Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia

Assessment of a systematic approach for implementing novel medications in clinical practice: an observational study with dapagliflozin

OBJECTIVE

To assess a systematic implementation approach for introducing dapagliflozin to individuals with heart failure and reduced ejection fraction in an outpatient clinical setting.

METHODS

Retrospective medical record data were analysed. All individuals diagnosed with heart failure who resided within the hospital catchment area and had visited cardiology or internal medicine department between 2010 and 2019 were screened by using the main inclusion criteria from the DAPA-HF trial. The effectiveness of the previously described seven-step systematic implementation approach was assessed by the proportion receiving information letter, dapagliflozin treatment, follow-ups at 2-12 weeks and 12 months post-dapagliflozin initiation, persistence on dapagliflozin, adverse events, and reasons for discontinuation.

RESULTS

Of the 2433 individuals, 352 met the main DAPA-HF trial criteria in step 2. After exclusions in steps 3 and 4, 191 individuals remained. Of these, 158 were invited for eligibility discussion in step 5, with 107 having received an information letter beforehand. In step 6, dapagliflozin was prescribed to 69 individuals, and in step 7, follow-ups were conducted with 56 individuals at 2-12 weeks and 62 individuals at 12 months. Sixty out of 69 persisted on dapagliflozin after 12 months. Adverse events were reported by nine individuals. Discontinuation was attributed to reasons such as urinary tract infections, genital or abdominal discomfort, and hypotension.

CONCLUSION

The systematic introduction of dapagliflozin to heart failure patients was effective. Despite this, challenges in uniformly implementing procedures across patients were evident, emphasizing the necessity for a systematic implementation approach.

Drug development for major chronic health conditions-aligning with growing public health needs: Proceedings from a multistakeholder think tank

The global pharmaceutical industry portfolio is skewed towards cancer and rare diseases due to more predictable development pathways and financial incentives. In contrast, drug development for major chronic health conditions that are responsible for a large part of mortality and disability worldwide is stalled. To examine the processes of novel drug development for common chronic health conditions, a multistakeholder Think Tank meeting, including thought leaders from academia, clinical practice, non-profit healthcare organizations, the pharmaceutical industry, the Food and Drug Administration (FDA), payors as well as investors, was convened in July 2022. Herein, we summarize the proceedings of this meeting, including an overview of the current state of drug development for chronic health conditions and key barriers that were identified. Six major action items were formulated to accelerate drug development for chronic diseases, with a focus on improving the efficiency of clinical trials and rapid implementation of evidence into clinical practice.

The future of allergic rhinitis management: A partnership between healthcare professionals and patients

Allergic rhinitis (AR) is a chronic respiratory condition that internationally continues to be burdensome and impacts quality of life. Despite availability of medicines and guidelines for healthcare providers for the optimal management of AR, optimisation of its management in the community continues to be elusive. The reasons for this are multi-faceted and include both environmental and healthcare related factors. One factor that we can no longer ignore is that AR management is no longer limited to the domain of healthcare provider and that people with AR make their own choices when choosing how to manage their condition, without seeking advice from a health care provider. We must build a bridge between healthcare provider knowledge and guidelines and patient decision-making. With this commentary, we propose that a shared decision-making approach between healthcare professionals and people with AR be developed and promoted, with a focus on patient health literacy. As custodians of AR knowledge, we have a responsibility to ensure it is accessible to those that matter most-the people with AR.

Insulin initiation in patients with type 2 diabetes is often delayed, but access to a diabetes nurse may help-insights from Norwegian general practice

Objective: We opted to study how support staff operational capacity and diabetes competences may impact the timeliness of basal insulin-initiation in general practice patients with type 2 diabetes (T2D).Design/Setting/Outcomes: This was an observational and retrospective study on Norwegian primary care patients with T2D included from the ROSA4-dataset. Exposures were (1) support staff size, (2) staff size relative to number of GPs, (3) clinic access to a diabetes nurse and (4) share of staff with diabetes course (1 and 2 both relate to staff operational capacity, whereas 3 and 4 are both indicatory of staff diabetes competences). Outcomes were 'timely basal insulin-initiation' (primary) and 'attainment of HbA1c<7%' after insulin start-up (secondary). Associations were analyzed using multiple linear regression, and directed acyclic graphs guided statistical adjustments.Subjects: Insulin naïve patients with 'timely' (N = 294), 'postponed' (N = 219) or 'no need of' (N = 3,781) basal insulin-initiation, respectively.Results: HbA1c [median (IQR)] increased to 8.8% (IQR, 8.0, 10.2) prior to basal insulin-initiation, which reduced HbA1c to 7.3 (6.8-8.1) % by which only 35% of the subjects reached HbA1c <7%. Adjusted risk of 'timely basal insulin-initiation' was more than twofold higher if access to a diabetes nurse (OR = 2.40, [95%CI, 1.68, 3.43]), but related only vaguely to staff size (OR = 1.01, [95%CI, 1.00, 1.03]). No other staff factors related significantly to neither the primary nor the secondary outcome.Conclusion: In Norwegian general practice, insulin initiation in people with T2D may be affected by therapeutic inertia but access to a diabetes nurse may help facilitating more timely insulin start-up.

The Impact of Web-Based Continuing Medical Education Using Patient Simulation on Real-World Treatment Selection in Type 2 Diabetes: Retrospective Case-Control Analysis

BACKGROUND

Despite guidelines recommending the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in certain patients with type 2 diabetes (T2D), they are not being prescribed for many of these patients. Web-based continuing medical education (CME) patient simulations have been used to identify clinicians' practice gaps and improve clinical decision-making as measured within a simulation, but the impact of this format on real-world treatment has not been researched.

