'The Hand on the Doorknob': Visit Agenda Setting by Complex Patients and Their Primary Care Physicians

The Medicare annual wellness visit: An opportunity to improve health system identification of hearing loss?

BACKGROUND

Hearing loss is prevalent and consequential but under-diagnosed and managed. The Medicare Annual Wellness Visit (AWV) health risk assessment elicits patient-reported hearing concerns but whether such information affects documentation, diagnosis, or referral is unknown.

METHODS

We use 5 years of electronic medical record (EMR) data (2017-2022) for a sample of 13,776 older primary care patients. We identify the first (index) AWV indication of hearing concerns and existing and subsequent hearing loss EMR diagnoses (visit diagnoses or problem list diagnoses) and audiology referrals. For a 20% random sample of AWV notes (n = 474) we compared hearing loss EMR diagnoses to documentation of (1) hearing concerns, (2) hearing loss/aid use, and (3) referrals for hearing care.

RESULTS

Of 3845 (27.9%) older adults who identified hearing concerns (mean age 79.1 years, 57% female, 75% white) 24% had an existing hearing diagnosis recorded. Among 474 patients with AWV clinical notes reviewed, 90 (19%) had an existing hearing loss diagnosis. Clinicians were more likely to document hearing concerns or hearing loss/aid use for those with (vs. without) an existing EMR diagnosis (50.6% vs. 35.9%, p = 0.01; 68.9% vs. 37.5%, p < 0.001, respectively). EMR diagnoses of hearing loss were recorded for no more than 40% of those with indicated hearing concerns. Among those without prior diagnosis 38 (9.9%) received a hearing care referral within 1 month. Subgroup analysis suggest greater likelihood of documenting hearing concerns for patients age 80+ (OR:1.51, 95% confidence interval [CI]: 1.03, 2.19) and decreased likelihood of documenting known hearing loss among patients with more chronic conditions (OR: 0.49, 95% CI: 0.27, 0.9), with no differences observed by race.

CONCLUSION

Documentation of hearing loss in EMR and AWV clinical notes is limited among older adults with subjective hearing concerns. Systematic support and incorporation of hearing into EMR and clinical notes may increase hearing loss visibility by care teams.

The Potential of Advanced Rooming to Improve Communication and Visit Efficiency in Federally Qualified Health Centers

Advanced rooming is a workflow that enables non-clinician staff to take on additional responsibilities to improve quality and productivity. However, the impact is not well understood, particularly in Federally Qualified Health Centers (FQHCs). In this observational study at two FQHC sites, we found that in advanced rooming more questions were asked by patients and staff and more problems were identified and addressed. Advanced rooming medical assistants spent more time with patients and huddled longer with clinicians without significant differences in the clinical portion of the visit or total visit length. Advanced rooming may be a way to enhance care, ease clinician burden, and increase efficiency.

"Good Care Is Slow Enough to Be Able to Pay Attention": Primary Care Time Scarcity and Patient Safety

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.

Care partners and consumer health information technology: A framework to guide systems-level initiatives in support of digital health equity

Introduction

Consumer-oriented health information technologies (CHIT) such as the patient portal have a growing role in care delivery redesign initiatives such as the Learning Health System. Care partners commonly navigate CHIT demands alongside persons with complex health and social needs, but their role is not well specified.

Methods

We assemble evidence and concepts from the literature describing interpersonal communication, relational coordination theory, and systems-thinking to develop an integrative framework describing the care partner's role in applied CHIT innovations. Our framework describes pathways through which systematic engagement of the care partner affects longitudinal work processes and multi-level outcomes relevant to Learning Health Systems.

Results

Our framework is grounded in relational coordination, an emerging theory for understanding the dynamics of coordinating work that emphasizes role-based relationships and communication, and the Systems Engineering Initiative for Patient Safety (SEIPS) model. Cross-cutting work systems geared toward explicit and purposeful support of the care partner role through CHIT may advance work processes by promoting frequent, timely, accurate, problem-solving communication, reinforced by shared goals, shared knowledge, and mutual respect between patients, care partners, and care team. We further contend that systematic engagement of the care partner in longitudinal work processes exerts beneficial effects on care delivery experiences and efficiencies at both individual and organizational levels. We discuss the utility of our framework through the lens of an illustrative case study involving patient portal-mediated pre-visit agenda setting.

Conclusions

Our framework can be used to guide applied embedded CHIT interventions that support the care partner role and bring value to Learning Health Systems through advancing digital health equity, improving user experiences, and driving efficiencies through improved coordination within complex work systems.

