Technology and Medicine: Reimagining Provider Visits as the New Tertiary Care

Increasing Access to Buprenorphine for Opioid Use Disorder in Primary Care: an Assessment of Provider Incentives

BACKGROUND

Primary care providers (PCPs) are essential to increasing access to office-based buprenorphine medication treatment for opioid use disorder (B-MOUD). Barriers to B-MOUD prescribing are well-documented, but there is little information regarding incentives to overcome these barriers.

OBJECTIVE

To identify optimal incentives for PCPs to promote B-MOUD prescribing and compare incentive preferences across provider and practice characteristics.

DESIGN

We surveyed PCPs using best-worst scaling (BWS) to prioritize seven potential incentives for B-MOUD prescribing (monetary compensation, paid vacation, protected time, professional development, reduced workload, service recognition, clinical resources). We then used a direct elicitation approach to determine preferred incentive levels (e.g., monetary thresholds) and types (e.g., specific clinical resources).

PARTICIPANTS

Primary care physicians and advanced practice providers (APPs) at a large Department of Veterans Affairs healthcare system.

MAIN MEASURES

B-MOUD prescribing incentive preferences and relative preference levels using descriptive statistics and conditional logistic regression with relative importance scale transformation (coefficients sum to 100, higher coefficient=greater importance).

KEY RESULTS

Fifty-three PCPs responded (73% response), including 47% APPs and 36% from community-based clinics. Reduced workload (relative importance score=26.8), protected time (18.7), and clinical resources (16.8) were significantly more preferred (Ps < 0.001) than professional development (10.5), paid vacation (10.3), or service recognition (1.5). Relative importance of monetary compensation varied between physicians (12.6) and APPs (17.5) and between PCPs located at a medical center (11.4) versus community clinic (22.3). APPs were more responsive than physicians to compensation increases of $5000 and $12,000 but less responsive to $25,000; trends were similar for medical center versus community clinic PCPs. The most frequently requested clinical resource was on-demand consult access to an addiction specialist.

CONCLUSIONS

Interventions promoting workload reductions, protected time, and clinical resources could increase access to B-MOUD in primary care. Monetary incentives may be additionally needed to improve B-MOUD prescribing among APPs and within community clinics.

A Mobile Phone App Improves Patient-Physician Communication and Reduces Emergency Department Visits After Colorectal Surgery

BACKGROUND

Emergency visits after colorectal surgery are common and require significant health care resources. However, many visits may be avoidable with alternative access to care. Mobile health technologies can facilitate patient access to health care providers.

OBJECTIVE

We hypothesized that a mobile app for postdischarge monitoring with patient-provider communication ability would reduce emergency visits after elective abdominopelvic colorectal surgery.

DESIGN

This is a prospective cohort study with a regression analysis after coarsened exact matching.

SETTING

The study was conducted at a single colorectal referral center from May 2019 to September 2020.

PATIENTS

A total of 114 patients were recruited to the intervention and were matched to a retrospective cohort of 608 patients from the 24 months before the study. All patients were managed according to an enhanced recovery pathway.

INTERVENTIONS

A mobile phone app comprised of patient education material, daily questionnaires assessing postdischarge recovery, and patient-provider chat function was used.

MAIN OUTCOME MEASURES

The primary outcomes included potentially preventable 30-day emergency visits defined according to a validated algorithm. Secondary outcomes included length of stay, complications, total emergency department visits, readmissions, and app usability.

RESULTS

Coarsened-exact matching resulted in a matched sample of 94 prospective intervention patients and 256 retrospective control patients. The prospective group was associated with fewer preventable emergency department visits (incidence rate ratio 0.34; p = 0.043) and shorter length of stay (-1.62 days; p = 0.011). There were no differences in 30-day complications, total number of emergency visits, or readmissions. Patient-reported usability of the mobile app was high, with 88% of patients reporting that the app improved their ability to communicate with their surgeon.

