Electronic Health Record Population Health Management for Chronic Kidney Disease Care: A Cluster Randomized Clinical Trial

Importance

Large gaps in clinical care in patients with chronic kidney disease (CKD) lead to poor outcomes.

Objective

To compare the effectiveness of an electronic health record-based population health management intervention vs usual care for reducing CKD progression and improving evidence-based care in high-risk CKD.

Design, Setting, and Participants

The Kidney Coordinated Health Management Partnership (Kidney CHAMP) was a pragmatic cluster randomized clinical trial conducted between May 2019 and July 2022 in 101 primary care practices in Western Pennsylvania. It included patients aged 18 to 85 years with an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 with high risk of CKD progression and no outpatient nephrology encounter within the previous 12 months.

Interventions

Multifaceted intervention for CKD comanagement with primary care clinicians included a nephrology electronic consultation, pharmacist-led medication management, and CKD education for patients. The usual care group received CKD care from primary care clinicians as usual.

Main Outcomes and Measures

The primary outcome was time to 40% or greater reduction in eGFR or end-stage kidney disease.

Results

Among 1596 patients (754 intervention [47.2%]; 842 control [52.8%]) with a mean (SD) age of 74 (9) years, 928 (58%) were female, 127 (8%) were Black, 9 (0.6%) were Hispanic, and the mean (SD) estimated glomerular filtration rate was 36.8 (7.9) mL/min/1.73m2. Over a median follow-up of 17.0 months, there was no significant difference in rate of primary outcome between the 2 arms (adjusted hazard ratio, 0.96; 95% CI, 0.67-1.38; P = .82). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker exposure was more frequent in intervention arm compared with the control group (rate ratio, 1.21; 95% CI, 1.02-1.43). There was no difference in the secondary outcomes of hypertension control and exposure to unsafe medications or adverse events between the arms. Several COVID-19-related issues contributed to null findings in the study.

Conclusion and Relevance

In this study, among patients with moderate-risk to high-risk CKD, a multifaceted electronic health record-based population health management intervention resulted in more exposure days to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers but did not reduce risk of CKD progression or hypertension control vs usual care.

Trial Registration

ClinicalTrials.gov Identifier: NCT03832595.

Electronic health record based population health management to optimize care in CKD: Design of the Kidney Coordinated HeAlth Management Partnership (K-CHAMP) trial

Primary care physicians (PCPs) provide the majority of medical care to patients with non-dialysis dependent CKD. However, PCPs report numerous limitations to providing expert CKD care, including poor patient education, inadequate diagnostic evaluation, suboptimal use of medications, and time limitations. The Kidney Coordinated HeAlth Management Partnership (Kidney CHAMP) trial is a cluster randomized controlled trial to evaluate the effectiveness of a novel centralized electronic health records (EHR)-delivered population health management (PHM) strategy for high-risk CKD patients on patient care, safety, and other outcomes of interest to patients, providers, and payors. Over a 42-month period, the trial will compare the effectiveness of a multifaceted intervention that combines early identification of high-risk patients, timely nephrology guidance, pharmacist-led medication management services, and CKD patient education to usual care and enroll 1650 high-risk CKD patients from 100 primary care practices. The primary outcome will be ≥40% decline in estimated glomerular filtration rate (eGFR) or end stage kidney disease. Key secondary outcomes will include blood pressure, renin-angiotensin aldosterone system inhibitors use, and exposure to potentially unsafe medications. If successful, our treatment approach could improve CKD care delivery and safety, resource allocation, and adoption of evidence-based CKD guideline-concordant care.

Lifestyle strategies after intentional weight loss: results from the MAINTAIN-pc randomized trial

Introduction/Purpose

Weight maintenance following intentional weight loss is challenging and often unsuccessful. Physical activity and self-monitoring are strategies associated with successful weight loss maintenance. However, less is known about the type and number of lifestyle strategies used following intentional weight loss. The purpose of this study was to determine the types and amounts of strategies associated with successful long-term weight loss maintenance.

