Reducing Care Overuse in Older Patients Using Professional Norms and Accountability : A Cluster Randomized Controlled Trial

BACKGROUND

Effective strategies are needed to curtail overuse that may lead to harm.

OBJECTIVE

To evaluate the effects of clinician decision support redirecting attention to harms and engaging social and reputational concerns on overuse in older primary care patients.

DESIGN

18-month, single-blind, pragmatic, cluster randomized trial, constrained randomization. (ClinicalTrials.gov: NCT04289753).

SETTING

60 primary care internal medicine, family medicine and geriatrics practices within a health system from 1 September 2020 to 28 February 2022.

PARTICIPANTS

371 primary care clinicians and their older adult patients from participating practices.

INTERVENTION

Behavioral science-informed, point-of-care, clinical decision support tools plus brief case-based education addressing the 3 primary clinical outcomes (187 clinicians from 30 clinics) were compared with brief case-based education alone (187 clinicians from 30 clinics). Decision support was designed to increase salience of potential harms, convey social norms, and promote accountability.

MEASUREMENTS

Prostate-specific antigen (PSA) testing in men aged 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women aged 65 years and older, and overtreatment of diabetes with hypoglycemic agents in patients aged 75 years and older and hemoglobin A1c (HbA1c) less than 7%.

RESULTS

At randomization, mean clinic annual PSA testing, unspecified urine testing, and diabetes overtreatment rates were 24.9, 23.9, and 16.8 per 100 patients, respectively. After 18 months of intervention, the intervention group had lower adjusted difference-in-differences in annual rates of PSA testing (-8.7 [95% CI, -10.2 to -7.1]), unspecified urine testing (-5.5 [CI, -7.0 to -3.6]), and diabetes overtreatment (-1.4 [CI, -2.9 to -0.03]) compared with education only. Safety measures did not show increased emergency care related to urinary tract infections or hyperglycemia. An HbA1c greater than 9.0% was more common with the intervention among previously overtreated diabetes patients (adjusted difference-in-differences, 0.47 per 100 patients [95% CI, 0.04 to 1.20]).

LIMITATION

A single health system limits generalizability; electronic health data limit ability to differentiate between overtesting and underdocumentation.

CONCLUSION

Decision support designed to increase clinicians' attention to possible harms, social norms, and reputational concerns reduced unspecified testing compared with offering traditional case-based education alone. Small decreases in diabetes overtreatment may also result in higher rates of uncontrolled diabetes.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Remote physiologic monitoring for hypertension in primary care: a prospective pragmatic pilot study in electronic health records using propensity score matching

Objectives

Since 2019, the Centers for Medicare and Medicaid Services covers remote physiologic monitoring (RPM) for blood pressure (BP) per hypertension diagnosis and treatment guidelines. Here, we integrated Omron VitalSight RPM into the health system's electronic health record to transmit BP and pulse without manual entry, assessed feasibility, and used pragmatic prospective matched cohort studies to assess initial effects in (1) uncontrolled (last two office BP ≥140/90 mmHg) and (2) general (diagnosed hypertension or last office BP ≥140/90 mmHg) hypertension patient populations.

Materials and Methods

Seventeen clinicians at two internal medicine practices were oriented. Eligible patients were aged 65-85 years had Medicare insurance with ≥1 office visit in the previous year. We prospectively identified matched controls (age, sex, BP, and number of office visits in previous year) from other primary care practices within the health system and estimated the association between RPM availability (clinic-level) and patient BP outcomes after 6 months. ClinicalTrials.gov: NCT04604925.

Results

Feasibility. Uptake was low at pilot clinics: 10 physicians prescribed RPM to 118 patients during the 6-month pilot. This included 7% (14/207) of the prespecified uncontrolled hypertension cohort and 3.3% (78/2356) of the general hypertension cohort. Surveyed clinicians (n = 4) reported changing their patients' medical treatment in response to RPM BPs, although they recommended having a dedicated RN or LPN to review BP readings. Effectiveness. At 6 months, BP control was greater at pilot practices than among matched controls (uncontrolled: 31.4% vs 22.8%; P = .007; general: 64.0% vs 59.7%; P < .001). Systolic BP at last office visit did not differ (mean [SD] 146.0 [15.7] vs 147.1 [15.6]; P = .48) in the uncontrolled population, and was lower in the general population (131.8 [15.7] vs 132.8 [15.9]; P = .04).The frequency of antihypertensive medication changes was similar in both groups (uncontrolled P = .986; general P = .218).

Discussion and Conclusions

Uptake notwithstanding, RPM may have improved BP control. A potential mechanism is increased physician awareness of and attention to uncontrolled hypertension. Barriers to RPM use among physicians require further study.