LIMITATIONS

We did not account for patient activation or perform a cost-analysis.

CONCLUSION

Use of a mobile app was associated with fewer potentially preventable emergency visits and shorter length of stay after major elective colorectal surgery, which may be due to enhanced postdischarge monitoring and patient-provider communication. See Video Abstract at http://links.lww.com/DCR/B878 .

APLICACIN DE TELFONO MVIL MEJORA LA COMUNICACIN ENTRE MDICO Y PACIENTE Y REDUCE LAS VISITAS AL DEPARTAMENTO DE EMERGENCIAS DESPUS DE CIRUGA COLORECTAL

ANTECEDENTES:Las visitas de emergencia después de la cirugía colorrectal son frecuentes y requieren importantes recursos sanitarios. Sin embargo, muchas visitas pueden evitarse con un acceso alternativo a la atención. Las tecnologías de salud móviles pueden facilitar el acceso de los pacientes a los proveedores de atención médica.OBJETIVO:Se planteó la hipótesis de que una aplicación móvil para el seguimiento posterior al alta con capacidad de comunicación entre el paciente y el médico reduciría las visitas de emergencia después de cirugía colorrectal abdominopélvica electiva.DISEÑO:Este es un estudio de cohorte prospectivo con un análisis de regresión después de un emparejamiento exacto aproximado.ENTORNO CLINICO:El estudio se llevó a cabo en un solo centro de referencia colorrectal entre 05/2019 y 09/2020.PACIENTES:Se reclutó un total de 114 pacientes para la intervención y se emparejaron con una cohorte retrospectiva de 608 pacientes de los 24 meses anteriores al estudio. Todos los pacientes fueron tratados con protocolo de enhanced recovery .INTERVENCIONES:Se utilizó una aplicación para teléfono móvil compuesta de material educativo para el paciente, cuestionarios diarios que evalúan la recuperación posterior al alta y una función de chat entre el paciente y el médico.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron visitas a la emergencia en 30 días potencialmente prevenibles, definidas según un algoritmo validado. Los resultados secundarios incluyeron la duración de la estancia, complicaciones, total de visitas al departamento de emergencias, reingresos y la usabilidad de la aplicación.RESULTADOS:El emparejamiento aproximado-exacto resultó en una muestra emparejada de 94 APP + y 256 APP-. APP + se asoció con menos visitas evitables al servicio de urgencias (IRR 0,34, p = 0,043) y una estancia más corta (-1,62 días, p = 0,011). No hubo diferencias en las complicaciones a los 30 días, número total de visitas de emergencia y reingresos. La usabilidad de la aplicación móvil informada por los pacientes fue alta, y el 88% de los pacientes informaron que la aplicación mejoró su capacidad para comunicarse con su cirujano.LIMITACIONES:No contabilizamos la activación del paciente ni realizamos un análisis de costos.CONCLUSIÓNES:El uso de una aplicación móvil se asoció con menos visitas a la emergencia potencialmente prevenibles y una estadía más corta después de una gran cirugía colorrectal electiva, lo que puede deberse a una mejor monitorización posterior al alta y a la comunicación entre el paciente y el médico. Consulte Video Resumen en http://links.lww.com/DCR/B878 . (Traducción-Dr. Francisco M. Abarca-Rendon ).

An International, Mixed-Methods Study of the Perceived Intrusiveness of Remote Digital Diabetes Monitoring

OBJECTIVE

To assess the relationship between remote digital monitoring (RDM) modalities for diabetes and intrusiveness in patients' lives.

