundle. The objective of this study was to examine the use of a LHS in PCT by utilising the Consolidated Framework for Implementation Research (CFIR) to categorise implementation lessons from the initial two PCT clinics to inform further implementation of the PCT within the health system. DESIGN This was a formative evaluation in which semistructured qualitative interviews were carried out. Observational field notes were also taken. Inductive coding of the data was performed and resultant codes were mapped to the CFIR. SETTING Two suburban primary care clinics in the Twin Cities, Minnesota. PARTICIPANTS Twenty-two care team members from the first two clinics to adopt the PCT. RESULTS Seventeen codes emerged to describe care team members' perceived implementation influences. Codes occurred in each of the five CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals and process), with most codes occurring in the 'inner setting' domain. CONCLUSIONS Using an LHS approach to determine early-stage implementation influences is key to guiding further PCT implementation, understanding modifications that need to be made and additional research that needs to occur.
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Affiliation(s)
- Deborah L Pestka
- College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Katie M White
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Bradley J Benson
- School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Timothy J Beebe
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Overgaard SM, Peterson KJ, Wi CI, Kshatriya BSA, Ohde JW, Brereton T, Zheng L, Rost L, Zink J, Nikakhtar A, Pereira T, Sohn S, Myers L, Juhn YJ. A Technical Performance Study and Proposed Systematic and Comprehensive Evaluation of an ML-based CDS Solution for Pediatric Asthma. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2022:25-35. [PMID: 35854754 PMCID: PMC9285150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Achieving optimal care for pediatric asthma patients depends on giving clinicians efficient access to pertinent patient information. Unfortunately, adherence to guidelines or best practices has shown to be challenging, as relevant information is often scattered throughout the patient record in both structured data and unstructured clinical notes. Furthermore, in the absence of supporting tools, the onus of consolidating this information generally falls upon the clinician. In this study, we propose a machine learning-based clinical decision support (CDS) system focused on pediatric asthma care to alleviate some of this burden. This framework aims to incorporate a machine learning model capable of predicting asthma exacerbation risk into the clinical workflow, emphasizing contextual data, supporting information, and model transparency and explainability. We show that this asthma exacerbation model is capable of predicting exacerbation with an 0.8 AUC-ROC. This model, paired with a comprehensive informatics-based process centered on clinical usability, emphasizes our focus on meeting the needs of the clinical practice with machine learning technology.
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Affiliation(s)
| | | | - Chung Ii Wi
- Precision Population Science Lab, Mayo Clinic, Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bhavani Singh Agnikula Kshatriya
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester
| | - Joshua W Ohde
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota
| | - Tracey Brereton
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota
| | - Lu Zheng
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota
| | - Lauren Rost
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota
| | - Janet Zink
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota
| | - Amin Nikakhtar
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota
| | - Tara Pereira
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota
| | - Sunghwan Sohn
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester
| | - Lynnea Myers
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Young J Juhn
- Precision Population Science Lab, Mayo Clinic, Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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Mollica RF, Fricchione GL. Mental and physical exhaustion of health-care practitioners. Lancet 2021; 398:2243-2244. [PMID: 34922665 PMCID: PMC8676692 DOI: 10.1016/s0140-6736(21)02663-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/16/2021] [Indexed: 10/31/2022]
Affiliation(s)
- Richard F Mollica
- Harvard Program in Refugee Trauma, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | - Gregory L Fricchione
- Benson-Henry Institute of Mind-Body Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Pestka DL, Brummel AR, Wong MT, Rajpurohit A, Elert BA, Farley JF. Characterizing the reach of comprehensive medication management in a population health primary care model. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021; 4:1410-1419. [PMID: 34805778 PMCID: PMC8596459 DOI: 10.1002/jac5.1525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/11/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION As care teams adopt team-based models of care, it is important to examine the reach of interdisciplinary services, such as pharmacists providing comprehensive medication management (CMM). This study examined the reach of pharmacist-delivered CMM in the first 10 months of a population health-focused primary care transformation (PCT). METHODS Using electronic health record data, descriptive statistics (counts and percentages, as well as means and standard deviations) were quantified to summarize the patients who received CMM in two PCT pilot clinics pre- and post-PCT. RESULTS Patients who had at least one CMM visit increased from 554 during the pre-PCT window to 880 during the post-PCT window. However, when adjusted for the increased pharmacist full-time equivalents (FTE) included as part of the PCT, 462 and 330 patients/FTE were seen in the pre- vs post-PCT periods, respectively. When calculating the percentage of patients who received CMM, this increased from 2.3% of all primary care patients seen in the two pilot clinics before the PCT began to 4.4% after the PCT was implemented. Most patient demographics remained largely the same between the pre- and post-PCT periods. However, CMM patients seen in the post-PCT period had more medication therapy problems across all medication therapy problem categories compared to patients in the pre-PCT period. Additionally, patients receiving CMM had significantly more conditions and medications and higher hospitalizations and emergency department use compared to the general clinic population. CONCLUSIONS Reach is an important implementation outcome to determine the representativeness of individuals participating in a given service. This study illustrates that pharmacists providing CMM see complex patients with a high propensity for medication therapy problems. However, opportunities exist to improve the reach of CMM and, in turn, enhance team-based care.