OBJECTIVE

This study aimed to evaluate the effect of a simulation-based CME intervention on real-world use of GLP-1 RAs by endocrinologists and primary care physicians.

METHODS

Two evaluation phases of the CME simulation were conducted: phase I, the CME simulation phase, was a paired, pre-post study of 435 physician learners in the United States; and phase II, the real-world phase, was a retrospective, matched case-control study of 157 of the 435 physicians who had claims data available for the study period.

RESULTS

Phase I CME results showed a 29 percentage point increase in correct decisions from pre- to postfeedback (178/435, 40.9% to 304/435, 69.9%; P<.001) in selecting treatment that addresses both glycemic control and cardiovascular event protection. Phase II results showed that 39 of 157 (24.8%) physicians in the intervention group increased use of GLP-1 RAs, compared to 20 of 157 (12.7%) in the comparison group. Being in the intervention group predicted GLP-1 RA use after education (odds ratio 4.49; 95% CI 1.45-13.97; P=.001).

CONCLUSIONS

A web-based CME simulation focused on secondary prevention of cardiovascular events in a patient with T2D was associated with increased use of evidence-based treatment selection in the real world.

Treatment Patterns, Adherence, Persistence, and Health Care Resource Utilization in Acromegaly: A Real-World Analysis

Context

Treatment of acromegaly is multimodal for many patients, and medical treatments include somatostatin receptor ligands (SRLs), dopamine agonists (DAs), and growth hormone receptor antagonists (GHRAs). However, recent real-world evidence on treatment patterns for patients with acromegaly is limited.

Objective

This study evaluated medication usage, treatment changes, adherence, persistence, comorbidities, and health care resource utilization using deidentified data from MarketScan, a US claims database.

Methods

Eligible patients (n = 882) were those receiving monotherapy or combination therapy for ≥90 days without treatment gaps.

Results

Mean age at diagnosis was 48.6 years; 50.1% of patients were female. Over half (59.4%) had 1 line of treatment (LOT); 23.1% had 2 LOTs; 17.5% had at least 3 LOTs. Most patients (94.6%) initiated treatment with monotherapies. The most common first-line monotherapy treatments were cabergoline (DA, 36.8%), octreotide long-acting release (first-generation SRL, 29.5%), and lanreotide depot (first-generation SRL, 22.5%). Adherence for first-line treatments (proportion of days covered) was higher for first-generation SRLs (lanreotide depot: 0.8) compared with DAs (0.7). Treatment persistence (time between the first treatment record and a change in LOT/censoring) in LOT 1 was higher for GHRAs (24.8 months) and first-generation SRLs (20.0 months) compared with DAs (14.4 months). Female patients and those diagnosed at a younger age were more likely to have shorter treatment persistence. The most prevalent comorbidities were hyperlipidemia, essential hypertension, and sleep apnea.

Conclusion

Patients with more comorbidities had more health care visits during the first year after diagnosis, suggesting increased disease burden. Real-world evidence on treatment patterns provides insights into recommendations for individualized therapy.

Using Administrative Data in Primary Care to Evaluate the Effectiveness of a Continuing Professional Development Program Focused on the Management of Patients Living With Obesity

INTRODUCTION

There are guidelines for referral to medical and/or surgical weight loss interventions (MSWLI) in Ontario; however, only about one-third of eligible patients in our region are being referred for consideration of MSWLI.

METHODS

A planning committee, including a registered dietician, psychiatrist, endocrinologist, bariatric surgeon, family physician, and educationalists, developed an interdisciplinary continuing professional development (CPD) program focused on practical approaches to the management of patients living with obesity. The Kirkpatrick model was used to evaluate the educational outcomes of the CPD program specifically focusing on Level-2, -3, and -4 outcomes based on self-reported questionnaire and health administrative data.

RESULTS

Eighteen primary care providers from the CPD program agreed to participate in this study, and 16 primary care providers (89%) completed the postintervention questionnaire and granted us access to their MSWLI referral data; 94% of study participants reported changes to their knowledge, comfort, and confidence (Level 2), as well as expected change in their future behaviour (Level 3) following the CPD program. However, there was no change in Kirkpatrick Level-4 outcomes, despite more than 90% of participants indicating that they will be making changes to their practice after the program.

DISCUSSION

The CPD program in our study was overwhelmingly well received and participants reported knowledge (Level 2) and behavioural (Level 3) changes following participation; however, there was no detectable change in their clinical practice (Level 4). The methodology described in our proof-of-concept study can be modified and adopted to evaluate Level-4 outcomes in other studies of effectiveness of CPD interventions.

Design of a Non-Interventional Study to Assess Neurologists' Perspectives and Pharmacological Treatment Decisions in Early Alzheimer's Disease

INTRODUCTION

The current therapeutic landscape of Alzheimer's disease (AD) is evolving rapidly. Our treatment options include new anti-amyloid-β protein disease-modifying therapies (DMTs) that decrease cognitive decline in patients with early AD (prodromal and mild AD dementia). Despite these advances, we have limited information on how neurologists would apply the results of recent DMT trials to make treatment decisions. Our goal is to identify factors associated with the use of new AD DMTs among neurologists applying concepts from behavioral economics.