Asynchronous Versus Synchronous Screening for Depression and Suicidality in a Primary Health Care System: Quality Improvement Study

Background

Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety.

Objective

We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9.

Methods

This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers' clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion.

Results

Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 "more than half the days" (OR 1.62, 95% CI 1.06-2.48) and "nearly every day" (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 "several days" (P=.002).

Conclusions

Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.

Challenges to Exploring the Patient Perspective in Palliative Care Conversations: A Qualitative Study Among Chronic Obstructive Pulmonary Disease and Chronic Heart Failure Patients and Their Health Care Professionals

Objectives

The aim of this study was to reveal the challenges faced in exploring the patient's perspective as experienced by patients with chronic obstructive pulmonary disease or chronic heart failure and their health care professionals (HCPs), including the circumstances under which these challenges are experienced during palliative care conversations.

Methods

This is a qualitative, explorative study in the Netherlands using purposive sampling to create diversity in demographic variables of both patients and HCPs. Semistructured interviews with 12 patients and 7 HCPs were carried out with the use of topic lists. All interviews were audiorecorded, verbatim transcribed, and thematically analyzed.

Results

Patients find it challenging to express their wishes, preferences, and boundaries and say what is really preoccupying them, especially when they do not feel a good connection with their HCP. HCPs find it challenging to get to know the patient and discuss the patient's perspective particularly when patients are not proactive, open or realistic, or unable to understand or recall information.

Conclusions

Patients and HCPs seem to share the same aim: patients want to be known and understood and HCPs want to know and understand the patient as a unique individual. At the same time, they seem unable to personalize their conversations. To move beyond this impasse patients and HCPs need to take steps and be empowered to do so.

Assessment of Disaster Preparedness at the Household Level in a Pediatric Cardiology Clinic Population

Natural and human-provoked disasters pose serious health risks to children, particularly children and youth with special healthcare needs, including many cardiology patients. The American Academy of Pediatrics (AAP) provides preparedness recommendations for families, but little is known about recommendation adherence. Caregivers of children seen in a pediatric cardiology clinic network were recruited to complete an electronic survey. Participants self-reported child medical history and their household's implementation of AAP recommended disaster preparedness items. Families received a link to AAP resources and a child ID card. Data were analyzed using descriptive statistics with Fisher's exact and Wilcoxon rank sum tests. 320 caregivers participated in the study, of whom 124 (38.8%) indicated that their child has a diagnosed cardiac condition, and 150 (46.9%) indicated that their child had special healthcare needs. The average preparedness item completion rate was 70.7% for household preparedness, 40.1% for reunification preparedness, and 26.3% for community preparedness. Households of children with medical needs had similar rates of preparedness compared to overall rates. Of all respondents, 27.8% previously received disaster preparedness resources, 67.7% would like resources on discussing disaster preparedness, and 93.0% intend to talk with their household about disaster preparedness after completing the survey. These results demonstrate a gap between AAP recommendations and household-level disaster preparedness, including patients with cardiac conditions and those with special healthcare needs. Families expressed that they were interested in getting resources for disaster preparedness. Pediatric cardiologists may consider asking about disaster preparedness and providing disaster preparedness resources tailored to the needs of their patients.

Developing a Collaborative Agenda-Setting Intervention (CASI) to promote patient-centered communication in ovarian cancer care: A design thinking approach

OBJECTIVES

Patient-centered communication (PCC) occurs when clinicians respond to patients' needs, preferences, and concerns. While PCC is associated with better health-related quality of life in patients with cancer, patients with ovarian cancer have reported unmet communication needs. We used design thinking to develop an intervention to promote PCC in ovarian cancer care.

METHODS

Following the steps of design thinking, we empathized with stakeholders by reviewing the literature, then created stakeholder and journey maps to define the design challenge. To ideate solutions, we developed a challenge map. Finally, we developed wireframe prototypes and tested them with stakeholders.

RESULTS

Empathizing revealed that misaligned visit priorities precipitated suboptimal communication. Defining the design challenge and ideating solutions highlighted the need to normalize preference assessments, promote communication self-efficacy, and enhance visit efficiency. The Collaborative Agenda-Setting Intervention (CASI) elicits patients' needs and preferences and delivers communication guidance at the point of care. Stakeholders approved of the prototype.

CONCLUSION

Design thinking provided a systematic approach to empathizing with stakeholders, identifying challenges, and innovating solutions.

PRACTICE IMPLICATIONS

To our knowledge, the CASI is the first intervention to set the visit agenda and support communication from within the electronic health record. Future research will assess its usability and acceptability.