Methods

Data from the 24-month Maintaining Activity and Nutrition Through Technology-Assisted Innovation in Primary Care (MAINTAIN-pc) trial were analyzed. MAINTAIN-pc recruited adults (n=194; 53.4±12.2 years of age, body mass index (BMI): 30.4±5.9 kg/m2, 74% female) with recent intentional weight loss of ≥5%, randomized to tracking tools plus coaching (i.e., coaching group) or tracking tools without coaching (i.e., tracking-only group). At baseline, 6, 12, and 24 months, participants reported lifestyle strategies used in the past 6 months, including self-monitoring, group support, behavioral skills, and professional support. General linear models evaluated changes in the number of strategies over time between groups and the consistency of strategies used over the 24-month intervention.

Results

At baseline, 100% used behavioral skills, 73% used group support, 69% used self-monitoring, and 68% used professional support in the past 6 months; at 24 months, these rates were 98%, 60%, 75%, and 61%, respectively. While the number of participants utilizing individual strategies did not change significantly over time, the overall number of strategies participants reported decreased. More strategies were used at baseline and 6 months compared to 12- and 24-month follow-ups. The coaching group used more strategies at months 6 and 12 than the tracking-only group. Consistent use of professional support strategies over the 24-month study period was associated with less weight regain.

Conclusion

Weight loss maintenance interventions that incorporate continued follow-up and support from healthcare professionals are likely to prevent weight regain after intentional weight loss.

Identifying barriers to shared decision-making about bariatric surgery in two large health systems

OBJECTIVE

Prior research suggests shared decision-making (SDM) could improve patient and health care provider communication about bariatric surgery. The aim of this work was to identify and prioritize barriers to SDM around bariatric surgery to help guide implementation of SDM.

METHODS

Two large US health care systems formed multidisciplinary teams to facilitate the implementation of SDM around bariatric surgery. The teams used a nominal group process approach involving (1) generation of multilevel barriers, (2) round-robin recording of barriers, (3) facilitated discussion, and (4) selection and ranking of barriers according to importance and feasibility to address.

RESULTS

One health system identified 13 barriers and prioritized 5 as the most important and feasible to address. The second health system identified 14 barriers and prioritized 6. Both health systems commonly prioritized six barriers: lack of insurance coverage; lack of understanding of insurance coverage; lack of organizational prioritization of SDM; lack of knowledge about bariatric surgery; lack of interdepartmental clarity between primary and specialty care; and limited training on SDM conversations and tools.

CONCLUSIONS

Health systems face numerous barriers to SDM around bariatric surgery, and these can be easily identified and prioritized by multistakeholder teams. Future research should seek to identify effective strategies to address these common barriers.

Do patients want clinicians to ask about social needs and include this information in their medical record?

Background

Social needs screening in primary care may be valuable for addressing non-medical health-related factors, such as housing insecurity, that interfere with optimal medical care. Yet it is unclear if patients welcome such screening and how comfortable they are having this information included in electronic health records (EHR).

Objective

To assess patient attitudes toward inclusion of social needs information in the EHR and key correlates, such as sociodemographic status, self-rated health, and trust in health care.

Design, participants, and main measures

In a cross-sectional survey of patients attending a primary care clinic for annual or employment exams, 218/560 (38%) consented and completed a web survey or personal interview between 8/20/20-8/23/21. Patients provided social needs information using the Accountable Care Communities Screening Tool. For the primary outcome, patients were asked, “Would you be comfortable having these kinds of needs included in your health record (also known as your medical record or chart)?”

Analyses

Regression models were estimated to assess correlates of patient comfort with including social needs information in medical records.

Key results

The median age was 45, 68.8% were female, and 78% were white. Median income was $75,000 and 84% reported education beyond high school. 85% of patients reported they were very or somewhat comfortable with questions about social needs, including patients reporting social needs. Social need ranged from 5.5% (utilities) to 26.6% (housing), and nonwhite and gender-nonconforming patients reported greater need. 20% reported “some” or “complete” discomfort with social needs information included in the EHR. Adjusting for age, gender, race, education, trust, and self-rated health, each additional reported social need significantly increased discomfort with the EHR for documenting social needs.