METHODS

This non-interventional, cross-sectional, web-based study will assess 400 neurologists with expertise in AD from across Spain. Participants will start by completing demographic information, practice settings, and a behavioral battery to address their tolerance to uncertainty and risk preferences. Participants will then be presented with 10 simulated case scenarios or vignettes of common encounters in patients with early AD to evaluate treatment initiation with anti-amyloid-β DMTs (e.g., aducanumab, lecanemab, etc.). The primary outcomes will be therapeutic inertia and suboptimal decisions. Discrete choice experiments will be used to determine the weight of factors influencing treatment choices.

RESULTS

The results of this study will provide new insights into a better understanding of the most relevant factors associated with therapeutic decisions on the use of DMTs, assessing how neurologists handle uncertainty when making treatment choices, and identifying the prevalence of therapeutic inertia in the management of early AD.

Key Predictors of Primary Care Providers' Self-Efficacy in Caring for Children with Overweight or Obesity

OBJECTIVE

Self-efficacy is a crucial factor in enabling pediatric primary care providers (PCPs) to deliver recommended care to children with overweight and obesity. This study, conducted with a large, national sample of PCPs, aimed to identify key factors, which may contribute to PCP self-efficacy for obesity-related care, from a list of previously reported barriers and facilitators.

METHODS

A national random sample of American Academy of Pediatrics members was surveyed in 2017 (analytic n = 704). Factor analysis was used to identify self-efficacy variables from relevant indicators and assess fit. Multivariable linear regression analyses were conducted to identify key predictors of PCP self-efficacy from reported facilitators or barriers to care, including characteristics of the PCP, practice, community, and payment systems.

RESULTS

Two PCP self-efficacy variables were identified: health risk assessment and patient-centered counseling. Both were positively predicted by relevant training, the belief that pediatricians play an important role in obesity, and awareness of barriers to payment for dietitians or weight management programs. Both were negatively predicted by a perceived lack of available PCP time for counseling and inadequacy of available referral resources to assist with treatment. Additional predictors of counseling self-efficacy included PCP beliefs that they are paid for treatment (+) and that patients/families lack time for healthy behaviors (-). Electronic health record clinical decision supports or registries and patient social disadvantage were not predictive.

CONCLUSIONS

Results suggest multiple potential roles and strategies for local and national organizations seeking to facilitate improvements to PCP self-efficacy in caring for children with overweight and obesity.

Sodium-glucose co-transporter-2 inhibitors in patients with type 2 diabetes: Barriers and solutions for improving uptake in routine clinical practice

Recent advances in type 2 diabetes (T2D) research have highlighted the benefits of sodium-glucose co-transporter-2 (SGLT-2) inhibitors, including cardiovascular and renal protection. However, uptake rates of these drugs remain low in patients with T2D, particularly in subpopulations most likely to benefit from them. This review considers the potential barriers to prescribing SGLT-2 inhibitors in T2D in clinical practice and outlines potential multidisciplinary recommendations to overcome these barriers. Safety concerns and a lack of clarity in and divergence of guidelines around the introduction of SGLT-2 inhibitors into treatment regimens may represent a barrier to uptake from the clinicians' perspective, including a general lack of understanding of the benefits associated with SGLT-2 inhibitors. Patient characteristics, such as socioeconomic status, may influence uptake because of the cost of SGLT-2 inhibitors, especially in the United States, where health insurance coverage could be a concern. SGLT-2 inhibitor prescription rates vary between clinical specialty (endocrinology, primary care, cardiology, and nephrology) and country, with cardiologists the lowest prescribers, and endocrinologists the highest. Primary care practitioners may experience more challenges in following SGLT-2 inhibitor-related guidelines than diabetes specialists as there may be fewer opportunities for education on how this drug class improves cardiovascular and renal outcomes in patients with T2D. Uptake rates appear to vary between countries because of differences in guidelines and health insurance systems. The amendment of SGLT-2 inhibitor-related guidelines for more multidisciplinary use and the implementation of patient and clinician education may encourage uptake of these drugs, potentially improving long-term health outcomes among patients with T2D.

Personalized Treatment of Asthma: The Importance of Sex and Gender Differences

An individual's sex (nominally male or female, based on biological attributes) and gender (a complex term referring to socially constructed roles, behaviors, and expressions of identity) influence the clinical course of asthma in several ways. The physiologic development of the lungs and effects of sex hormones may explain why more boys than girls have asthma, and after puberty, more women than men have asthma. Female sex hormones have an impact throughout the life span and are associated with poor asthma control. Gender may influence exposure to asthma triggers, and sex and gender can influence the prevalence of comorbidities and interactions with health care professionals. Despite widely reported sex- and gender-based differences in asthma and asthma management, these issues frequently are not considered by health care professionals. There is also inconsistency regarding the use of "sex" and "gender" in scientific discourse; research is needed to define sex- and gender-based differences better and how they might interact to influence asthma outcomes. This review outlines the impact an individual's sex and gender can have on the pathogenesis, clinical course, diagnosis, treatment, and management of asthma.

The Retail Outlet Health Kiosk Hypertension Trial (ROKHYT): Pilot Results

BACKGROUND

Blood pressure (BP) control was only 43.7% in the National Health and Nutrition Survey (NHANES) survey in 2017-2018. Scalable, nonclinic-based strategies to control BP are needed. We therefore conducted a pilot trial of a text-messaging intervention in a national network of retail outlet health kiosks with BP devices. All study procedures were conducted remotely.

METHODS

Eligible individuals (N = 140), based on average BP greater than or equal to 140/90 mm Hg at kiosks during the prior year, were randomized to intervention vs. usual care. Intervention consisted of tailored text messages providing educational information with embedded links to educational videos on topics related to BP control. BP measurements were obtained at kiosks at 3, 6, and 12 months following randomization; control was defined as BP < 140/90 mm Hg. Follow-up at 12 months was curtailed due to SARS-CoV-2. We therefore combined 12-month (N = 62) or carried forward 6-month (N = 61) data as the primary end point.