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Affiliation(s)
- Deborah L. Pestka
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Abhijeet Rajpurohit
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | | | - Joel F. Farley
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
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28
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Seol HY, Shrestha P, Muth JF, Wi CI, Sohn S, Ryu E, Park M, Ihrke K, Moon S, King K, Wheeler P, Borah B, Moriarty J, Rosedahl J, Liu H, McWilliams DB, Juhn YJ. Artificial intelligence-assisted clinical decision support for childhood asthma management: A randomized clinical trial. PLoS One 2021; 16:e0255261. [PMID: 34339438 PMCID: PMC8328289 DOI: 10.1371/journal.pone.0255261] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/08/2021] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Clinical decision support (CDS) tools leveraging electronic health records (EHRs) have been an approach for addressing challenges in asthma care but remain under-studied through clinical trials. OBJECTIVES To assess the effectiveness and efficiency of Asthma-Guidance and Prediction System (A-GPS), an Artificial Intelligence (AI)-assisted CDS tool, in optimizing asthma management through a randomized clinical trial (RCT). METHODS This was a single-center pragmatic RCT with a stratified randomization design conducted for one year in the primary care pediatric practice of the Mayo Clinic, MN. Children (<18 years) diagnosed with asthma receiving care at the study site were enrolled along with their 42 primary care providers. Study subjects were stratified into three strata (based on asthma severity, asthma care status, and asthma diagnosis) and were blinded to the assigned groups. MEASUREMENTS Intervention was a quarterly A-GPS report to clinicians including relevant clinical information for asthma management from EHRs and machine learning-based prediction for risk of asthma exacerbation (AE). Primary endpoint was the occurrence of AE within 1 year and secondary outcomes included time required for clinicians to review EHRs for asthma management. MAIN RESULTS Out of 555 participants invited to the study, 184 consented for the study and were randomized (90 in intervention and 94 in control group). Median age of 184 participants was 8.5 years. While the proportion of children with AE in both groups decreased from the baseline (P = 0.042), there was no difference in AE frequency between the two groups (12% for the intervention group vs. 15% for the control group, Odds Ratio: 0.82; 95%CI 0.374-1.96; P = 0.626) during the study period. For the secondary end points, A-GPS intervention, however, significantly reduced time for reviewing EHRs for asthma management of each participant (median: 3.5 min, IQR: 2-5), compared to usual care without A-GPS (median: 11.3 min, IQR: 6.3-15); p<0.001). Mean health care costs with 95%CI of children during the trial (compared to before the trial) in the intervention group were lower than those in the control group (-$1,036 [-$2177, $44] for the intervention group vs. +$80 [-$841, $1000] for the control group), though there was no significant difference (p = 0.12). Among those who experienced the first AE during the study period (n = 25), those in the intervention group had timelier follow up by the clinical care team compared to those in the control group but no significant difference was found (HR = 1.93; 95% CI: 0.82-1.45, P = 0.10). There was no difference in the proportion of duration when patients had well-controlled asthma during the study period between the intervention and the control groups. CONCLUSIONS While A-GPS-based intervention showed similar reduction in AE events to usual care, it might reduce clinicians' burden for EHRs review resulting in efficient asthma management. A larger RCT is needed for further studying the findings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02865967.
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Affiliation(s)
- Hee Yun Seol
- Precision Population Science Lab, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Pragya Shrestha
- Precision Population Science Lab, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Joy Fladager Muth
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Chung-Il Wi
- Precision Population Science Lab, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sunghwan Sohn
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Euijung Ryu
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kathy Ihrke
- Precision Population Science Lab, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sungrim Moon
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Katherine King
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Philip Wheeler
- Precision Population Science Lab, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Bijan Borah
- Department of Health Service Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - James Moriarty
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jordan Rosedahl
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Hongfang Liu
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Deborah B. McWilliams
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Young J. Juhn
- Precision Population Science Lab, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
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Can We Ask Everyone? Addressing Sexual Abuse in Primary Care. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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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.
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Matulis JC, McCoy R. Patient-Centered Appointment Scheduling: a Call for Autonomy, Continuity, and Creativity. J Gen Intern Med 2021; 36:511-514. [PMID: 32885369 PMCID: PMC7471539 DOI: 10.1007/s11606-020-06058-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/13/2020] [Indexed: 10/25/2022]
Abstract
When making an appointment, patients are generally unaware of how much clinician time is available to address their concerns. Similarly, the primary care clinician is often unaware of what the patient expects to accomplish during the visit, leading to uncertainty about how much time they can allot to each sequentially appearing concern, and whether they can reasonably expect to address necessary preventive services and chronic disease management. Neither patient nor clinician expectations can be adequately managed through standardized scheduling templates, which assign a fixed appointment length based on a single stated reason for the visit. As such, standardized appointment scheduling may contribute to inefficient use of valuable face-to-face time, patient and clinician dissatisfaction, and low-value care. Herein, we suggest several potential mechanisms for improving the scheduling process, including (1) entrusting scheduling to the primary care team; (2) advance visit planning; (3) pro-active engagement of ancillary team members including behavioral health, nursing, social work, and pharmacy; and (4) application of innovative, technologically advanced solutions such as telehealth and artificial intelligence to the scheduling process. These changes have the potential to improve efficiency, patient and clinician satisfaction, and health outcomes, while decreasing low-value testing and return visits for unaddressed concerns.
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Affiliation(s)
- John C Matulis
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, 200 1st ST SW, Rochester, MN, 55905, USA.
| | - Rozalina McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, 200 1st ST SW, Rochester, MN, 55905, USA
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Vesco KK, Leo MC, Bulkley JE, Beadle KR, Stoneburner AB, Francisco M, Clark AL. Improving management of the genitourinary syndrome of menopause: evaluation of a health system-based, cluster-randomized intervention. Am J Obstet Gynecol 2021; 224:62.e1-62.e13. [PMID: 32693097 DOI: 10.1016/j.ajog.2020.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 07/01/2020] [Accepted: 07/15/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Genitourinary symptoms are common in postmenopausal women and adversely affect the quality of life. National surveys and data collected from our healthcare system indicate that postmenopausal women with the genitourinary syndrome of menopause often fail to receive appropriate diagnosis or treatment. OBJECTIVE To promote greater detection and treatment of the genitourinary syndrome of menopause, we created and tested a clinician-focused health system intervention that included clinician education sessions and a suite of evidence-based electronic health record tools. STUDY DESIGN Using a cluster-randomized design, we allocated primary care (16) and gynecology (6) clinics to the intervention or control group. From September to November 2014, we provided training about the diagnosis and treatment of genitourinary syndrome of menopause in face-to-face presentations at each intervention clinic and in an online video. We developed clinical decision support tools in the electronic health record that contained an evidence-based, point-of-care knowledge resource, a standardized order set, and a checklist of patient education materials for the patient's after visit summary. The tools aimed to facilitate accurate diagnostic coding and prescribing (SmartSet, SmartRx) along with relevant patient information (SmartText). Clinicians who only performed visits at control clinics received no training or notification about the tools. Our primary outcome was vulvovaginal diagnoses made at well visits for women at the age of 55 years and older from November 15, 2014 to November 15, 2015. We also assessed urinary diagnoses, vaginal estrogen prescriptions, and use of the electronic tools. There was departmental support for the intervention but no prioritization within the healthcare system to incentivize change. RESULTS In the 1-year period, 386 clinicians performed 14,921 well visits for women at the age of 55 years and older. Among the 190 clinicians who performed well visits in the intervention clinics, 109 (57.4%) completed either in-person or online educational training. The proportion of visits that included a vulvovaginal (7.2% vs 5.8%; odds ratio, 1.27; 95% confidence interval, 0.65-2.51) or urinary diagnosis (2.5% vs 3.1%; odds ratio, 0.79; 95% confidence interval, 0.55-1.13) or vaginal estrogen prescription (4.5% vs 3.7%; odds ratio, 1.24; 95% confidence interval, 0.63-2.46) did not differ between study arms. There was a significant interaction for primary care and gynecology, which revealed more vulvovaginal diagnoses by gynecology but not primary care intervention clinics (odds ratio, 1.63; 95% confidence interval, 1.15-2.31), but there was no significant interaction for prescriptions. Clinicians in the intervention clinics were more likely to use decision support tools than those in control clinics-SmartSet (22.2% vs 1.5%; odds ratio, 18.8; 95% confidence interval, 5.5-63.8) and SmartText for patient information (38.0% vs 24.4%; odds ratio, 1.91; 95% confidence interval, 1.10-3.34). A per-protocol analysis revealed similar findings. CONCLUSION Overall, the intervention did not lead to more diagnoses or prescription therapy for postmenopausal genitourinary symptoms but did result in greater distribution of patient information. Gynecology clinicians were more likely to address genitourinary symptoms generally and were more likely to make a vulvovaginal diagnosis after the intervention. Further efforts for improving care should consider ongoing clinician education beginning with enhanced menopause curricula in residency training. Additional interventions to consider include greater access for postmenopausal women to gynecologic care, addressing treatment barriers, and development of national performance metrics.