Conclusions

People with greater social needs were more wary of having this information placed in the EHR. This is a concerning finding, since one rationale for collecting social need data is to use this information (presumably in the EHR) for addressing needs.

A Longitudinal Ambulatory Quality Improvement Curriculum That Aligns Resident Education With Patient Outcomes: A 3-Year Experience

Quality improvement (QI) plays a vital role in practice management, patient care, and reimbursement. The authors implemented a 3-year longitudinal curriculum that combined QI didactics, intervention development, and implementation at university-based, community-based, and Veterans Administration-based practices. Highlights included Plan-Do-Study-Act cycle format, team-based collaboration to brainstorm interventions, interdisciplinary QI council to select and plan interventions, system-wide intervention implementation across entire clinic populations with outcome monitoring, and intervention modifications based on challenges. A pre-post survey assessed residents' confidence in QI skills and interdisciplinary team participation, while quarterly quality data assessed patient outcomes. All 150 internal medicine residents participated. Confidence in QI and interdisciplinary team participation improved significantly (P < .001). Patient outcomes improved for 6 of 9 targeted projects and were sustained at 1 year. This curriculum is a systems-based innovation designed to improve patient care and encourage interdisciplinary teamwork and can be adopted by residencies seeking to improve engagement in QI.

Improving Pneumococcal Vaccination Rates in Rheumatology Patients by Using Best Practice Alerts in the Electronic Health Records

Objective

To improve pneumococcal vaccination (PV) rates among rheumatology clinic patients on immunosuppressive therapy in the outpatient settings.

Methods

This quality improvement project was based on the pre–post intervention design. Phase I of the project targeted patients with rheumatoid arthritis from 13 rheumatology clinics (January 2013–July 2015) on immunosuppressive therapy to receive the pneumococcal polysaccharide vaccine (PPSV23). In the Phase II study (January 2016–October 2017), all patients on immunosuppressive medications regardless of diagnosis were targeted to receive PPSV23 and the pneumococcal conjugate vaccine (PCV13). The best practice alerts (BPAs) for both PVs were developed based on the Centers for Disease Control and Prevention guidelines, which appeared on electronic medical records for eligible patients at the time of assessment by the medical assistant. The BPA was designed to inform the vaccination status and enable the physician to order the PV, or to document refusal or deferral reasons. Education regarding vaccine guidelines, BPAs, vaccination process, and regular feedback of results were important project interventions. The vaccination rates during pre–post intervention for each study phase were compared using chi-square test.

Results

During phase I, PPSV23 vaccination rates improved from a 28% preintervention rate to 61.5% (P < 0.0001). During phase II, 77.4% of patients had received either PPSV23, PCV13, or both, compared to 49.6% of patients in the preintervention period (P < 0.0001). The documentation rates (vaccine received, ordered, patient refusal and deferral reasons) increased significantly in both phases.

Conclusion

Electronic identification of vaccine eligibility and implementation of BPAs with capabilities to order and document resulted in significantly improved PV rates. The process has potential for self-sustainability and generalizability.

Efficacy of an Online Physical Activity Intervention Coordinated With Routine Clinical Care: Protocol for a Pilot Randomized Controlled Trial

Background

Most adults are not achieving recommended levels of physical activity (150 minutes/week, moderate-to-vigorous intensity). Inadequate activity levels are associated with numerous poor health outcomes, and clinical recommendations endorse physical activity in the front-line treatment of obesity, diabetes, dyslipidemia, and hypertension. A framework for physical activity prescription and referral has been developed, but has not been widely implemented. This may be due, in part, to the lack of feasible and effective physical activity intervention programs designed to coordinate with clinical care delivery.

Objective

This manuscript describes the protocol for a pilot randomized controlled trial (RCT) that tests the efficacy of a 13-week online intervention for increasing physical activity in adult primary care patients (aged 21-70 years) reporting inadequate activity levels. The feasibility of implementing specific components of a physical activity clinical referral program, including screening for low activity levels and reporting patient program success to referring physicians, will also be examined. Analyses will include participant perspectives on maintaining physical activity.