RESULTS

Participants were 51.4% male, 70.7% white/Caucasian, had mean age of 52.1 years, and mean baseline BP 145.5/91.8 mm Hg. At the end point, 37.7% intervention vs. 27.4% usual care subjects achieved BP control (difference, 10.3%, 95% confidence interval -6.2%, 26.8%). In an intention-to-treat analysis with multiple imputation of missing data, 12-month BP control was 29.0% vs. 19.8% favoring intervention (difference, 9.2%. 95% confidence interval -7.3%, 25.7%); intervention vs. control differences in adjusted mean BP levels were systolic BP: -5.4 mm Hg (95% confidence interval: -13.5, 2.7) and diastolic BP: +0.6 mm Hg (95% confidence interval: -4.2, 5.4).

CONCLUSIONS

These pilot results support the potential for a highly scalable text-messaging intervention to improve BP.

CLINICAL TRIALS REGISTRATION

Trial Number NCT03515681.

Analysis of Therapeutic Inertia and Race and Ethnicity in the Systolic Blood Pressure Intervention Trial: A Secondary Analysis of a Randomized Clinical Trial

Importance

Therapeutic inertia may contribute to racial and ethnic differences in blood pressure (BP) control.

Objective

To determine the association between race and ethnicity and therapeutic inertia in the Systolic Blood Pressure Intervention Trial (SPRINT).

Design, Setting, and Participants

This cross-sectional study was a secondary analysis of data from SPRINT, a randomized clinical trial comparing intensive (<120 mm Hg) vs standard (<140 mm Hg) systolic BP treatment goals. Participants were enrolled between November 8, 2010, and March 15, 2013, with a median follow-up 3.26 years. Participants included adults aged 50 years or older at high risk for cardiovascular disease but without diabetes, previous stroke, or heart failure. The present analysis was restricted to participant visits with measured BP above the target goal. Analyses for the present study were performed in from October 2020 through March 2021.

Exposures

Self-reported race and ethnicity, mutually exclusively categorized into groups of Hispanic, non-Hispanic Black, or non-Hispanic White participants.

Main Outcomes and Measures

Therapeutic inertia, defined as no antihypertensive medication intensification at each study visit where the BP was above target goal. The association between self-reported race and ethnicity and therapeutic inertia was estimated using generalized estimating equations and stratified by treatment group. Antihypertensive medication use was assessed with pill bottle inventories at each visit. Blood pressure was measured using an automated device.

Results

A total of 8556 participants, including 4141 in the standard group (22 844 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1467 women [35.4%]) and 4415 in the intensive group (35 453 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1584 women [35.9%]) with at least 1 eligible study visit were included in the present analysis. Among non-Hispanic White, non-Hispanic Black, and Hispanic participants, the overall prevalence of therapeutic inertia in the standard vs intensive groups was 59.8% (95% CI, 58.9%-60.7%) vs 56.0% (95% CI, 55.2%-56.7%), 56.8% (95% CI, 54.4%-59.2%) vs 54.5% (95% CI, 52.4%-56.6%), and 59.7% (95% CI, 56.5%-63.0%) vs 51.0% (95% CI, 47.4%-54.5%), respectively. The adjusted odds ratios in the standard and intensive groups for therapeutic inertia associated with non-Hispanic Black vs non-Hispanic White participants were 0.85 (95% CI, 0.79-0.92) and 0.94 (95% CI, 0.88-1.01), respectively. The adjusted odds ratios for therapeutic inertia comparing Hispanic vs non-Hispanic White participants were 1.00 (95% CI, 0.90-1.13) and 0.89 (95% CI, 0.79-1.00) in the standard and intensive groups, respectively.

Conclusions and Relevance

Among SPRINT participants above BP target goal, this cross-sectional study found that therapeutic inertia prevalence was similar or lower for non-Hispanic Black and Hispanic participants compared with non-Hispanic White participants. These findings suggest that a standardized approach to BP management, as used in SPRINT, may help ensure equitable care and could reduce the contribution of therapeutic inertia to disparities in hypertension.

Trial Registration

ClinicalTrials.gov identifier: NCT01206062.

Replicating dissemination and identifying mechanisms of implementation of an empirically supported treatment

OBJECTIVE

Implementation research is needed in cancer control. Replication of the dissemination of empirically supported treatments (ESTs) is important as is the identification of mechanisms by which dissemination leads to implementation. Addressing these gaps, Study 1 (Cohorts 3-6, N = 104) tests for replication of a successful dissemination to community providers (Brothers et al., 2015; Cohorts 1-2; N = 62) and Study 2 (Cohorts 1-6) tests providers' changes on dissemination outcomes as mechanisms of EST usage.

METHOD

The Biobehavioral Intervention (BBI), a psychological EST in cancer control, was disseminated to oncology mental health providers using manual provision, didactics, roleplays, and other strategies. Study 1 tested for pre/post changes in dissemination outcomes (BBI knowledge/skills and attitudes toward and self-efficacy to deliver ESTs/BBI) between cohorts (1-2 vs. 3-6) with repeated measures ANOVAs. In Study 2, the implementation outcome was providers' (N = 166) BBI usage with patients (percent treated). Structural equation models tested dissemination outcome changes as predictors of usage at 2- and 4-months.