The Annual Wellness Visit Health Risk Assessment: Potential of Patient Portal-Based Completion and Patient-Oriented Education and Support

Background and Objectives

Patient portals are secure online platforms that allow patients to perform electronic health management tasks and engage in bidirectional information exchange with their care team. Some health systems administer Medicare Annual Wellness Visit (AWV) health risk assessments through the patient portal. Scalable opportunities from portal-based administration of risk assessments are not well understood. Our objective is 2-fold-to understand who receives vs misses an AWV and health risk assessment and explore who might be missed with portal-based administration.

Research Design and Methods

This is an observational study of electronic medical record and patient portal data (10/03/2021-10/02/2022) for 12 756 primary care patients 66+ years from a large academic health system.

Results

Two-thirds (n = 8420) of older primary care patients incurred an AWV; 81.0% of whom were active portal users. Older adults who were active portal users were more likely to incur AWV than those who were not, though portal use was high in both groups (81.0% with AWV vs 76.8% without; p < .001). Frequently affirmative health risk assessment categories included falls/balance concerns (44.2%), lack of a documented advanced directive (42.3%), sedentary behaviors (39.9%), and incontinence (35.1%). Mean number of portal messages over the 12-month observation period varied from 7.2 among older adults affirmative responses to concerns about safety at home to 13.8 for older adults who reported difficulty completing activities of daily living. Portal messaging varied more than 2-fold across affirmative health risk categories and were marginally higher with greater number affirmative (mean = 13.8 messages/year no risks; 19.6 messages/year 10+ risks).

Discussion and Implications

Most older adults were active portal users-a group more likely to have incurred a billed AWV. Efforts to integrate AWV risk assessments in the patient portal may streamline administration and scalability for dissemination of tailored electronically mediated preventive care but must attend to equity issues.

Telehealth During COVID-19 for Adults with Multiple Chronic Conditions: Associations with Self-Reported Food Insecurity and with Physical Limitations

Background: Adults with chronic medical conditions complicated by food insecurity or physical limitations may have higher barriers to accessing telehealth implemented during the COVID-19 pandemic. Objective: To examine the relationships of self-reported food insecurity and physical limitations with changes in health care utilization and medication adherence comparing the year before (March 2019-February 2020) and the first year of the COVID-19 pandemic (April 2020-March 2021) among patients with chronic conditions insured by Medicaid or Medicare Advantage. Methods: A prospective cohort study of 10,452 Kaiser Permanente Northern California members insured by Medicaid and 52,890 Kaiser Permanente Colorado members insured by Medicare Advantage was conducted. Difference-in-differences (DID) between the pre-COVID and COVID years in telehealth versus in-person health care utilization and adherence to chronic disease medicines by food insecurity and by physical limitation status were measured. Results: Food insecurity and physical limitations were each associated with small but significantly greater shifts from in-person to telehealth. Medicare Advantage members with physical limitations also had significantly greater decline in adherence to chronic medications from year to year compared with those without physical limitations (DID from pre-COVID year to COVID year ranged from 0.7% to 3.6% greater decline by medication class, p < 0.01). Conclusions: Food insecurity and physical limitations did not present significant barriers to the transition to telehealth during the COVID pandemic. The greater decrease in medication adherence among older patients with physical limitations suggests that care systems must further address the needs of this high-risk population.

"It helps us say what's important..." Developing Serious Illness Topics: A clinical visit agenda-setting tool

BACKGROUND

Skillful communication with attention to patient and care partner priorities can help people with serious illnesses. Few patient-facing agenda-setting tools exist to facilitate such communication.

OBJECTIVE

To develop a tool to facilitate prioritization of patient and care partner concerns during serious illness visits.

PATIENT OR FAMILY INVOLVEMENT

Two family members of seriously ill individuals advised.

METHODS

We performed a literature review and developed a prototype agenda-setting tool. We modified the tool based on cognitive interviews with patients, families and clinicians. We piloted the tool with patients, care partners and clinicians to gain an initial impression of its perceived value.

RESULTS

Interviews with eight patients, eight care partners and seven clinicians, resulted in refinements to the initial tool, including supplementation with visual cues. In the pilot test, seven clinicians used the tool with 11 patients and 12 family members. Qualitatively, patients and care partners reported the guide helped them consider and assert their priorities. Clinicians reported the tool complemented usual practice. Most participants reported no distress, disruption or confusion.

DISCUSSION

Patients, care partners and clinicians appreciated centering patient priorities in serious illness visits using the agenda-setting tool. More thorough evaluation is required.