Methods

This pilot study includes a 3-month wait-listed control RCT (1:1 ratio within age strata 21-54 and 55-70 years). After the RCT primary end point at 3 months, wait-listed participants are offered the full intervention and all participants are followed to 6 months after starting the intervention program. Primary RCT outcomes include differences across randomized groups in average step count, moderate-to-vigorous physical activity, and sedentary behavior (minutes/day) derived from accelerometers. Maintenance of physical activity changes will be examined for all participants at 6 months after the intervention start.

Results

Recruitment took place between October 2018 and May 2019 (79 participants were randomized). Data collection was completed in February 2020. Primary data analyses are ongoing.

Conclusions

The results of this study will inform the development of a clinical referral program for physical activity improvement that combines an online intervention with clinical screening for low activity levels, support for postintervention behavior maintenance, and feedback to the referring physician.

Trial Registration

ClinicalTrials.gov NCT03695016; https://clinicaltrials.gov/ct2/show/NCT03695016.

International Registered Report Identifier (IRRID)

DERR1-10.2196/18891

Lifestyle Habits Associated with Weight Regain After Intentional Loss in Primary Care Patients Participating in a Randomized Trial

BACKGROUND

Though long-term weight loss maintenance is the treatment goal for obesity, weight regain is typical and few studies have evaluated lifestyle habits associated with weight regain.

OBJECTIVE

To identify dietary and physical activity habits associated with 6- and 24-month weight regain among participants in a weight loss maintenance clinical trial.

DESIGN

Secondary analysis of randomized clinical trial data.

PARTICIPANTS

Adult primary care patients with recent, intentional weight loss of at least 5%.

MAIN MEASURES

Lifestyle habits included consumption of low-fat foods, fish, desserts, sugary beverages, fruits, and vegetables and eating at restaurants from the Connor Diet Habit Survey; moderate-vigorous physical activity by self-report; steps recorded by a pedometer; and sedentary behavior by self-report. The outcome variable was weight change at 6 and 24 months. Linear regression models estimated adjusted associations between changes in weight and changes in dietary and physical activity habits.

KEY RESULTS

Overall, participants (mean (SD): 53.4 (12.2) years old; 26% male; 88% white) maintained weight loss at 6 months (n = 178, mean (SD): - 0.02 (5.70)% change) but began to regain weight by 24 months (n = 157, mean (SD): 4.22 (9.15)% increase). When considered all together, more eating at restaurants, reduced fish consumption, and less physical activity were most consistently associated with weight regain in fully adjusted models at both 6 and 24 months of follow-up. In addition, more sedentary behavior was associated with weight regain at 6 months while reduced consumption of low-fat foods, and more desserts and sugary beverages were associated with weight regain at 24 months.

CONCLUSIONS

Consuming less fish, fewer steps per day, and more frequent restaurant eating were most consistently associated with weight regain in primary care patients. Primary care providers may consider addressing specific lifestyle behaviors when counseling patients after successful weight loss.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01946191.

The elephant in the room: a postphenomenological view on the electronic health record and its impact on the clinical encounter

Use of electronic health records (EHR) within clinical encounters is increasingly pervasive. The digital record allows for data storage and sharing to facilitate patient care, billing, research, patient communication and quality-of-care improvement-all at once. However, this multifunctionality is also one of the main reasons care providers struggle with the EHR. These problems have often been described but are rarely approached from a philosophical point of view. We argue that a postphenomenological case study of the EHR could lead to more in-depth insights. We will focus on two concepts-transparency and multistability-and translate them to the specific situation of the EHR. Transparency is closely related to an embodiment relation in which the user becomes less aware of the technology: it fades into the background, becoming a means of experience. A second key concept is that of multistability, referring to how a technology can serve multiple purposes or can have different meanings in different contexts. The EHR in this sense is multistable by design. Future EHR design could incorporate multistable information differently, allowing the provider to focus on patient care when interacting with the EHR. Moreover we argue that the use of the EHR in the daily workflow should become more transparent, while awareness of the computer in the specific context of the patient-provider relationship should increase.

Effect of Electronic Health Record-Based Coaching on Weight Maintenance: A Randomized Trial

BACKGROUND

Weight regain after intentional loss is common. Most evidence-based weight management programs focus on short-term loss rather than long-term maintenance.