RESULTS

Study 1 replicated high dissemination outcomes and significant gains in BBI knowledge (p < .001) in Cohorts 3-6. Unlike Cohorts 1-2, significant gains were observed in self-efficacy (ps < .001) but not attitudes toward ESTs (p = .523) in Cohorts 3-6. In Study 2, gains in providers' self-efficacy (ps < .05) and EST attitudes (p = .008) predicted greater 2-month (58.4% ± 35.5%) and 4-month (66.2% ± 35.0%) usage of the BBI with patients, respectively.

CONCLUSIONS

This is the only replication of a dissemination for a psychological EST in cancer control. Results reliably show disseminations enhancing providers' self-efficacy to use and positive attitudes toward ESTs as mechanisms for EST implementation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Intervention for Alleviating Clinical Inertia in the Management of Urinary Incontinence

PURPOSE

The purpose of this study was to determine whether clinical inertia exists in the care of patients with urinary incontinence and to test the effects of an educational intervention designed to alleviate inertia related to care of urinary incontinence.

DESIGN

Single-group, pretest/posttest design.

SUBJECTS AND SETTING

The sample comprised 132 participants practicing in 6 medical-surgical inpatient care units at an urban hospital in Almería, Spain; 66 (50%) were RNs, and all other participants were unlicensed assistive personnel. Most participants (87.9%) were female; their average age was 43.99 years (SD = 7.85 years).

METHODS

An educational intervention (online course) was provided. The main objective of the course was application of evidence-based knowledge for prevention and management of urinary incontinence in hospitalized patients. The course program comprised 3 didactic units: (1) introduction and evaluation of the patient with urinary incontinence, (2) care plans, and (3) instructions and rational use of absorbent products. Data collection included demographic and professional characteristics of respondents, desired results when caring for patients with incontinence, a medical record checklist, an occupational environment and satisfaction scale, and an assessment record of knowledge/skills and training activity satisfaction.

RESULTS

After comparing the pre- and posttest scores of knowledge on urinary incontinence, significant differences were found before and after the intervention (z = -14.113, P = .000). Specifically, analysis revealed differences in caring actions related to urinary incontinence (z = -14.248, P = .000) and differences in direct observation of urinary incontinence practice following the intervention (z = -14.326, P = .000).

CONCLUSIONS

Our findings indicate existence of inertia in nursing care for hospitalized patients with urinary incontinence. The educational intervention improved knowledge, observable nursing care activities related to incontinence management, and improved documentation of care.

Interventions to Influence Opioid Prescribing Practices for Chronic Noncancer Pain: A Systematic Review and Meta-Analysis

CONTEXT

This study is a systematic review of interventions to improve adherence to guideline recommendations for prescribing opioids for chronic noncancer pain.

EVIDENCE ACQUISITION

Investigators searched CINAHL, Embase, MEDLINE, PsycINFO, the Cochrane Library, and Joanna Briggs Institute Evid Based Pract database from inception until June 3, 2019. Interventional studies to improve adherence to recommendations made by opioid guidelines for chronic noncancer pain in North America were eligible if outcomes included adherence to guideline recommendations or change in quantity of opioids prescribed. Data were extracted independently and in duplicate. Quantitative synthesis was performed using random effects meta-analysis. Confidence in evidence was determined using the Grades of Recommendation, Assessment, Development, and Evaluation.

EVIDENCE SYNTHESIS

A total of 20 studies (8 controlled and 12 prospective cohort) involving 1,491 providers and 72 clinics met inclusion. Interventions included education, audit and feedback, interprofessional support, shared decision making, and multifaceted strategies. Multifaceted interventions improved the use of urine drug testing (n=2, or =2.31, 95% CI=1.53, 3.49, z=3.98, p<0.01; high-certainty evidence), treatment agreements (n=2, or =1.96, 95% CI=1.47, 2.61, z=4.56, p<0.01; moderate-certainty evidence), and mental health screening (n=2, 2.57-fold, 95% CI=1.56, 4.24, z=2.32, p=0.02; low-certainty evidence) when prescribing opioids for chronic noncancer pain. Very low-certainty evidence suggests that several interventions improved the use of treatment agreements, urine drug testing, and prescription drug monitoring programs.

CONCLUSIONS

Mostly very low-certainty evidence supports a number of interventions for improving adherence to risk management strategies when prescribing opioids for chronic noncancer pain; however, the effect on patient important outcomes (e.g., overdose, addiction, death) is uncertain.

Critical Race Theory as a Lens for Examining Primary Care Provider Responses to Persistently-Elevated HbA1c

INTRODUCTION

Clinical inertia remains a persistent problem in the treatment of diabetes in clinical care. Primary care provider behavior is thought to be a significant contributor to diabetes clinical inertia. This study used the lens of Critical Race Theory to examine whether provider's diabetes management activities differ by patient race and frame implications for future research.

METHODS

Chart abstractors retrospectively reviewed a random sample of charts from primary care patients with persistently-elevated HbA1c to assess providers' diabetes management activities in the subsequent year. Provider activities aligned with the American Diabetes Association's standards of medical care and included HbA1c test ordering, documentation of patient medication adherence, counseling on lifestyle modification, lifestyle modification referral, endocrinologist participation in care, and medication titration. Differences in provider actions by patient race (Black, white, or other) were examined using chi-square tests.

RESULTS

A total of 188 patient charts were reviewed. For all provider actions, there were statistically-significant differences by patient race. Black patients were least likely to be counseled on dietary changes (72.0%) or physical activity (57.7%) by their primary care provider, but most likely to be referred to an outside specialist for this counseling (46.2%). Black patients were also least likely to have medication adjustments made (72%).