PRACTICAL VALUE

The agenda-setting tool may operationalize elements of good serious illness care.

Integrating peer support services into primary care-based OUD treatment: Lessons from the Penn integrated model

Opioid use disorder (OUD) is a major public health emergency in the United States. In 2020, 2.7 million individuals had an OUD. Medication for opioid use disorder is the evidence-based, standard of care for treating OUD in outpatient settings, especially buprenorphine because it is effective and has low toxicity. Buprenorphine is increasingly prescribed in primary care, a setting that provides greater anonymity and convenience than substance use disorder treatment centers. Yet two-thirds of people who begin buprenorphine treatment discontinue within the first six months. Treatment dropout elevates the risks of return to use, infections, higher levels of medical care and related costs, justice system involvement, and death. One promising form of retention support is peer service programs. Peers combine their lived experience of substance use and recovery with formal training to help patients engage and persist in OUD treatment. They provide a range of services, including health education, encouragement and empathy, coping skills, recovery modeling, and concrete assistance in overcoming the situational barriers to retention. However, guidance is needed to define the peer role in primary care, the specific tasks peers should perform, the competencies those tasks require, training and professional development needs, and peer performance standards. Guidance also is needed to integrate peers into the care team, allocate and coordinate responsibilities among care team members, manage peer operations and workflow, and facilitate effective team communication. Here we describe a peer support program in the University of Pennsylvania Health System (UPHS or Penn Medicine) network of primary care practices. This paper details the program's core components, values, and activities. We also report the organizational challenges, unresolved questions, and lessons for the field in administering a peer support program to meet the needs of patients served by a large, urban medical system with an extensive suburban and rural catchment area. CLINICAL TRIALS REGISTRATION: www.clinicaltrials.gov registration: NCT04245423.

Reflection in Rural Family Medicine Education

Reflection in medical education is vital for students' development as professionals. The lack of medical educators in rural family medicine can impinge on the effective reflection of residents' learning. Hence, based on qualitative research, we proposed a framework regarding reflection in rural family medicine education, indicating when, where, and how reflection is performed and progresses. The contents of reflection include clinical issues regarding knowledge and skills, professionalism in clinical decisions, and work-life balance. The settings of reflection include conference rooms, clinical wards, residents' desks, and hospital hallways. The timing of educational reflection includes during and after patient examination and discussion with various professionals, before finishing work, and during "doorknob" times (right before going back home). Rural medical teachers need competence as clinicians and medical educators to promote learning in medical residents and sustain rural medical care. Furthermore, medical teachers must communicate and collaborate with medical residents and nurses for educational reflection to take place in rural family medicine education, especially regarding professionalism. In rural family medicine education, reflection can be performed in various clinical situations through collaboration with learners and various medical professionals, aiding the enrichment of residents' learning and sustainability of rural medical care.

Racial Differences in Diagnosis of Overweight and Obesity: Results from the National Health and Nutrition Examination Survey (NHANES) 2009-2016

BACKGROUND

Diagnostic standards and codes related to excessive weight exist so that clinicians may inform patients that they are overweight: a status which may be a harbinger of more severe obesity and negative health outcomes. Equipped with this knowledge, patients may pursue medical interventions or behavioral changes to reduce their risk. However, diagnoses of overweight are unequally applied in the United States along racial lines.

METHODS

Binary logistic regression was used to analyze National Health and Nutrition Examination Survey (NHANES) 2009-2016 data from 7460 participants to examine the relationship between race of non-Hispanic White and non-Hispanic Black Americans and having ever been told that one is overweight by a clinician when controlling for demographic and socioeconomic factors. The body mass index (BMI) of participants along with obesity-associated comorbidities was then incorporated into the model to see if physical size or disease status mediated the primary relationship.

RESULTS

Black Americans are significantly less likely to report being told that they are overweight by a clinician than are White Americans regardless of clinical weight status and weight-associated comorbidities. We find that these racial differences are greatest when respondents' BMIs approach the lower threshold for clinical obesity.

CONCLUSIONS

Our findings suggest that the lower likelihood of Black Americans to be told they are overweight compared to their White counterparts can result in serious health implications. We posit that implicit biases among clinicians may partly explain this disparity, which may exacerbate health outcome inequalities.