PATIENTS AND METHODS

Online vignette-based survey (February 1 through July 1, 2019). Adults with diabetes (type 1, 2, or subtypes such as latent autoimmune diabetes of adulthood) assessed three randomly selected vignettes among 36 that combined different modalities for monitoring tools (three options: glucose- and physical activity [PA]-monitoring only, or glucose- and PA-monitoring with occasional or regular food monitoring), duration/feedback loops (six options: monitoring for a week before all vs before specific consultations with feedback given in consultation, vs monitoring permanently, with real-time feedback by one's physician vs by anoter caregiver, vs monitoring permanently, with real-time, artificial intelligence-generated treatment feedback vs treatment and lifestyle feedback), and data handling (two options: by the public vs private sector). We compared intrusiveness (assessed on a 5-point scale) across vignettes and used linear mixed models to identify intrusiveness determinants. We collected qualitative data to identify aspects that drove participants' perception of intrusiveness.

RESULTS

Overall, 1010 participants from 30 countries provided 2860 vignette-assessments (52% were type 1 diabetes). The monitoring modalities associated with increased intrusiveness were food monitoring compared with glucose- and PA-monitoring alone (β=0.34; 95% CI, 0.26 to 0.42; P<.001) and permanent monitoring with real-time physician-generated feedback compared with monitoring for a week with feedback in consultation (β=0.25; 95% CI, 0.16 to 0.34, P<.001). Public-sector data handling was associated with decreased intrusiveness as compared with private-sector (β=-0.15; 95% CI, -0.22 to -0.09; P<.001). Four drivers of intrusiveness emerged from the qualitative analysis: practical/psychosocial burden (eg, RDM attracting attention in public), control, data safety/misuse, and dehumanization of care.

CONCLUSION

RDM is intrusive when it includes food monitoring, real-time human feedback, and private-sector data handling.

Impact of Project ECHO Models of Medical Tele-Education: a Systematic Review

BACKGROUND

Extension for Community Healthcare Outcomes (ECHO) and related models of medical tele-education are rapidly expanding; however, their effectiveness remains unclear. This systematic review examines the effectiveness of ECHO and ECHO-like medical tele-education models of healthcare delivery in terms of improved provider- and patient-related outcomes.

METHODS

We searched English-language studies in PubMed, Embase, and PsycINFO databases from 1 January 2007 to 1 December 2018 as well as bibliography review. Two reviewers independently screened citations for peer-reviewed publications reporting provider- and/or patient-related outcomes of technology-enabled collaborative learning models that satisfied six criteria of the ECHO framework. Reviewers then independently abstracted data, assessed study quality, and rated strength of evidence (SOE) based on Cochrane GRADE criteria.

RESULTS

Data from 52 peer-reviewed articles were included. Forty-three reported provider-related outcomes; 15 reported patient-related outcomes. Studies on provider-related outcomes suggested favorable results across three domains: satisfaction, increased knowledge, and increased clinical confidence. However, SOE was low, relying primarily on self-reports and surveys with low response rates. One randomized trial has been conducted. For patient-related outcomes, 11 of 15 studies incorporated a comparison group; none involved randomization. Four studies reported care outcomes, while 11 reported changes in care processes. Evidence suggested effectiveness at improving outcomes for patients with hepatitis C, chronic pain, dementia, and type 2 diabetes. Evidence is generally low-quality, retrospective, non-experimental, and subject to social desirability bias and low survey response rates.

DISCUSSION

The number of studies examining ECHO and ECHO-like models of medical tele-education has been modest compared with the scope and scale of implementation throughout the USA and internationally. Given the potential of ECHO to broaden access to healthcare in rural, remote, and underserved communities, more studies are needed to evaluate effectiveness. This need for evidence follows similar patterns to other service delivery models in the literature.

Access to Affordable, High-Quality Health Insurance for Rural Residents and Its Impact on Their Health and on Rural Hospitals

Access to rural health care is an ongoing challenge for those living in America's countryside. Hospital closures, a fragmented and dislocated care delivery system, disproportionate levels of chronic illness, and poverty combine to present significant obstacles to health reform. This article highlights the major challenges in rural health care and specifies financial and delivery policy options that can strengthen rural health care. In particular, this article suggests a return to a prepaid approach within the umbrella organizational framework of what we term "rural convening entities." These entities would serve as the control of telehealth hubs for the communities they serve.