Validation testing of five home blood pressure monitoring devices for the upper arm according to the ISO 81060-2:2018/AMD 1:2020 protocol

The accuracy of Omron 10 Series BP7450 (HEM-7342T-Z), Omron Platinum BP5450 (HEM-7343T-Z), Walmart Equate Premium 8000 Series UA-8000WM, Walgreens Premium 15+ WGNBPA-960BT, and CVS Series 800 BP3MW1-4YCVS were assessed in an adult general population compared to a mercury sphygmomanometer standard according to the ISO 81060-2:2018/AMD 1:2020 validation procedure. Omron selected the monitors and included three non-Omron monitors because they were from large retail vendors in the United States and these monitors did not have accessible results from validation testing. The BP7450, N = 85, passed both criteria for the standard. Mean (SD) differences in paired SBP and DBP determinations between the test device and reference were 0.5 (7.7) and 2.5 (6.8) mm Hg. The BP5450, N = 86, passed both criteria. Mean (SD) differences in paired SBP and DBP determinations were 1.9 (7.0) and 3.6 (6.4) mm Hg. The UA-8000WM, N = 85, did not meet the first criterion for the standard. Mean (SD) differences in paired SBP and DBP determinations were 2.5 (8.0) and 5.1 (6.4) mm Hg. The WGNBPA-240BT, N = 85, did not meet the first criterion for the standard. Mean (SD) differences in paired SBP and DBP determinations were 7.9 (8.5) and 5.5 (6.7) mm Hg. The BP3MW1-4YCVS, N = 85, did not meet the first criterion for the standard. Mean (SD) differences in paired SBP and DBP determinations were 5.8 (8.7) and 3.1 (5.6) mm Hg. These findings emphasize the importance of verifying the validation status of home blood pressure monitors before use by consumers.

Abstract B90: Researching the perception of risk about colorectal cancer among African immigrants in the Chicago metropolitan area: A preliminary study

Objectives: There has been a strong presence of African immigrants in Chicago, especially since 1996. According to an assessment by United African Organization (UAO), a major hub to provide social services for African Americans in the Chicago area, more than 70 percent of these immigrants arrived between the years of 1996 and 2008. Colorectal cancer affects every 62 of 100,000 African Americans according to CDC, and is the third leading cause of cancer death in America according to the American Cancer Society. Yet, there is no such data to study how the disease affects African immigrants, or an educational blueprint to create awareness to the health risk among African immigrants. The purpose of this study is to document colorectal cancer baseline data among African immigrants in Illinois in an effort to identify some of the barriers, risks and screening behaviors that exposes the priority population to colorectal cancer.

Methods: This study was based on a convenience sample of 68 participants response to quantitative survey tool, which was administered over the course of three months at a church that served the congregation in Chicago, and three semi-structured interviews of community leaders from United African Organization, Ghana National Council and ACUMC to document baseline data and to serve as a guideline to designing the survey. Demographic questions such as age, family income, place of birth, marital status etc, was asked to assess demographic status. Other questions such as overall health rating, insurance coverage, having a primary physician, most recent visit to the doctor etc were also asked to understand the priority population's utilization of the healthcare system upon immigrating to America. Furthermore, questions regarding risk and overall health ratings, knowledge of colorectal, breast and lung cancers etc were asked as a step to understanding the priority population's perceived risk of colorectal cancer compared to other popularly known cancers and how they may be at risk of colorectal cancer in particular.

Results: Majority of the participants (n = 66) were born in Africa and even though majority of participants also reported to having completed college in their respective African countries (45.2%), majority earned only between $25,000 and $50,000 (35.5%). Despite reports of low earnings, majority reported having some health insurance (58.1%), majority of the sample had been living in the United States for at least 20 years (38.7%), and believed they are at no risk of colorectal cancer (32.3%). Analysis suggested that 67.7% of the participants either heard about colorectal cancer from a doctor visit or in the news. Majority (78%) of the participants who had lived in the U.S. for more than 10 years had heard about CRC. Moreover, Nearly 41% of the participants believed that they had zero risk of CRC on a 0 (no risk at all) to 10 (extremely high risk) scale. The other 38.3% considered themselves with very low risk, 1 or 2 on the 10-point scale. Results from data analysis suggest income, among other factors plays a significant role in the priority population's knowledge of colorectal cancer (p = 0.011).

Conclusion: Although there was a small sample of people surveyed, results suggest the potential many members of the priority population believe they are at no risk of colorectal cancer. However, the literature point to western diets as the main risk of colorectal cancer for African immigrants. Data collected allowed for the creation of an educational brochure that seeks to educate the priority population and create awareness in an effort to promote screening for colorectal cancer.

Citation Format: Yaw Amofa Peprah, Karen E. Kim, Helen Lam. Researching the perception of risk about colorectal cancer among African immigrants in the Chicago metropolitan area: A preliminary study. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B90. doi:10.1158/1538-7755.DISP13-B90