Factors affecting primary care physician decision-making for patients with complex multimorbidity: a qualitative interview study

BACKGROUND

Patients with multiple chronic conditions (multimorbidity) and additional psychosocial complexity are at higher risk of adverse outcomes. Establishing treatment or care plans for these patients must account for their disease interactions, finite self-management abilities, and even conflicting treatment recommendations from clinical practice guidelines. Despite existing insight into how primary care physicians (PCPs) approach care decisions for their patients in general, less is known about how PCPs make care planning decisions for more complex populations particularly within a medical home setting. We therefore sought to describe factors affecting physician decision-making when care planning for complex patients with multimorbidity within the team-based, patient-centered medical home setting in the integrated healthcare system of the U.S. Department of Veterans Affairs, the Veterans Health Administration (VHA).

METHODS

This was a qualitative study involving semi-structured telephone interviews with PCPs working > 40% time in VHA clinics. Interviews were conducted from April to July, 2020. Content was analyzed with deductive and inductive thematic analysis.

RESULTS

23 physicians participated in interviews; most were MDs (n = 21) and worked in hospital-affiliated clinics (n = 14) across all regions of the VHA's national clinic network. We found internal, external, and relationship-based factors, with developed subthemes describing factors affecting decision-making for complex patients with multimorbidity. Physicians described tailoring decisions to individual patients; making decisions in keeping with an underlying internal style or habit; working towards an overarching goal for care; considering impacts from patient access and resources on care plans; deciding within boundaries provided by organizational structures; collaborating on care plans with their care team; and impacts on decisions from their own emotions and relationship with patient.

CONCLUSIONS

PCPs described internal, external, and relationship-based factors that affected their care planning for high-risk and complex patients with multimorbidity in the VHA. Findings offer useful strategies employed by physicians to effectively conduct care planning for complex patients in a medical home setting, such as delegation of follow-up within multidisciplinary care teams, optimizing visit time vs frequency, and deliberate investment in patient-centered relationship building to gain buy-in to care plans.

Healthcare Provider Engagement with a Novel Dashboard for Tracking Medication Ingestion: Impact on Treatment Decisions and Clinical Assessments for Adults with Schizophrenia

PURPOSE

Schizophrenia is a severe, chronic condition accounting for disproportionate healthcare utilization. Antipsychotics can reduce relapse rates, but the characteristics of schizophrenia may hinder medication adherence. A phase 3b open-label clinical trial used aripiprazole tablets with sensor (AS; includes pills with ingestible event-marker, wearable sensor patches and smartphone application) in adults with schizophrenia. This post hoc analysis explored how healthcare providers' (HCPs) usage of a dashboard that provided medication ingestion information impacted treatment decisions and clinical assessments.

PATIENTS AND METHODS

Participants used AS for 3-6 months. HCPs were instructed to check the dashboard regularly, identify features used, and report impact on treatment decisions. After stratifying HCPs by frequency of dashboard checks and resulting treatment decisions, changes from baseline were calculated for Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression (CGI)-Severity of Illness and CGI-Improvement (CGI-I), and Personal and Social Performance (PSP), and compared using Mann-Whitney U-tests and rank-biserial correlation coefficient (r) effect sizes.

RESULTS

To ensure sufficient opportunity for AS engagement, 113 participants who completed ≥3 months on study were analyzed. HCPs most often accessed dashboard data regarding medication ingestion and missed doses. HCPs recommended adherence counseling and participant education most often. Participants whose HCPs used the dashboard more and recommended adherence counseling and participant education (n=61) improved significantly more than participants with less dashboard-active HCPs (n=49) in CGI-I mean score (2.9 versus 3.4 [p=0.004]), total PANSS (mean change: -9.2 versus -3.1 [p=0.0002]), PANSS positive subscale (-3.2 versus -1.5 [p=0.003]), PANSS general subscale (-4.3 versus -1.2 [p=0.02]), and Marder factor for negative symptoms (-1.9 versus 0.0 [p=0.03]). Most HCPs found the dashboard easy to use (74%) and helpful for improving conversations with participants about their treatment plan and progress (78%).

CONCLUSION

This provider dashboard may facilitate discussions with patients about regular medication-taking, which can improve patient outcomes.

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care

BACKGROUND

Patients and families are important contributors to the diagnostic team, but their perspectives are not reflected in current diagnostic measures. Patients/families can identify some breakdowns in the diagnostic process beyond the clinician's view. We aimed to develop a framework with patients/families to help organisations identify and categorise patient-reported diagnostic process-related breakdowns (PRDBs) to inform organisational learning.

METHOD

A multi-stakeholder advisory group including patients, families, clinicians, and experts in diagnostic error, patient engagement and safety, and user-centred design, co-developed a framework for PRDBs in ambulatory care. We tested the framework using standard qualitative analysis methods with two physicians and one patient coder, analysing 2165 patient-reported ambulatory errors in two large surveys representing 25 425 US respondents. We tested intercoder reliability of breakdown categorisation using the Gwet's AC1 and Cohen's kappa statistic. We considered agreement coefficients 0.61-0.8=good agreement and 0.81-1.00=excellent agreement.