DISCUSSION

Study findings showed an association between provider diabetes management behaviors and patient race, Future studies showed explore providers' racial beliefs, attitudes and clinical decision-making, and patients' experiences with historical exclusion from medical care and racism in healthcare encounters In addition, more research is needed to explore the role of structural racism in clinical inertia.

Worldwide inertia to the use of cardiorenal protective glucose-lowering drugs (SGLT2i and GLP-1 RA) in high-risk patients with type 2 diabetes

The disclosure of proven cardiorenal benefits with certain antidiabetic agents was supposed to herald a new era in the management of type 2 diabetes (T2D), especially for the many patients with T2D who are at high risk for cardiovascular and renal events. However, as the evidence in favour of various sodium-glucose transporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) accumulates, prescriptions of these agents continue to stagnate, even among eligible, at-risk patients. By contrast, dipeptidyl peptidase-4 inhibitors (DPP-4i) DPP-4i remain more widely used than SGLT2i and GLP-1 RA in these patients, despite a similar cost to SGLT2i and a large body of evidence showing no clear benefit on cardiorenal outcomes. We are a group of diabetologists united by a shared concern that clinical inertia is preventing these patients from receiving life-saving treatments, as well as placing them at greater risk of hospitalisation for heart failure and progression of renal disease. We propose a manifesto for change, in order to increase uptake of SGLT2i and GLP-1 RA in appropriate patients as a matter of urgency, especially those who could be readily switched from an agent without proven cardiorenal benefit. Central to our manifesto is a shift from linear treatment algorithms based on HbA1c target setting to parallel, independent considerations of atherosclerotic cardiovascular disease, heart failure and renal risks, in accordance with newly updated guidelines. Finally, we call upon all colleagues to play their part in implementing our manifesto at a local level, ensuring that patients do not pay a heavy price for continued clinical inertia in T2D.

Rational drug use in hospital settings - areas that can be changed

Irrational use of drugs occurs at all levels of healthcare. This phenomenon can also be observed in hospitals. Irrational use of a drug contributes to a decrease in the patient's quality of treatment and often causes negative health consequences. For this reason, it is essential to consider methods that can be introduced in hospitals to increase the safety and effectiveness of the drugs used. The article presents selected methods of rationalization of drug management that can be used in hospitals.

A systematic approach for introduction of novel treatments to a chronic patient group: sacubitril-valsartan as a case study

Purpose

To develop a model for systematic introduction and to test the feasibility in a chronic disease population. We also investigated how the approach was received by the patients.

Methods and results

The systematic introduction approach is a seven-step procedure: step 1, define a few main criteria; step 2, primary scan patients with the one or two main criteria using computerized medical records/databases/clinical registries; step 3, identify patients applying the other predefined criteria; step 4, evaluate if any examinations/laboratory test updates are required; step 5, summon identified patients to the clinic with an information letter; step 6, discuss treatment with the patient and prescribe if appropriate; and step 7, follow up on initiated therapy and evaluate the applied process. The model was tested in a case study during introduction of the new drug sacubitril-valsartan in a heart failure population. In total, 76 out of 1924 patients were identified to be eligible for sacubitril-valsartan and summoned to the clinic to discuss treatment. Patient experiences with the approach were investigated in an interview study with general inductive approach using qualitative content analysis. This resulted in three final categories: a good approach, role of the information letter, and trust in care.

Conclusions

The systematic introduction approach ensures that strict criteria are used in the selection process and that a treatment can be implemented in eligible patients within a specified population with limited resources and time. The model was effective in our case study and maintained the patient’s confidence in healthcare.

Role of phototherapy in the era of biologics

Phototherapy is a safe and effective treatment for many dermatologic conditions. With the advent of novel biologics and small molecule inhibitors, it is important to critically evaluate the role of phototherapy in dermatology. Surveys have shown that many dermatology residency programs do not dedicate time to teaching residents how to prescribe or administer phototherapy. Limitations of phototherapy include access to a center, time required for treatments, and insurance approval. Home phototherapy, a viable option, is also underused. However, it should be emphasized that modern phototherapy has been in use for over 40 years, has an excellent safety profile, and does not require laboratory monitoring. It can be safely combined with many other treatment modalities, including biologics and small molecule inhibitors. In addition, phototherapy costs significantly less than these novel agents. Dermatologists are the only group of physicians who have the expertise and proper training to deliver this treatment modality to our patients. Therefore, to continue to deliver high-quality, cost-effective care, it is imperative that phototherapy be maintained as an integral part of the dermatology treatment armamentarium.

What factors could influence physicians' management of women of childbearing age with chronic inflammatory disease? A systematic review of behavioural determinants of clinical inertia

BACKGROUND

Pregnancy represents a complex challenge to clinicians treating women with chronic inflammatory disease. Many clinicians face a situation of heightened sensitivity to the potential risks and uncertainties associated with the effect of pharmacological treatment on pregnancy outcomes. This may create an environment vulnerable to clinical inertia, whereby behavioural factors such as cognitive heuristics and biases, and other factors such as attitudes to risk and emotion can contribute. This systematic review was undertaken to assess if clinical inertia has been investigated/identified in this setting and took a behavioural science approach to identify and understand the potential determinants of clinical inertia in this treatment setting.

METHODS

A systematic literature search was conducted to identify publications which investigated or described clinical inertia or its determinants (e.g. heuristics, biases etc.). Results were coded for thematic analysis using two inter-related behavioural models: the COM-B model and the Theoretical Domains Framework.