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Affiliation(s)
- Kimberly K Vesco
- Kaiser Permanente Center for Health Research, Portland, OR; Department of Obstetrics and Gynecology, Kaiser Permanente Northwest, Portland, OR.
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, OR
| | | | - Kate R Beadle
- Department of Obstetrics and Gynecology, Kaiser Permanente Northwest, Portland, OR
| | | | | | - Amanda L Clark
- Kaiser Permanente Center for Health Research, Portland, OR; Department of Obstetrics and Gynecology, Kaiser Permanente Northwest, Portland, OR
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Neprash HT, Everhart A, McAlpine D, Smith LB, Sheridan B, Cross DA. Measuring Primary Care Exam Length Using Electronic Health Record Data. Med Care 2021; 59:62-66. [PMID: 33301282 DOI: 10.1097/mlr.0000000000001450] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Physicians' time with patients is a critical input to care, but is typically measured retrospectively through survey instruments. Data collected through the use of electronic health records (EHRs) offer an alternative way to measure visit length. OBJECTIVE To measure how much time primary care physicians spend with their patients, during each visit. RESEARCH DESIGN We used a national source of EHR data for primary care practices, from a large health information technology company. We calculated exam length and schedule deviations based on timestamps recorded by the EHR, after implementing sequential data refinements to account for non-real-time EHR use and clinical multitasking. Observational analyses calculated and plotted the mean, median, and interquartile range of exam length and exam length relative to scheduled visit length. SUBJECTS A total of 21,010,780 primary care visits in 2017. MEASURES We identified primary care visits based on physician specialty. For these visits, we extracted timestamps for EHR activity during the exam. We also extracted scheduled visit length from the EHR's practice management functionality. RESULTS After data refinements, the average primary care exam was 18.0 minutes long (SD=13.5 min). On average, exams ran later than their scheduled duration by 1.2 minutes (SD=13.5 min). Visits scheduled for 10 or 15 minutes were more likely to exceed their allotted time than visits scheduled for 20 or 30 minutes. CONCLUSIONS Time-stamped EHR data offer researchers and health systems an opportunity to measure exam length and other objects of interest related to time.
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Affiliation(s)
- Hannah T Neprash
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Alexander Everhart
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Donna McAlpine
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN
| | | | | | - Dori A Cross
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN
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Lee M, Leonard C, Greene P, Kenney R, Whittington MD, Kirsh S, Ho PM, Sayre G, Simonetti J. Perspectives of VA Primary Care Clinicians Toward Electronic Consultation-Related Workload Burden: A Qualitative Analysis. JAMA Netw Open 2020; 3:e2018104. [PMID: 33125494 PMCID: PMC7599439 DOI: 10.1001/jamanetworkopen.2020.18104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Electronic consultation (e-consultation) is increasingly being adopted to expand access to specialty care and reduce health care costs. Little is known about clinicians' perceptions of using e-consultations, which may be associated with program adoption. OBJECTIVE To identify perceptions of primary care clinicians in the US Veterans Health Administration (VHA) system about e-consultation and workload. DESIGN, SETTING, AND PARTICIPANTS A qualitative study using semistructured interviews was conducted from September 2017 through March 2018 in a national sample of VHA primary care clinics in the US. Participants were primary care clinicians who had at least 300 total patient encounters from July 2016 to June 2017, including at least 1 e-consultation request. A convenience sample of participants was recruited using email invitations. Deductive and inductive content analysis were used to identify themes. Data were analyzed from October 2017 to April 2018. EXPOSURES Use of e-consultation. MAIN OUTCOMES AND MEASURES Primary care clinician perspectives regarding e-consultation and their workload. RESULTS A total of 34 primary care clinicians enrolled working across 27 VHA clinical sites were included; 9 (26%) were between ages 40-49 years; 23 (68%) were female. Three themes were identified. First, the process of entering, tracking, and following up on e-consultations added a time burden to primary care clinicians. Second, e-consultation was perceived to shift diagnostic and follow-up responsibilities from specialists to primary care clinicians. Third, e-consultations were thought to improve the timeliness and quality of care provided despite a perceived increase in workload. CONCLUSIONS AND RELEVANCE In this study, participants perceived e-consultation as valuable for patient care but also as an increase in their workload. Further work is warranted to quantify the workload increase on clinician burnout, job satisfaction, and turnover.
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Affiliation(s)
- Marcie Lee
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
| | - Chelsea Leonard
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
| | - Preston Greene
- Department of Health Services, University of Washington, Seattle
| | - Rachael Kenney
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
| | - Melanie D. Whittington
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | - Susan Kirsh
- Office of Specialty Care and Specialty Care Transformation, Washington, DC
| | - P. Michael Ho
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - George Sayre
- Department of Health Services, University of Washington, Seattle
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Joseph Simonetti
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora
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Almeida SS, Zizzi FB, Cattaneo A, Comandini A, Di Dato G, Lubrano E, Pellicano C, Spallone V, Tongiani S, Torta R. Management and Treatment of Patients With Major Depressive Disorder and Chronic Diseases: A Multidisciplinary Approach. Front Psychol 2020; 11:542444. [PMID: 33101117 PMCID: PMC7546762 DOI: 10.3389/fpsyg.2020.542444] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/01/2020] [Indexed: 12/26/2022] Open
Abstract
In patients with physical chronic diseases, the prevalence of major depressive disorder (MDD) is approximately 2- to 3-fold higher than in the general population, and it can reach up to 20-40%. The comorbidity of MDD with chronic medical diseases is associated with poorer quality of life, increased medical symptom burden, poor adherence to self-care regimens, increased risk of functional impairment, morbidity, and mortality, and also higher medical costs. Despite this evidence, in routine practice, psychological issues and concerns are frequently inadequately managed. This consensus document proposes that a proper diagnosis, a multidisciplinary approach, and a personalized treatment plan would allow patients with MDD and chronic comorbidities to be more compliant, to improve the outcomes, to reduce possible relapses in the long term, and to prevent or better manage complications and adverse events. This proposal might be useful for any health professionals who deal with patients with chronic diseases, as it can help to pay more attention to the emotional impact of these conditions, in particular in terms of depressive symptoms.