RESULTS

The framework describes 7 patient-reported breakdown categories (with 40 subcategories), 19 patient-identified contributing factors and 11 potential patient-reported impacts. Patients identified breakdowns in each step of the diagnostic process, including missing or inaccurate main concerns and symptoms; missing/outdated test results; and communication breakdowns such as not feeling heard or misalignment between patient and provider about symptoms, events, or their significance. The frequency of PRDBs was 6.4% in one dataset and 6.9% in the other. Intercoder reliability showed good-to-excellent reliability in each dataset: AC1 0.89 (95% CI 0.89 to 0.90) to 0.96 (95% CI 0.95 to 0.97); kappa 0.64 (95% CI 0.62, to 0.66) to 0.85 (95% CI 0.83 to 0.88).

CONCLUSIONS

The PRDB framework, developed in partnership with patients/families, can help organisations identify and reliably categorise PRDBs, including some that are invisible to clinicians; guide interventions to engage patients and families as diagnostic partners; and inform whole organisational learning.

Supporting collaborative reflection on personal values and health

People with multiple chronic conditions (MCC) need support to identify and articulate how their personal values relate to their health. We drew on previous research involving people with MCC to develop three prototypes for supporting reflection on relationships between values and health. We tested these prototypes in a qualitative study involving 12 people with MCC. We identified benefits and limitations to building on patients' existing visit-preparation practices; revealed varying levels of comfort with deep, exploratory reflection involving a facilitator; and found that reflection oriented toward the future could elicit hopeful attitudes and plans for change, while reflection on the past elicited strong resistance. We discuss these findings in relation to previous literature on designing for reflection in three areas: shifting between self-guided and facilitator-guided reflection, balancing between outcome-oriented and exploratory reflection, and exploring temporality in reflection.

Emerging models of care for individuals with multiple chronic conditions

OBJECTIVE

To characterize emerging and current practice models to more effectively treat and support patients with multiple chronic conditions (MCC).

DATA SOURCES/STUDY SETTING

We conducted a rapid literature scoping augmented by key informant interviews with clinicians knowledgeable about MCC care from a broad spectrum of US delivery systems and feedback from multidisciplinary experts at two virtual meetings.

STUDY DESIGN

Literature findings were triangulated with data from semi-structured interviews with clinical experts. Reflections on early results were obtained from policy, research, clinical, advocacy, and patient representatives at two virtual meetings sponsored by the Agency for Healthcare Research and Quality. Emergent themes addressed were as follows: (1) more timely strategies for MCC care; and (2) trends not previously represented in the peer-reviewed literature.

DATA COLLECTION/EXTRACTION METHODS

The rapid literature scoping relied on Ovid MEDLINE(R) and Epub Ahead of Print databases for the most recent 5-year period. Qualitative interviews were conducted by telephone. Virtual meetings provided oral and written (chat) captured inputs.

PRINCIPAL FINDINGS

Although the literature scoping did not identify a specific set of evidence-based care models, key informant discussions identified eight themes reflecting emerging approaches to population-based MCC care. For example, addressing the needs of individuals with MCC through a complexity lens by assessing and addressing social risk factors; extending the care continuum with home-based care; understanding how to address ongoing patient and caregiver supports outside of clinical encounters; and engaging available community resources.

CONCLUSIONS

Integrating care for MCC patient populations requires processes for determining different subpopulation needs in various settings and lived experiences. Innovation should be anchored at the nexus of payment systems, social risks, medical needs, and community-based resources. Our learnings suggest a need for an ongoing MCC care research agenda to inform new approaches to care delivery incorporating innovations in technology and home-based supports for patients and caregivers.

Implementation of Patient Engagement Tools in Electronic Health Records to Enhance Patient-Centered Communication: Protocol for Feasibility Evaluation and Preliminary Results

Background

Patient–physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient–physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters.

Objective

In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient–physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters.

Methods

We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit “patient important issue” questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient–staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes.

Results

The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient–clinician communication, particularly during the COVID-19 pandemic.

Conclusions

EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians’ work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians.

Trial Registration

ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512

International Registered Report Identifier (IRRID)

DERR1-10.2196/30431

I am ready to see you now, Doctor! A mixed-method study of the Let's Discuss Health website implementation in Primary Care

Background

Let's Discuss Health (LDH) is a website that encourages patients to prepare their health‐care encounters by providing communication training, review of topics and questions that are important to them.