RESULTS

Whilst studies investigating or describing clinical inertia in this treatment setting were not identified, the behavioural analysis revealed a number of barriers to the pharmacological management of women of fertile age affected by chronic inflammatory disease. Factors which may be influencing clinician's behaviour were identified in all domains of the COM-B model. The primary factors identified were a lack of knowledge of treatment guidelines and fears concerning the safety of medications for mother and fetus. Lack of experience of treating pregnant patients was also identified as a contributing factor to undertreatment.

CONCLUSION

Using a behavioural approach, it was possible to identify potential factors which may be negatively influencing clinician's behaviour in this treatment setting, although specific research was limited.

Alerting Doctors About Patient Life Challenges: A Randomized Control Trial of a Previsit Inventory of Contextual Factors

Objective. Effective care attends to relevant patient life context. We tested whether a patient-completed inventory helps providers contextualize care and increases patients’ perception of patient-centered care (PCC). Method. The inventory listed six red flags (e.g., emergency room visits) and if the patient checked any, prompted for related contextual factors (e.g., transportation difficulties). Patients were randomized to complete the inventory or watch health videos prior to their visit. Patients presented their inventory results to providers during audio-recorded encounters. Audios were coded for physician probing and incorporating context in care plans. Patients completed the Consultation and Relational Empathy (CARE) instrument after the encounter. Results. A total of 272 Veterans were randomized. Adjusting for covariates and clustering within providers, inventory patients rated visits as more patient-centered (44.5; standard error = 1.1) than controls (42.7, standard error = 1.1, P = 0.04, CARE range = 10–50). Providers were more likely to probe red flags (odds ratio = 1.54; confidence interval = 1.07–2.22; P = 0.02) when receiving the inventory, but not incorporating context into care planning. Conclusion. A previsit inventory of life context increased perceptions of PCC and providers’ likelihood of exploring context but not contextualizing care. Information about patients’ life challenges is not sufficient to assure that context informs provider decision making even when provided at the point of care by patients themselves.

Clinical inertia in hypertension: a new holistic and practical concept within the cardiovascular continuum and clinical care process

Purpose: Recognition of clinical inertia is essential to improve the control of chronic diseases. Although it is very intuitive, a better interpretation of the concept of clinical inertia is lacking, likely due to its high complexity. Materials and Methods: After a review of the published articles, we propose a practical vision of inertia, contextualized within the clinical process of hypertension care. Results: This new vision enables the integration of previous terms and definitions of clinical inertia, as well as proposing specific strategies for its reduction. Conclusion: Although some concepts should be considered as 'justified inertia' or 'investigator inertia', the idea that inertia may be present throughout the continuum of care gives physicians a holistic view of the problem that is easily applicable to their clinical practice. Measures to overcome inertia are complicated because of the intrinsic complexity of the concept.

Healthcare provider knowledge, attitudes, beliefs, and practices surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review

BACKGROUND

Evidence from diverse areas of medicine (e.g., cardiovascular disease, diabetes) indicates that healthcare providers (HCPs) often do not adhere to clinical practice guidelines (CPGs) despite a clear indication to implement recommendations-a phenomenon commonly termed clinical inertia. There are a variety of reasons for clinical inertia, but HCP-related factors (e.g., knowledge, motivation, agreement with guidelines) are the most salient and amenable to intervention aimed to improve adherence. CPGs have been developed to support the safe and effective prescription of opioid medication for the management of chronic non-cancer pain. The extent of physician uptake and adherence to such guidelines is not yet well understood. The purpose of this review is to synthesize the published evidence about knowledge, attitudes, beliefs, and practices that HCPs hold regarding the prescription of opioids for chronic non-cancer pain.

METHODS

An experienced information specialist will perform searches of CINAHL, Embase, MEDLINE, and PsycINFO bibliographic databases. The Cochrane library, PROSPERO, and the Joanna Briggs Institute will be searched for systematic reviews. Searches will be performed from inception to the present. Quantitative and qualitative study designs that report on HCP knowledge, attitudes, beliefs, or practices in North America will be eligible for inclusion. Studies reporting on interventions to improve HCP adherence to opioid prescribing CPGs will also be eligible for inclusion. Two trained graduate-level research assistants will independently screen articles for inclusion, perform data extraction, and perform risk of bias and quality assessment using recommended tools. Confidence in qualitative evidence will be evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation-Confidence in the Evidence from Qualitative Reviews (GRADE-CERQual) approach. Confidence in quantitative evidence will be assessed using the GRADE approach.

DISCUSSION

The ultimate goal of this work is to support interventions aiming to optimize opioid prescribing practices in order to prevent opioid-related morbidity and mortality without restricting a HCP's ability to select the most appropriate treatment for an individual patient.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018091640 .

Linking Reminders and Physician Breast Cancer Screening Recommendations: Results From a National Survey

PURPOSE

Physician reminders have successfully increased rates of mammography. However, considering recent changes to breast cancer screening guidelines that disagree on the optimal age to start and stop mammography screening, we sought to examine the extent to which reminders have been deployed for breast cancer screening targeting younger and older patients.

METHODS

A mailed survey was sent to a national sample of 2,000 primary care physicians between May and September 2016. Physicians were asked whether they received reminders to screen women in various age groups (40 to 44, 45 to 49, and ≥ 75 years), the organizational screening guidelines they trusted most, and whether they recommended routine breast cancer screening to average-risk women in the different age groups. Using regression models, we assessed the association between reminders and physician screening recommendations, controlling for physician and practice characteristics, and evaluated whether the association varied by the guidelines they trusted.