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Affiliation(s)
- Susana Sousa Almeida
- Portuguese Institute of Oncology Porto (IPO Porto), Hospital Cuf Porto (HCuf Porto), University of Porto (FMUP), Porto, Portugal
| | | | - Agnese Cattaneo
- Angelini RR&D (Research, Regulatory & Development) - Angelini S.p.A, Rome, Italy
| | - Alessandro Comandini
- Angelini RR&D (Research, Regulatory & Development) - Angelini S.p.A, Rome, Italy
| | - Giorgio Di Dato
- Angelini RR&D (Research, Regulatory & Development) - Angelini S.p.A, Rome, Italy
| | - Ennio Lubrano
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della salute "Vincenzo Tiberio", Università degli Studi del Molise, Campobasso, Italy
| | - Clelia Pellicano
- Laboratory of Neuropsychiatry, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Santa Lucia Foundation, Rome, Italy
| | - Vincenza Spallone
- Division of Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Serena Tongiani
- Angelini RR&D (Research, Regulatory & Development) - Angelini S.p.A, Rome, Italy
| | - Riccardo Torta
- Clinical Psychology and Psycho-Oncology Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, A.O.U. "Città della Salute e della Scienza" Hospital, Turin, Italy
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36
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Job stress among GPs: associations with practice organisation in 11 high-income countries. Br J Gen Pract 2020; 70:e657-e667. [PMID: 32661010 PMCID: PMC7363272 DOI: 10.3399/bjgp20x710909] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/25/2020] [Indexed: 11/29/2022] Open
Abstract
Background Job stress among GPs is an issue of growing concern. Aim To investigate whether the structural and organisational features of GPs’ practices were associated with job stress in 11 countries. Design and setting Secondary analysis of the 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, an international cross-sectional study. A total of 11 Western countries participated in the 2015 edition. Method Random samples of practising GPs were drawn from government or private lists in each country (N = 12 049). Job stress was measured by the question: ‘How stressful is your job as a GP?’ (5-point Likert scale). Numerous practices’ organisation and functioning characteristics were considered. Multilevel mixed-effects ordered logistic regression was performed. Results The prevalence of job stress varied from 18% to 59% according to country. Job stress was higher among GPs aged 45–54 years (middle age) (odds ratio [OR] 1.35, 95% confidence interval [CI] = 1.07 to 1.70) and those practising in an urban area (OR 1.23, 95% CI = 1.15 to 1.31). It was also associated with a high weekly workload (OR 2.88, 95% CI = 2.38 to 3.50) if >50 hours/week workload, large administrative burden (OR 1.65, 95% CI = 1.44 to 1.89), long delays in receiving hospital discharge, poor possibilities in offering same-day appointments (OR 1.74, 95% CI = 1.18 to 2.56), and performance assessment (OR 1.15, 95% CI = 1.05 to 1.24). Finally, long consultations (OR 0.64, 95% CI = 0.53 to 0.76) and working with a case manager attached to the practice were associated with a lower job stress. The vast majority of results were consistent across the countries. Conclusion Heavy workloads and time pressure are clearly associated with GP job stress. However, organisational changes such as employing case managers and allowing longer consultations could potentially reduce this burden.
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Feng Z, Williams D, Ladapo JA. Differences in Cardiovascular Care Between Adults With and Without Opioid Prescriptions in the United States. J Am Heart Assoc 2020; 9:e015961. [PMID: 32458701 PMCID: PMC7429007 DOI: 10.1161/jaha.120.015961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Patients prescribed opioids often have chronic conditions that increase their risk of adverse cardiovascular outcomes, but little is known about the primary preventive cardiovascular care these patients receive. Methods and Results We analyzed data from the 2014 to 2016 National Ambulatory Medical Care Survey to evaluate physicians’ provision of primary preventive cardiovascular care to adults with and without opioid prescriptions. We included all visits made by adults 40 to 79 years old with at least 1 cardiovascular risk factor but no existing atherosclerotic cardiovascular disease. There were ≈32 million visits by adults who were prescribed opioids and ≈167 million visits by adults not prescribed opioids on an annual basis. The prevalence of primary preventive care was modest in patients with versus those without opioid prescriptions, respectively: (1) statins for patients with dyslipidemia (52.1% versus 46.3%); (2) statins for patients with diabetes mellitus (49.1% versus 37.9%); (3) antihypertensive agents for patients with hypertension (76.5% versus 65.8%); (4) diet/exercise counseling (40.5% versus 45.3%); and (5) smoking cessation therapy (25.3% versus 19.3%). In multivariate analyses, opioid use was associated with higher rates of statin therapy in patients with diabetes mellitus (adjusted relative risk [aRR], 1.25; 95% CI, 1.06–1.47; P=0.007) and antihypertensive medication in patients with hypertension (aRR 1.14; 95% CI, 1.06–1.22; P<0.001). Conclusions Overall adherence to guideline‐recommended primary preventive cardiovascular care during ambulatory visits was suboptimal. Findings show that patients prescribed opioids versus those without opioid prescriptions were more likely to receive statin therapy and antihypertensive agents in the setting of diabetes mellitus and hypertension, respectively. Ongoing efforts to bridge these gaps in primary prevention of cardiovascular disease remain a high priority.
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Affiliation(s)
- Zekun Feng
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Dominic Williams
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Joseph A Ladapo
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
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Berk SI. Time to Care: Primary Care Visit Duration and Value-Based Healthcare. Am J Med 2020; 133:655-656. [PMID: 32017894 DOI: 10.1016/j.amjmed.2019.12.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 12/30/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Steven I Berk
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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Prasad K, Poplau S, Brown R, Yale S, Grossman E, Varkey AB, Williams E, Neprash H, Linzer M. Time Pressure During Primary Care Office Visits: a Prospective Evaluation of Data from the Healthy Work Place Study. J Gen Intern Med 2020; 35:465-472. [PMID: 31797160 PMCID: PMC7018911 DOI: 10.1007/s11606-019-05343-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 07/10/2019] [Accepted: 08/28/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND The relationship between worklife factors, clinician outcomes, and time pressure during office visits is unclear. OBJECTIVE To quantify associations between time pressure, workplace characteristics ,and clinician outcomes. DESIGN Prospective analysis of data from the Healthy Work Place randomized trial. PARTICIPANTS 168 physicians and advanced practice clinicians in 34 primary care practices in Upper Midwest and East Coast. MAIN MEASURES AND METHODS Time pressure was present when clinicians needed more time than allotted to provide quality care. Other metrics included work control, work pace (calm to chaotic), organizational culture and clinician satisfaction, stress, burnout, and intent to leave the practice. Hierarchical analysis assessed relationships between time pressure, organizational characteristics, and clinician outcomes. Adjusted differences between clinicians with and without time pressure were expressed as effect sizes (ESs). KEY RESULTS Sixty-seven percent of clinicians needed more time for new patients and 53% needed additional time for follow-up appointments. Time pressure in new patient visits was more prevalent in general internists than in family physicians (74% vs 55%, p < 0.05), women versus men (78% vs 55%, p < 0.01), and clinicians with larger numbers of complex psychosocial (81% vs 59%, p < 0.01) and Limited English Proficiency patients (95% vs 57%, p < 0.001). Time pressure in new patient visits was associated with lack of control, clinician stress, and intent to leave (ESs small to moderate, p < 0.05). Time pressure in follow-up visits was associated with chaotic workplaces and burnout (small to moderate ESs, p's < 0.05). Time pressure improved over time in workplaces with values alignment and an emphasis on quality. CONCLUSIONS Time pressure, more common in women and general internists, was related to chaos, control and culture, and stress, burnout, and intent to leave. Future studies should evaluate these findings in larger and more geographically diverse samples.