Objective

To describe LDH implementation during primary care (PC) visits for chronic illnesses.

Methods

Design: Descriptive mixed‐method study. Setting: 6 PC clinics. Participants: 156 patients and 51 health‐care providers (HCP). Intervention: LDH website implementation. Outcome Measures: Perceived quality and usefulness of LDH; perceived quality of HCP‐patient communication; patient activation; LDH integration in routine PC practices and barriers to its use.

Results

Patients reported a positive perception of the website in that it helped them to adopt an active role in the encounters; recall their visit agenda and reduce encounter‐related stress; feel more confident to ask questions, feel more motivated to prepare their future medical visits and improve their chronic illness management. However, a certain disconnect emerged between HCP and patient perceptions as to the value of LDH in promoting a sense of partnership and collaboration. The main barriers to the use of LDH are HCP lack of interest, limited access to technology, lack of time and language barriers.

Conclusion

Our findings indicate that it is advantageous for patients to prepare their medical encounters. However, the study needs to be replicated in other medical environments using larger and more diverse samples.

Patient and Public Contribution

Patient partners were involved in the conduct of this study.

Is it me? The impact of patient-physician interactions on lupus patients' psychological well-being, cognition and health-care-seeking behaviour

Objective

The aim was to explore the impact of patient–physician interactions, pre- and post-diagnosis, on lupus and UCTD patients’ psychological well-being, cognition and health-care-seeking behaviour.

Methods

Participants were purposively sampled from the 233 responses to a survey on patient experiences of medical support. Twenty-one semi-structured interviews were conducted and themes generated using thematic analysis.

Results

The study identified six principal themes: (i) the impact of the diagnostic journey; (ii) the influence of key physician(s) on patient trust and security, with most participants reporting at least one positive medical relationship; (iii) disparities in patient–physician priorities, with patients desiring more support with quality-of-life concerns; (iv) persisting insecurity and distrust, which was prevalent and largely influenced by previous and anticipated disproportionate (often perceived as dismissive) physician responses to symptoms and experiences of widespread inadequate physician knowledge of systemic autoimmune diseases; (v) changes to health-care-seeking behaviours, such as curtailing help-seeking or under-reporting symptoms; and (vi) empowerment, including shared medical decision-making and knowledge acquisition, which can mitigate insecurity and improve care.

Conclusion

Negative medical interactions pre- and post-diagnosis can cause a loss of self-confidence and a loss of confidence and trust in the medical profession. This insecurity can persist even in subsequent positive medical relationships and should be addressed. Key physicians implementing empowering and security-inducing strategies, including being available in times of health crises and validating patient-reported symptoms, might lead to more trusting medical relationships and positive health-care-seeking behaviour.

Communication about Drug-Related Problems (DRPs) during Patients' Visits to Dutch Physicians and Pharmacies

The objective of this study is to assess the frequency and type of drug-related problems (DRPs) (1) raised and discussed (2) raised but not discussed or (3) not raised during patients' visits to healthcare practitioners (HCPs). In this cross-sectional study in Dutch outpatient clinics, GP practices and pharmacies, verbal cues from patients and HCPs indicating DRPs were inventoried by an observer during visits. It was also observed whether raised DRPs were discussed between patient and HCP. Post-encounter interviews (HCPs) were conducted and post-encounter questionnaires (patient) were distributed to identify DRPs not raised. In total, 431 patients were observed during a single visit. In 42.2% of these visits, 311 DRPs were raised (weighted mean (SD) 0.7 (±1.1) DRP/patient). Of these 311 DRPs, 82.0% were discussed between HCP and patient. HCPs did not raise existing DRPs in 3.9% of the 431 visits; in 6.3% of the 176 questionnaires the patient reported an existing DRP that had not been raised. In conclusion, almost one in six of the DRPs raised during visits are not discussed between HCP and patient. Furthermore, existing DRPs are not even raised in 4-6% of the visits. HCPs and patients should be aware that, although patients often have DRPs, these are not always discussed or not even raised during patients' visits.

Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial

BACKGROUND

Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits.

OBJECTIVE

To test the hypothesis that a "Pre-Visit Prioritization" secure email message could improve visit communication and glycemic control among patients with type 2 diabetes.

DESIGN

We conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system.

PARTICIPANTS

Eligible patients had at least 1 year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c) > = 8.0%, and were registered users of the KPNC online patient portal.

INTERVENTIONS

Patients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care.