OBJECTIVE

To evaluate the benefit of coaching in an electronic health record (EHR)-based weight maintenance intervention.

DESIGN

Randomized controlled trial. (ClinicalTrials.gov: NCT01946191).

SETTING

Practices affiliated with an academic medical center.

PARTICIPANTS

Adult outpatients with body mass index (BMI) of 25 kg/m2 or higher, intentional weight loss of at least 5% in the previous 2 years, and no bariatric procedures in the previous 5 years.

INTERVENTION

Participants were randomly assigned to EHR tools (tracking group) versus EHR tools plus coaching (coaching group). The EHR tools included weight, diet, and physical activity tracking flow sheets; standardized surveys; and reminders. The coaching group received 24 months of personalized coaching through the EHR patient portal, with 24 scheduled contacts.

MEASUREMENTS

The primary outcome was weight change at 24 months. Secondary outcomes included 5% weight loss maintenance and changes in BMI, waist circumference, number of steps per day, health-related quality of life, physical function, blood pressure, and satisfaction.

RESULTS

Among 194 randomly assigned participants (mean age, 53.4 years [SD, 12.2]; 143 [74%] women; 171 [88%] white), 157 (81%) completed the trial. Mean baseline weight and BMI were 85.8 kg (SD, 19.1) and 30.4 kg/m2 (SD, 5.9). At 24 months, mean weight regain (± SE) was 2.1 ± 0.62 kg and 4.9 ± 0.63 kg in the coaching and tracking groups, respectively. The between-group difference in weight change at 24 months was significant (-2.86 kg [95% CI, -4.60 to -1.11 kg]) in the linear mixed model. At 24 months, 65% of participants in the coaching group and 50% in the tracking group maintained weight loss of at least 5%.

LIMITATION

Single-site trial, which limits generalizability.

CONCLUSION

Among adults with intentional weight loss of at least 5%, use of EHR tools plus coaching resulted in less weight regain than EHR tools alone.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and National Institutes of Health.

Resident and Attending Physicians' Perceptions of Patient Access to Provider Notes: Comparison of Perceptions Prior to Pilot Implementation

BACKGROUND

As electronic health records have become a more integral part of a physician's daily life, new electronic health record tools will continue to be rolled out to trainees. Patient access to provider notes is becoming a more widespread practice because this has been shown to increase patient empowerment.

OBJECTIVE

In this analysis, we compared differences between resident and attending physicians' perceptions prior to implementation of patient access to provider notes to facilitate optimal use of electronic health record features and as a potential for patient empowerment.

METHODS

This was a single-site study within an academic internal medicine program. Prior to implementation of patient access to provider notes, we surveyed resident and attending physicians to assess differences in perceptions of this new electronic health record tool using an open access survey provided by OpenNotes.

RESULTS

We surveyed 37% (20/54 total) of resident physicians and obtained a 100% response rate and 72% (31/44 total) of attending physicians. Similarities between the groups included concerns about documenting sensitive topics and anticipation of improved patient engagement. Compared with attending physicians, resident physicians were more concerned about litigation, discussing weight, offending patients, and communicated less overall with patients through electronic health record.

CONCLUSIONS

Patient access to provider notes has the potential to empower patients but concerns of the resident physicians need to be validated and addressed prior to its utilization.

UPMC Prescription for Wellness: A Quality Improvement Case Study for Supporting Patient Engagement and Health Behavior Change

Addressing patient health and care behaviors that underlie much of chronic disease continues to challenge providers, medical practices, health systems, and insurers. Improving health and care as described by the Quadruple Aim requires innovation at the front lines of clinical care: the doctor-patient interaction and office practice. This article describes the use of Lean Six Sigma in a quality improvement (QI) effort to design an effective and scalable method for physicians to prescribe health coaching for healthy behaviors in a primary care medical home within a large integrated delivery and financing system. Building on the national Agency for Healthcare Research and Quality and Robert Wood Johnson Foundation-funded Prescription for Health multisite demonstration, this QI case study provides important lessons for transforming patient-physician-practice support systems to better address lifestyle and care management challenges critical to producing better outcomes.