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Affiliation(s)
- Kriti Prasad
- Division of General Internal Medicine, Hennepin Healthcare, Minneapolis, MN, USA.,Office of Professional Worklife, Hennepin Healthcare, Minneapolis, MN, USA.,Hennepin Healthcare Research Institute, Hennepin Healthcare, Minneapolis, MN, USA
| | - Sara Poplau
- Division of General Internal Medicine, Hennepin Healthcare, Minneapolis, MN, USA.,Office of Professional Worklife, Hennepin Healthcare, Minneapolis, MN, USA.,Hennepin Healthcare Research Institute, Hennepin Healthcare, Minneapolis, MN, USA
| | - Roger Brown
- School of Nursing, UW-Madison, Madison, WI, USA
| | - Steven Yale
- University of Central Florida College of Medicine, Lake Nona, Orlando, FL, USA
| | | | - Anita B Varkey
- Loyola University Stritch School of Medicine, Maywood, IL, USA
| | | | - Hannah Neprash
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Mark Linzer
- Division of General Internal Medicine, Hennepin Healthcare, Minneapolis, MN, USA. .,Office of Professional Worklife, Hennepin Healthcare, Minneapolis, MN, USA. .,Hennepin Healthcare Research Institute, Hennepin Healthcare, Minneapolis, MN, USA. .,Department of Medicine, Hennepin Healthcare, 701 Park Ave (G5), Minneapolis, MN, 55415, USA.
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40
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Manze MG, Calixte C, Romero DR, Roberts L, Perlman M, Langston A, Jones HE. Physician perspectives on routine pregnancy intention screening and counseling in primary care. Contraception 2019; 101:91-96. [PMID: 31881220 DOI: 10.1016/j.contraception.2019.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 11/07/2019] [Accepted: 11/10/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To assess factors associated with routine pregnancy intention screening by primary care physicians and their support for such an initiative. STUDY DESIGN We conducted a cross-sectional survey study of 443 primary care physicians in New York State. We performed multivariable logistic regression analyses of physician support for routine pregnancy intention screening and implementation of screening in the last year. Predictors included in the models were physician age, sex, specialty, clinic setting, and, for the outcome of support for screening, experience with screening in the last year. RESULTS In this convenience sample, the vast majority of respondents from all specialties (88%) felt pregnancy intention screening should be routinely included in primary care, with 48% reporting that they routinely perform such screening. The preferred wording for this question was one which assessed reproductive health service needs. In multivariable analyses, internal medicine physicians were less likely than family medicine physicians to have provided routine pregnancy intention screening (aOR = 0.15, 95% CI 0.09, 0.25). Only 8% of the sample reported they required more training to implement pregnancy intention screening, but more reported needing training prior to contraceptive provision (17%), contraceptive counseling (16%), and preconception care (15%). More internal medicine and other types of doctors cited a need for this additional training than family medicine physicians. CONCLUSIONS Most responding primary care physicians supported routine integration of pregnancy intention screening. Incorporating additional training, especially for internal medicine physicians, in contraception and preconception care counseling is key to ensuring success. IMPLICATIONS STATEMENT Responding primary care physicians supported routine inclusion of reproductive health needs assessment in primary care. Primary care may become increasingly important for ensuring access to a full range of reproductive health services. Providing necessary training, especially for internal medicine physicians, is needed prior to routine inclusion.
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Affiliation(s)
- Meredith G Manze
- City University of New York (CUNY), School of Public Health, New York, NY, United States
| | - Cynthia Calixte
- City University of New York (CUNY), School of Public Health, New York, NY, United States; Institute for Family Health, 2006 Madison Ave., New York, NY, United States
| | - Diana R Romero
- City University of New York (CUNY), School of Public Health, New York, NY, United States
| | - Lynn Roberts
- City University of New York (CUNY), School of Public Health, New York, NY, United States
| | - Michele Perlman
- Community Healthcare Network, 60 Madison Ave., New York, NY, United States
| | - Aileen Langston
- NYC Health and Hospitals, Woodhull Medical and Mental Health Center, 760 Broadway, Brooklyn, NY, United States
| | - Heidi E Jones
- City University of New York (CUNY), School of Public Health, New York, NY, United States
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41
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Hoffman S. Physician Burnout Calls for Legal Intervention. Hastings Cent Rep 2019; 49:8-9. [PMID: 31813182 DOI: 10.1002/hast.1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Physician burnout is receiving more attention in the medical literature, and deservedly so. For example, in October of 2019, the National Academies of Sciences, Engineering, and Medicine published a lengthy report called Taking Action against Clinician Burnout: A Systems Approach to Professional Well-Being. The report is comprehensive and well worth reading, and it offers a series of sound recommendations for addressing the burnout problem. However, the recommendations are quite ambitious, and implementing them would require a considerable investment of time, staffing, and financial resources. The medical community should not be left to grapple with the phenomenon of physician burnout alone. The law has a significant role to play in addressing the problem. As a first step, it is useful to consider a few concrete interventions that regulators could realistically implement in the short term.