MAIN MEASURES

Glycemic control; change in HbA1c 6 and 12 months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences.

KEY RESULTS

During the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n = 457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p = 0.048) and being given treatment choices to consider (81% vs 73%, p = 0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56% ± 1.45%), with no significant differences between arms.

CONCLUSIONS

A "light touch" email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation.

TRIAL REGISTRY

NCT02375932.

The time is now: Fostering relationship-centered discussions about patients' social determinants of health

OBJECTIVE

This paper discusses the importance of developing best practices in communication strategies to identify and act on social determinants of health (SDOH) in care settings in ways that minimizes shame and builds patient trust in the process.

DISCUSSION

We leverage the relationship-centered care framework to provide health care teams guidance in how to foster meaningful discussions about SDOH at three pivotal points in the process: 1) at the initial screening; 2) once an unmet social need has been identified; and 3) when exchanging SDOH data with team members and external organizations.

CONCLUSION

This discussion piece uses a relationship-centered framework to offer several evidence-based recommendations for health care systems on how to help their workforce respectfully listen and collaborate with patients to address SDOH. Additional research into patient and provider perceptions of relationship-centered communication surrounding screening and referral practices can help further adapt and refine best practices to maximize chances for addressing patients' SDOH.

Addressing Mental Health Concerns in Primary Care: Practices Among Medical Residents in a Rural Setting

Behavioral health issues like anxiety and depression negatively impact numerous aspects of primary care, including medical regimen adherence, communication, physical well-being, and engagement in beneficial health behaviors. This study aimed to examine internal and family medicine residents': (1) patterns of addressing mental health concerns (e.g., frequency of referral for psychotherapy and/or medication), (2) self-perceptions of competency in assessment and treatment of specific mental health disorders, and (3) frequency of utilization of efficacious therapeutic strategies during clinical encounters. Self-report surveys were administered to Family Medicine and Internal Medicine residents (N = 39). Descriptive analyses indicated that 81% of the time, residents discussed mental health concerns when it was the presenting concern, and routinely offered medication and psychotherapy (71% and 68% of the time, respectively). Residents felt most competent in addressing major depressive disorder and generalized anxiety disorder, and least competent in addressing somatization disorder and bipolar disorder. Residents reported that they most often used motivational interviewing (MI), followed by Cognitive Behavioral Therapy, psychoeducation, and solution-focused strategies during medical encounters. These findings highlight a need to identify barriers to addressing mental health conditions in primary care and potential gaps in training that might address low levels of perceived competency among medical residents.

Patient-Family Agenda Setting for Primary Care Patients with Cognitive Impairment: the SAME Page Trial

BACKGROUND

Establishing priorities for discussion during time-limited primary care visits is challenging in the care of patients with cognitive impairment. These patients commonly attend primary care visits with a family companion.

OBJECTIVE

To examine whether a patient-family agenda setting intervention improves primary care visit communication for patients with cognitive impairment DESIGN: Two-group pilot randomized controlled study PARTICIPANTS: Patients aged 65 + with cognitive impairment and family companions (n = 93 dyads) and clinicians (n = 14) from two general and one geriatrics primary care clinic INTERVENTION: A self-administered paper-pencil checklist to clarify the role of the companion and establish a shared visit agenda MEASUREMENTS: Patient-centered communication (primary); verbal activity, information disclosure including discussion of memory, and visit duration (secondary), from audio recordings of visit discussion RESULTS: Dyads were randomized to usual care (n = 44) or intervention (n = 49). Intervention participants endorsed an active communication role for companions to help patients understand what the clinician says or means (90% of dyads), remind patients to ask questions or ask clinicians questions directly (84% of dyads), or listen and take notes (82% of dyads). Intervention dyads identified 4.4 health issues for the agenda on average: patients more often identified memory (59.2 versus 38.8%; p = 0.012) and mood (42.9 versus 24.5%; p = 0.013) whereas companions more often identified safety (36.7 versus 18.4%; p = 0.039) and personality/behavior change (32.7 versus 16.3%; p = 0.011). Communication was significantly more patient-centered in intervention than in control visits at general clinics (p < 0.001) and in pooled analyses (ratio of 0.86 versus 0.68; p = 0.046). At general clinics, intervention (versus control) dyads contributed more lifestyle and psychosocial talk (p < 0.001) and less biomedical talk (p < 0.001) and companions were more verbally active (p < 0.005). No intervention effects were found at the geriatrics clinic. No effect on memory discussions or visit duration was observed.

CONCLUSION

Patient-family agenda setting may improve primary care visit communication for patients with cognitive impairment.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02986958.