Improvement in Quality Metrics by the UPMC Enhanced Care Program: A Novel Super-Utilizer Program

The aim was to evaluate pre-post quality of care measures among super-utilizer patients enrolled in the Enhanced Care Program (ECP), a primary care intensive care program. A pre-post analysis of metrics of quality of care for diabetes, hypertension, cancer screenings, and connection to mental health care for participants in the ECP was conducted for patients enrolled in ECP for 6 or more months. Patients enrolled in ECP showed statistically significant improvements in hemoglobin A1c, retinal exams, blood pressure measurements, and screenings for colon cancer, and trends toward improvement in diabetic foot exams and screenings for cervical and breast cancer. There was a significant increase in connecting patients to mental health care. This study shows that super-utilizer patients enrolled in the ECP had significant improvements in quality metrics from those prior to enrollment in ECP.

Diet and Physical Activity Behaviors in Primary Care Patients with Recent Intentional Weight Loss

PURPOSE

Lifestyle habits of primary care patients with recent, intentional weight loss are unclear and need to be better understood to aid in translational health promotion efforts. We aimed to characterize diet and exercise habits in primary care patients with recent, intentional weight loss, comparing those with greater (≥10%) vs. lesser (5 to <10%) weight loss.

METHODS

This was a cross-sectional analysis of baseline data from a randomized trial comparing weight loss maintenance interventions. The study included primary care patients, 18-75 years old, with ≥5% intentional weight loss via lifestyle change in the past 2 years. Participants (74% female, 87% white) had mean age 53 (12) years, body mass index 30.4 (5.9) kg/m², and recent weight loss of 11 (8)%. Dietary habits were measured by the Diet Habits Survey. Physical activity and sedentary behavior were measured by self-report and objectively by pedometer.

RESULTS

On average, participants reported high fruits and vegetables intake (5 servings/day), and low intake of fried foods (1 serving/week), desserts (1 serving/week) and sugar-sweetened beverages (0 servings/week). Those with greater vs. lesser weight loss had higher intake of fruits and vegetables (p=0.037) and low fat foods or recipes (p=0.019). Average self-reported moderate-vigorous physical activity was 319 (281) minutes/week, with significant differences between greater (374 (328) minutes/week) vs. lesser (276 (230) minutes/week) weight loss groups (p=0.017). By pedometer, 30% had ≥7,500 steps/day; the proportion was higher in greater (43%) vs. lesser (19%) weight loss groups (p=0.005).

CONCLUSIONS

For weight loss, clinical patients typically employ simple strategies such as 5+ fruits and vegetables per day, fried foods and desserts ≤1 per week, elimination of sugary drinks, choosing low fat foods/recipes, and physical activity 45-60 min/day.

Using Health Information Technology to Foster Engagement: Patients' Experiences with an Active Patient Health Record

Personal health records (PHRs) typically employ "passive" communication strategies, such as non-personalized medical text, rather than direct patient engagement in care. Currently there is a call for more active PHRs that directly engage patients in an effort to improve their health by offering elements such as personalized medical information, health coaches, and secure messaging with primary care providers. As part of a randomized clinical trial comparing "passive" with "active" PHRs, we explore patients' experiences with using an "active" PHR known as HealthTrak. The "passive" elements of this PHR included problem lists, medication lists, information about patient allergies and immunizations, medical and surgical histories, lab test results, health reminders, and secure messaging. The active arm included all of these elements and added personalized alerts delivered through the secure messaging platform to patients for services coming due based on various demographic features (including age and sex) and chronic medical conditions. Our participants were part of the larger clinical trial and were eligible if they had been randomized to the active PHR arm, one that included regular personalized alerts. We conducted focus group discussions on the benefits of this active PHR for patients who are at risk for cardiovascular disease. Forty-one patients agreed to participate and were organized into five separate focus group sessions. Three main themes emerged from the qualitatively analyzed focus groups: participants reported that the active PHR promoted better communication with providers; enabled them to more effectively partner with their providers; and helped them become more proactive about tracking their health information. In conclusion, patients reported improved communication, partnership with their providers, and a sense of self-management, thus adding insights for PHR designers hoping to address low adoption rates and other patient barriers to the development and use of the technology.