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Mihailescu M, Neiterman E. A scoping review of the literature on the current mental health status of physicians and physicians-in-training in North America. BMC Public Health 2019; 19:1363. [PMID: 31651294 PMCID: PMC6814030 DOI: 10.1186/s12889-019-7661-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/20/2019] [Indexed: 11/29/2022] Open
Abstract
Background This scoping review summarizes the existing literature regarding the mental health of physicians and physicians-in-training and explores what types of mental health concerns are discussed in the literature, what is their prevalence among physicians, what are the causes of mental health concerns in physicians, what effects mental health concerns have on physicians and their patients, what interventions can be used to address them, and what are the barriers to seeking and providing care for physicians. This review aims to improve the understanding of physicians’ mental health, identify gaps in research, and propose evidence-based solutions. Methods A scoping review of the literature was conducted using Arksey and O’Malley’s framework, which examined peer-reviewed articles published in English during 2008–2018 with a focus on North America. Data were summarized quantitatively and thematically. Results A total of 91 articles meeting eligibility criteria were reviewed. Most of the literature was specific to burnout (n = 69), followed by depression and suicidal ideation (n = 28), psychological harm and distress (n = 9), wellbeing and wellness (n = 8), and general mental health (n = 3). The literature had a strong focus on interventions, but had less to say about barriers for seeking help and the effects of mental health concerns among physicians on patient care. Conclusions More research is needed to examine a broader variety of mental health concerns in physicians and to explore barriers to seeking care. The implication of poor physician mental health on patients should also be examined more closely. Finally, the reviewed literature lacks intersectional and longitudinal studies, as well as evaluations of interventions offered to improve mental wellbeing of physicians.
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Affiliation(s)
- Mara Mihailescu
- Telfer School of Management, University of Ottawa, 55 Laurier Ave E, Ottawa, ON, K1N 6N5, Canada.
| | - Elena Neiterman
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
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Das LT, Kaushal R, Garrison K, Carrillo V, Grinspan Z, Theis R, Shenkman E, Abramson E. Drivers of preventable high health care utilization: a qualitative study of patient, physician and health system leader perspectives. J Health Serv Res Policy 2019; 25:220-228. [PMID: 31505976 DOI: 10.1177/1355819619873685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES A small percentage of patients account for the bulk of population health care utilization and costs in many countries including the United States (US). In the US, 5% of the population has high health care utilization accounting for nearly 50% of health care costs. A subset of this utilization is deemed preventable, and thus potentially cost saving to patients as well as to the health care system. This study sought to identify drivers of preventable utilization from the perspectives of three stakeholder groups in the US: health system leaders; high-need, high-cost (HNHC) patients or their primary caregivers; and physicians. METHODS We performed a qualitative study using interviews of health system leaders and focus groups of HNHC patients, caregivers and physicians. We used a mixed inductive deductive approach to analyse transcripts and identify themes. RESULTS We identified three key drivers of preventable high health care utilization: (1) unmet behavioural health needs, (2) socio-economic determinants of health and (3) challenges associated with accessing health care delivery systems. CONCLUSIONS To be potentially more effective, interventions to reduce preventable high health care utilization should incorporate the perspectives of patients, health system leaders and physicians. Particularly important to stakeholders is increased access to mental-health resources, support for patients with low socio-economic resources and systemic changes that reduce wait times for primary care visits and allow providers more time during patient visits.
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Affiliation(s)
- Lala Tanmoy Das
- MD-PhD Student, Weill Cornell/Rockefeller/Sloan Kettering Tri-Institutional MD-PhD Program, USA.,MD-PhD Student, Weill Cornell Graduate School of Medical Sciences, USA.,MD-PhD Student, Weill Cornell Medicine, USA
| | - Rainu Kaushal
- Chair of Healthcare Policy & Research, Department of Healthcare Policy & Research, Weill Cornell Medicine, USA
| | - Kelsey Garrison
- M.S. Graduate Student, Weill Cornell Graduate School of Medical Sciences, USA
| | - Vanessa Carrillo
- Research Coordinator, Weill Cornell Graduate School of Medical Sciences, USA
| | - Zachary Grinspan
- Associate Professor of Health Care Policy & Research, Department of Healthcare Policy & Research, Weill Cornell Medicine, USA.,Associate Professor of Pediatrics, Department of Pediatrics, Weill Cornell Medicine, USA
| | - Ryan Theis
- Assistant Professor, Health Outcomes & Biomedical Informatics, Department of Health Outcomes and Policy, College of Medicine, Institute for Child Health Policy, University of Florida, USA
| | - Elizabeth Shenkman
- Professor and Department Chair, Health Outcomes & Biomedical Informatics, Department of Health Outcomes and Policy, College of Medicine, University of Florida, USA
| | - Erika Abramson
- Associate Professor of Pediatrics, Department of Pediatrics, Weill Cornell Medicine, USA.,Associate Professor of Healthcare Policy & Research, Department of Healthcare Policy & Research, Weill Cornell Medicine, USA
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Alarcon-Ruiz CA, Heredia P, Taype-Rondan A. Association of waiting and consultation time with patient satisfaction: secondary-data analysis of a national survey in Peruvian ambulatory care facilities. BMC Health Serv Res 2019; 19:439. [PMID: 31262280 PMCID: PMC6604432 DOI: 10.1186/s12913-019-4288-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 06/23/2019] [Indexed: 11/17/2022] Open
Abstract
Background Research suggested that waiting time and consultation time are associated with overall patient satisfaction concerning health services. However, there is a lack of information regarding this subject in Latin American countries, where particular aspects of health systems and population characteristics could modify this association. Our aim was to evaluate the association of waiting time and consultation time with patient satisfaction, in Peruvian ambulatory care facilities and propose a cut-off points of waiting and consultation time based on patient satisfaction. Methods Cross-sectional secondary data analysis of the National Survey on User Satisfaction of Health Services (ENSUSALUD-2015), a national-wide survey with a probabilistic sample of 181 Peruvian ambulatory care facilities. Patient satisfaction, waiting time, consultation time, and sociodemographic variables were collected from the ENSUSALUD-2015. All variables were collected by survey directly to patients, from the selected ambulatory care facilities, after their consultation. Complex survey sampling was considered for data analysis. In the association analysis, we grouped the waiting time and consultation time variables, every 10 min, because for it is more relevant and helpful in the statistical and practical interpretation of the results, instead of the every-minute unit. Results The survey was performed in 13,360 participants. Response rate were 99.8 to 100% in the main variables. Waiting time (for every 10 min) was inversely associated with patient satisfaction (aOR: 0.98, 95% CI: 0.97–0.99), although the aOR was lower among those who reported a waiting time ≤ 90 min (aOR: 0.92, 95% CI: 0.89–0.96). Consultation time (for every 10 min) was directly associated with patient satisfaction (aOR: 1.59, 95% CI: 1.26–2.01), although the aOR was higher among those who reported a consultation time ≤ 15 min (aOR: 2.31, 95% CI: 1.66–3.21). Conclusion In Peruvian ambulatory care facilities, both waiting time and consultation time showed an association with overall patient satisfaction, which was stronger in the first 90 min of waiting time and in the first 15 min of consultation time. This should be taken into consideration when designing interventions to improve waiting times and consultation times in ambulatory care facilities from Peru or from similar contexts.