RESULTS

A total of 871 physicians responded (adjusted response rate, 52.3%). Overall, 28.9% of physicians reported receiving reminders for patient ages 40 to 44 years, 32.5% for patient ages 45 to 49 years, and 16.5% for patient ages ≥ 75 years. Receiving reminders significantly increased the likelihood of physicians recommending mammography screening. In adjusted analyses, 84% (95% CI, 77% to 90%) of physicians who received reminders recommended screening for women ages ≥ 75 versus 65% (95% CI, 62% to 69%) of those who did not receive reminders. The associations between reminders and screening recommendations remained consistent regardless of which guidelines physicians reported trusting.

CONCLUSION

Reminders were significantly associated with increases in physician screening recommendations for mammography, underscoring the need for careful implementation in scenarios where guidelines are discordant.

Enablers and determinants of the provision of written action plans to patients with asthma: a stratified survey of Canadian physicians

Despite national recommendations, most patients with asthma are not given a written action plan . The objectives were to ascertain physicians' endorsement of potential enablers to providing a written action plan, and the determinants and proportion, of physician-reported use of a written action plan. We surveyed 838 family physicians, paediatricians, and emergency physicians in Quebec. The mailed questionnaire comprised 102 questions on asthma management, 11 of which pertained to written action plan and promising enablers. Physicians also selected a case vignette that best corresponded to their practice and reported their management. The survey was completed by 421 (56%) physicians (250 family physicians, 115 paediatricians and 56 emergency physicians); 43 (5.2%) reported providing a written action plan to ≥70% of their asthmatic patients and 126 (30%) would have used a written action plan in the selected vignette. Most (>60%) physicians highly endorsed the following enablers: patients requesting a written action plan, adding a blank written action plan to the chart, receiving a copy of the written action plan completed by a consultant, receiving a monetary compensation for its completion, and having another healthcare professional explain the completed written action plan to patients. Four determinants were significantly associated with providing a written action plan: being a paediatrician (RR:2.1), treating a child (RR:2.0), aiming for long-term asthma control (RR:2.5), and being aware of national recommendations to provide a written action plan to asthmatic patients (RR:2.9). A small minority of Quebec physicians reported providing a written action plan to most of their patients, revealing a huge care gap. Several enablers to improve uptake, highly endorsed by physicians, should be prioritised in future implementation efforts.

ASTHMA

ENCOURAGING DOCTORS TO PROVIDE WRITTEN ACTION PLANS: Changes to practice organization and doctors' perceptions should encourage the provision of written action plans for all asthma patients. International guidelines state that effective long-term treatment of asthma requires educated self-management, regular reviews and provision of a written action plan (WAP). However, many patients have poor asthma control and as few as 30 per cent have a WAP. Fabienne Djandji at the Saint-Justine University Central Hospital in Montreal, Canada, and co-workers conducted a survey of 421 doctors to determine their attitudes and provision of WAPs. Only 5.2 per cent of respondents provided WAPs to patients; those treating children or aiming for long-term asthma control were more likely to do so. The doctors said that incentives to provide WAPs would include requests from patients themselves, being paid to complete WAPs and having extra support from specialists or other health care professionals such as pharmacists.

Factors associated with initiation and persistence of urate-lowering therapy

Background

Gout is the most common inflammatory arthritic disease and is caused by crystal deposition secondary to persistent hyperuricemia. Etiological treatment with urate-lowering therapy (ULT) has been available since the 1950s but previous studies have demonstrated suboptimal degree of treatment. In recent years we have seen recommendations for ULT earlier in the course of the disease, but there are few contemporary reports reflecting the current situation. Therefore we set out to investigate proportion receiving and persisting with ULT after gout diagnosis and predictors thereof.

Method

A population-based cohort study using regional and national population-based registers. Cohort of patients (n = 7709) from western Sweden with incident gout aged 18 years and above from 2011 to 2013. An incident case of gout was defined as having been given a diagnosis of gout (ICD-10 M10, M14.0-14.1) not preceded by a gout diagnosis or a dispensation of ULT during the previous 5 years. Main outcome measures were cumulative incidence and predictors for start of, and persistence with, ULT in gout.

Results

Within the first year after first gout diagnosis, 32% received ULT. Male sex, presence of diabetes or cardiovascular comorbidity, reduced kidney function but not diagnosed “end-stage kidney failure” increased the likelihood of receiving ULT. Of those starting ULT a majority (75%) did not persist with ULT treatment within the first 2 years. Age <50 years, lack of comorbidities, and “normal kidney function” or “end-stage kidney failure” were associated with non-persistence with ULT.

Conclusions

Only a minority of patients received ULT and a majority of these did not persist with treatment over the next 2 years. However, the older patients with renal impairment and comorbidities, possibly suffering from a more severe gout disease, were more likely to receive and persist with treatment. There is thus still room for considerable improvement with regards to management of ULT in gout.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1211-y) contains supplementary material, which is available to authorized users.

Introduction to the Theme "New Methods and Novel Therapeutic Approaches in Pharmacology and Toxicology"

Major advances in scientific discovery and insights can result from the development and use of new techniques, as exemplified by the work of Solomon Snyder, who writes a prefatory article in this volume. The Editors have chosen "New Methods and Novel Therapeutic Approaches in Pharmacology and Toxicology" as the Theme for a number of articles in this volume. These include ones that review the development and use of new experimental tools and approaches (e.g., nanobodies and techniques to explore protein-protein interactions), new types of therapeutics (e.g., aptamers and antisense oligonucleotides), and systems pharmacology, which assembles (big) data derived from omics studies together with information regarding drugs and patients. The application of these new methods and therapeutic approaches has the potential to have a major impact on basic and clinical research in pharmacology and toxicology as well as on patient care.