Patterns of response to patient-centered decision support through a personal health record

BACKGROUND

Over 140 million people in the United States have at least one chronic medical condition, but they receive fewer than 60% of guideline-recommended services for these conditions. Increasing patients' involvement in their own care may improve the receipt of guideline-recommended services. We evaluated patients' patterns of responses to notifications regarding guideline-recommended services delivered through a personalized health record (PHR).

MATERIALS AND METHODS

We enrolled 584 participants with high cardiovascular disease risk from 73 primary care practices into an active PHR in which they received patient-centered decision support-notifications delivered via a PHR regarding prevention gaps (i.e., unmet preventive healthcare or chronic disease monitoring). Participants with prevention gaps received up to three weekly messages regarding all services due within a 2-month time frame. These three-message cycles could repeat up to every 2 months for a new, or continuing, prevention gap.

RESULTS

Of the 584 participants, 501 (86%) received at least one reminder. Approximately 61% of these participants accessed the PHR or received the care that triggered the message after the first message and 73% after the first two messages. In subsequent three-message cycles, we observed no change in the number of messages required prior to participants accessing the PHR or receiving recommended care (chi-squared = 12.4, p = 0.3). Of the 2,656 prevention gaps these participants had over 1 year, 1,539 (58%) were closed.

CONCLUSIONS

In this low-intensity intervention, participants accessed the PHR and received recommended care. Providing notification through the PHR allows patients to choose when they receive, and take action on, the message. Notifications can be provided to patients through a PHR without alert fatigue and may be an additional tool to help patients achieve better health.

Implementing health information technology in a patient-centered manner: patient experiences with an online evidence-based lifestyle intervention

The patient-centered care (PCC) model and the use of health information technology (HIT) are major initiatives for improving U.S. healthcare quality and delivery. A lack of published data on patient perceptions of Internet-based care makes patient-centered implementation of HIT challenging. To help ascertain patients' perceptions of an online intervention, patients completing a 1-year web-based lifestyle intervention were asked to complete a semistructured interview. We used qualitative methodology to determine frequency and types of interview responses. Overall satisfaction with program features was coded on a Likert-type scale. High levels of satisfaction were seen with the online lifestyle coaching (80%), self-monitoring tools (57%), and structured lesson features (54%). Moderated chat sessions and online resources were rarely used. Frequently identified helpful aspects were those that allowed for customized care and shared decision-making consistent with the tenets of PCC. Unhelpful program aspects were reported less often. Findings suggest that despite challenges for communicating effectively in an online forum, the personalized support, high-tech data management capabilities, and easily followed evidence-based curricula afforded by HIT may be a means of providing PCC and improving healthcare delivery and quality.

Counseling about medication-induced birth defects with clinical decision support in primary care

BACKGROUND

We evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects women's behavior.

METHODS

Between October 2008 and April 2010, all women aged 18-50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5-30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse.

RESULTS

Eight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26-3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling.

CONCLUSIONS

Physician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception.

Electronic reminders to patients within an interactive patient health record

Keeping patients with complex medical illnesses up to date with their preventive care and chronic disease management services, such as lipid testing and retinal exam in patients with diabetes, is challenging. Within a commercially available electronic health record (EHR) with a secure personal health record (PHR), we developed a system that sends up to three weekly reminders to patients who will soon be due for preventive care services. The reminder messages reside within the secure PHR, which is linked to the EHR, and are displayed on a screen where patients can also send to the physician's office an electronic message to request appointments for the needed services. The reminder messages stop when the patient logs on to review the reminders. The system, designed with patient input, groups together all services that will be due in the next 3 months to avoid repeatedly messaging the patient. After 2 months, the cycle of reminders begins again. This system, which is feasible and economical to build, has the potential to improve care and compliance with quality measures.