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Affiliation(s)
- Christoper A Alarcon-Ruiz
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru.
| | - Paula Heredia
- Faculty of Medicine, Universidad Ricardo Palma, Lima, Peru
| | - Alvaro Taype-Rondan
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
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Levy B, Hess C, Hogan J, Hogan M, Ellison JM, Greenspan S, Elber A, Falcon K, Driscoll DF, Hashmi AZ. Machine Learning Enhances the Efficiency of Cognitive Screenings for Primary Care. J Geriatr Psychiatry Neurol 2019; 32:137-144. [PMID: 30879363 DOI: 10.1177/0891988719834349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Incorporation of cognitive screening into the busy primary care will require the development of highly efficient screening tools. We report the convergence validity of a very brief, self-administered, computerized assessment protocol against one of the most extensively used, clinician-administered instruments-the Montreal Cognitive Assessment (MoCA). METHOD Two hundred six participants (mean age = 67.44, standard deviation [SD] = 11.63) completed the MoCA and the computerized test. Three machine learning algorithms (ie, Support Vector Machine, Random Forest, and Gradient Boosting Trees) were trained to classify participants according to the clinical cutoff score of the MoCA (ie, < 26) from participant performance on 25 features of the computerized test. Analysis employed Synthetic Minority Oversampling TEchnic to correct the sample for class imbalance. RESULTS Gradient Boosting Trees achieved the highest performance (accuracy = 0.81, specificity = 0.88, sensitivity = 0.74, F1 score = 0.79, and area under the curve = 0.81). A subsequent K-means clustering of the prediction features yielded 3 categories that corresponded to the unimpaired (mean = 26.98, SD = 2.35), mildly impaired (mean = 23.58, SD = 3.19), and moderately impaired (mean = 17.24, SD = 4.23) ranges of MoCA score ( F = 222.36, P < .00). In addition, compared to the MoCA, the computerized test correlated more strongly with age in unimpaired participants (ie, MoCA ≥26, n = 165), suggesting greater sensitivity to age-related changes in cognitive functioning. CONCLUSION Future studies should examine ways to improve the sensitivity of the computerized test by expanding the cognitive domains it measures without compromising its efficiency.
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Affiliation(s)
- Boaz Levy
- 1 Department of Counseling and School Psychology, University of Massachusetts, Boston, MA, USA
| | - Courtney Hess
- 1 Department of Counseling and School Psychology, University of Massachusetts, Boston, MA, USA
| | - Jacqueline Hogan
- 1 Department of Counseling and School Psychology, University of Massachusetts, Boston, MA, USA
| | | | - James M Ellison
- 3 Christiana Care Health System, Department of Psychiatry and Human Behavior, Sidney Kimmel Medical College, Thomas Jefferson University, DE, USA
| | - Sarah Greenspan
- 1 Department of Counseling and School Psychology, University of Massachusetts, Boston, MA, USA
| | - Allison Elber
- 1 Department of Counseling and School Psychology, University of Massachusetts, Boston, MA, USA
| | - Kathryn Falcon
- 1 Department of Counseling and School Psychology, University of Massachusetts, Boston, MA, USA
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Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized controlled trial. J Gen Intern Med 2018; 33:2070-2077. [PMID: 30076573 PMCID: PMC6258628 DOI: 10.1007/s11606-018-4612-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/20/2018] [Accepted: 07/18/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation. However, many patients with atrial fibrillation at elevated stroke risk are not treated with oral anticoagulants. OBJECTIVE To test whether electronic notifications sent to primary care physicians increase the proportion of ambulatory patients prescribed oral anticoagulants. DESIGN Randomized controlled trial conducted from February to May 2017 within 18 practices in an academic primary care network. PARTICIPANTS Primary care physicians (n = 175) and their patients with atrial fibrillation, at elevated stroke risk, and not prescribed oral anticoagulants. INTERVENTION Patients of each physician were randomized to the notification or usual care arm. Physicians received baseline email notifications and up to three reminders with patient information, educational material and primary care guidelines for anticoagulation management, and surveys in the notification arm. MAIN MEASURES The primary outcome was the proportion of patients prescribed oral anticoagulants at 3 months in the notification (n = 972) vs. usual care (n = 1364) arms, compared using logistic regression with clustering by physician. Secondary measures included survey-based physician assessment of reasons why patients were not prescribed oral anticoagulants and how primary care physicians might be influenced by the notification. KEY RESULTS Over 3 months, a small proportion of patients were newly prescribed oral anticoagulants with no significant difference in the notification (3.9%, 95% CI 2.8-5.3%) and usual care (3.2%, 95% CI 2.4-4.2%) arms (p = 0.37). The most common, non-exclusive reasons why patients were not on oral anticoagulants included atrial fibrillation was transient (30%) or paroxysmal (12%), patient/family declined (22%), high bleeding risk (20%), fall risk (19%), and frailty (10%). For 95% of patients, physicians stated they would not change their management after reviewing the alert. CONCLUSIONS Electronic physician notification did not increase anticoagulation in patients with atrial fibrillation at elevated stroke risk. Primary care physicians did not prescribe anticoagulants because they perceived the bleeding risk was too high or stroke risk was too low. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02950285.
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Gupta A. Speaking Concisely and Comprehensively: Importance of an Efficient Communication Model Between the Physician and the Patient. Cureus 2018; 10:e3156. [PMID: 30349763 PMCID: PMC6193567 DOI: 10.7759/cureus.3156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Ideal communication between a physician and a patient, where there are higher efficiency and the conveying of quality information, is the cornerstone of achieving meaningful health outcomes for the patient. Today, increasing constraints in the form of mandatory documentation, guideline-based requirements, and other bureaucratic necessities have limited the time that the physician can truly spend on communicating with the patient. As such, counseling often takes lower priority during a patient visit. To correct this deficiency, the modern physician must adapt to the new constraints to create a more-efficient communication model that incorporates greater literature and infographic-based technological usage with advanced preparation. It is a challenge that must be met in order to maintain a critical element of patient visits.
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Affiliation(s)
- Abhishek Gupta
- Geriatrics, Center for Addiction and Mental Health/University of Toronto, Toronto, CAN
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Ratanawongsa N, Quan J, Handley MA, Sarkar U, Schillinger D. Language-concordant automated telephone queries to assess medication adherence in a diverse population: a cross-sectional analysis of convergent validity with pharmacy claims. BMC Health Serv Res 2018; 18:254. [PMID: 29625571 PMCID: PMC5889590 DOI: 10.1186/s12913-018-3071-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 03/28/2018] [Indexed: 12/15/2022] Open
Abstract
Background Clinicians have difficulty accurately assessing medication non-adherence within chronic disease care settings. Health information technology (HIT) could offer novel tools to assess medication adherence in diverse populations outside of usual health care settings. In a multilingual urban safety net population, we examined the validity of assessing adherence using automated telephone self-management (ATSM) queries, when compared with non-adherence using continuous medication gap (CMG) on pharmacy claims. We hypothesized that patients reporting greater days of missed pills to ATSM queries would have higher rates of non-adherence as measured by CMG, and that ATSM adherence assessments would perform as well as structured interview assessments. Methods As part of an ATSM-facilitated diabetes self-management program, low-income health plan members typed numeric responses to rotating weekly ATSM queries: “In the last 7 days, how many days did you MISS taking your …” diabetes, blood pressure, or cholesterol pill. Research assistants asked similar questions in computer-assisted structured telephone interviews. We measured continuous medication gap (CMG) by claims over 12 preceding months. To evaluate convergent validity, we compared rates of optimal adherence (CMG ≤ 20%) across respondents reporting 0, 1, and ≥ 2 missed pill days on ATSM and on structured interview. Results Among 210 participants, 46% had limited health literacy, 57% spoke Cantonese, and 19% Spanish. ATSM respondents reported ≥1 missed day for diabetes (33%), blood pressure (19%), and cholesterol (36%) pills. Interview respondents reported ≥1 missed day for diabetes (28%), blood pressure (21%), and cholesterol (26%) pills. Optimal adherence rates by CMG were lower among ATSM respondents reporting more missed days for blood pressure (p = 0.02) and cholesterol (p < 0.01); by interview, differences were significant for cholesterol (p = 0.01). Conclusions Language-concordant ATSM demonstrated modest potential for assessing adherence. Studies should evaluate HIT assessments of medication beliefs and concerns in diverse populations. Trial registration NCT00683020, registered May 21, 2008. Electronic supplementary material The online version of this article (10.1186/s12913-018-3071-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Neda Ratanawongsa
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA.
| | - Judy Quan
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA
| | - Margaret A Handley
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA.,Department of Epidemiology and Biostatistics, Division of Preventive Medicine and Public Health, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA
| | - Urmimala Sarkar
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA
| | - Dean Schillinger
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA
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Walker J, Payne B, Clemans-Taylor BL, Snyder ED. Continuity of Care in Resident Outpatient Clinics: A Scoping Review of the Literature. J Grad Med Educ 2018; 10:16-25. [PMID: 29467968 PMCID: PMC5821030 DOI: 10.4300/jgme-d-17-00256.1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/27/2017] [Accepted: 10/30/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Continuity between patients and physicians is a core principle of primary care and an accreditation requirement. Resident continuity clinics face challenges in nurturing continuity for their patients and trainees. OBJECTIVE We undertook a scoping review of the literature to better understand published benchmarks for resident continuity; the effectiveness of interventions to improve continuity; and the impact of continuity on resident and patient satisfaction, patient outcomes, and resident career choice. METHODS We developed a MEDLINE search strategy to identify articles that defined continuity in residency programs in internal medicine, family medicine, and pediatrics published prior to December 31, 2015, and used a quality evaluation tool to assess included studies. RESULTS The review includes 34 articles describing 12 different measures of continuity. The usual provider of care and continuity for physician formulas were most commonly utilized, and mean baseline continuity was 56 and 55, respectively (out of a total possible score of 100). Clinic and residency program redesign innovations (eg, advanced access scheduling, team-based care, and block scheduling) were studied and had mixed impact on continuity. Continuity in resident clinics is lower than published continuity rates for independently practicing physicians. CONCLUSIONS Interventions to enhance continuity in resident clinics have mixed effects. More research is needed to understand how changes in continuity affect resident and patient satisfaction, patient outcomes, and resident career choice. A major challenge to research in this area is the lack of empanelment of residents' patients, creating difficulties in scheduling and measuring continuity visits.
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McNeil D, Kennedy S, Randall C, Addicks S, Wright C, Hursey K, Vaglienti R. Fear of Pain Questionnaire-9: Brief assessment of pain-related fear and anxiety. Eur J Pain 2018; 22:39-48. [PMID: 28758306 PMCID: PMC5730485 DOI: 10.1002/ejp.1074] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Fear and anxiety are important considerations in both acute and chronic pain. Effectively and efficiently measuring fear and anxiety associated with pain in healthcare settings is critical for identifying vulnerable patients. The length and administration time of current measures of pain-related fear and anxiety inhibit their routine use, as screening tools and otherwise, suggesting the need for a shorter, more efficient instrument. METHODS A 9-item shortened version of the Fear of Pain Questionnaire - III (FPQ-III), the Fear of Pain Questionnaire-9 (FPQ-9), was developed based upon statistical analyses of archival data from 275 outpatients with chronic pain and 275 undergraduates. Additionally, new data were collected from 100 outpatients with chronic pain and 190 undergraduates to directly compare the standard and short forms. Exploratory and confirmatory factor analyses, and other psychometric analyses, were conducted to examine and establish the FPQ-9 as a reliable and valid instrument. RESULTS The original three-factor structure of the FPQ-III was retained in the shortened version; a confirmatory factor analysis produced good model fit (RMSEA = 0.00, CFI = 1.00, TLI = 1.00, SRMR = 0.03). Results suggested a high degree of correlation between the original FPQ-III and the new FPQ-9 (r = 0.77, p < 0.001). Measures of internal consistency for FPQ-9 subscales were high; correlations with other pain and anxiety instruments suggested concurrent, convergent and divergent validity. CONCLUSIONS The FPQ-9 is a psychometrically sound alternative to longer instruments assessing fear and anxiety associated with pain, for use in both clinical and research situations that only allow brief screening. SIGNIFICANCE The FPQ-9 has considerable potential for dissemination and utility for routine, brief screening, given its length (completion time ~2 min; scoring time ~1 min), reading level and psychometric properties.
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Affiliation(s)
- D.W. McNeil
- Department of PsychologyWest Virginia UniversityMorgantownWVUSA
- Department of Dental Practice & Rural HealthWest Virginia University School of DentistryMorgantownWVUSA
| | - S.G. Kennedy
- Department of PsychologyWest Virginia UniversityMorgantownWVUSA
| | - C.L. Randall
- Department of PsychologyWest Virginia UniversityMorgantownWVUSA
| | - S.H. Addicks
- Department of PsychologyWest Virginia UniversityMorgantownWVUSA
| | - C.D. Wright
- Department of PsychologyWest Virginia UniversityMorgantownWVUSA
| | - K.G. Hursey
- Aachenor Psychology Consulting of West VirginiaMorgantownWVUSA
| | - R. Vaglienti
- Department of NeurosurgeryWest Virginia University School of MedicineMorgantownWVUSA
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