The patient-centered medical home: an ethical analysis of principles and practice

The patient-centered medical home (PCMH), with its focus on patient-centered care, holds promise as a way to reinvigorate the primary care of patients and as a necessary component of health care reform. While its tenets have been the subject of review, the ethical dimensions of the PCMH have not been fully explored. Consideration of the ethical foundations for the core principles of the PCMH can and should be part of the debate concerning its merits. The PCMH can align with the principles of medical ethics and potentially strengthen the patient-physician relationship and aspects of health care that patients value. Patient choice and these ethical considerations are central and at least as important as the economic and practical arguments in support of the PCMH, if not more so. Further, the ethical principles that support key concepts of the PCMH have implications for the design and implementation of the PCMH. This paper explores the PCMH in light of core principles of ethics and professionalism, with an emphasis both on how the concept of the PCMH may reinforce core ethical principles of medical practice and on further implications of these principles.

Promoting patient phronesis: communication patterns in an online lifestyle program coordinated with primary care

Phronesis, or practical wisdom developed through experience, is an Aristotelian concept that can shed light on the capacities of patients to make health-related decisions and engage in healthy behaviors. In this article, the authors develop a conceptual framework for understanding the role of phronesis in lifestyle change as well as its relationship to patient activation, which is considered to be a critical component of the Chronic Care Model and patient education in general. The authors develop the concept of phronesis by analyzing qualitatively the comments made by 35 participants working to manage chronic health issues in a weight-loss study. The authors iteratively coded transcribed passages of exit interviews for phronesis and patient activation. These passages provide experientially grounded content for evaluating the use of phronesis and its development among individuals engaging in lifestyle change. Phronesis is expressed in 31% of participant responses to questions regarding the relationship between the online lifestyle intervention, participant health, and participant readiness to engage in productive clinical encounters with health care practitioners. Of those responses, 73% express some level of patient activation. The authors conclude that phronesis may be an important new tool for understanding successful self-management support, with potential usefulness in the creation of tailored lifestyle interventions, the development of patient activation, and the ability of participants to enact health-related behaviors.

Clinical decision support to promote safe prescribing to women of reproductive age: a cluster-randomized trial

BACKGROUND

Potentially teratogenic medications are frequently prescribed without provision of contraceptive counseling.

OBJECTIVE

To evaluate whether computerized clinical decision support (CDS) can increase primary care providers' (PCPs') provision of family planning services when prescribing potentially teratogenic medications.

DESIGN

Cluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010.

PARTICIPANTS/INTERVENTIONS

Forty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The 'simple' CDS provided a cautionary alert; the 'multifaceted' CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter.

MAIN MEASURES

We assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception.

KEY RESULTS

Both CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction.

CONCLUSIONS

CDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.

Automated clinical reminders for primary care providers in the care of CKD: a small cluster-randomized controlled trial

BACKGROUND

Primary care physicians (PCPs) care for most non-dialysis-dependent patients with chronic kidney disease (CKD). Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSSs).

STUDY DESIGN

Cluster-randomized controlled trial.

SETTING & PARTICIPANTS

30 PCPs in a university-based outpatient general internal medicine practice and their 248 patients with moderate to advanced CKD who had not been referred to a nephrologist.

INTERVENTION

2 CKD educational sessions were held for PCPs in both arms. The 15 intervention-arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates <45 mL/min/1.73 m(2) recommending renal referral and urine albumin quantification if not done within the prior year.

OUTCOMES

Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (ie, <130/80 mm Hg), and use of renoprotective medications.

RESULTS

The intervention and control arms did not differ in renal referrals (9.7% vs 16.5%, respectively; between-group difference, -6.8%; 95% CI, -15.5% to 1.8%; P = 0.1) or proteinuria assessments (39.3% vs 30.1%, respectively; between-group difference, 9.2%; 95% CI, -2.7% to 21.1%; P = 0.1). For intervention and control patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively, had one at follow-up (P = 0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between groups.

LIMITATIONS

Small single-center university-based practice, use of a passive CDSS that required PCPs to trigger the electronic order set.

CONCLUSIONS

PCPs were willing to partake in a randomized trial of a CDSS to improve outpatient CKD care. Although CDSSs may have potential, larger studies are needed to further explore how best to deploy them to enhance CKD care.

Patient perspectives on the integration of an intensive online behavioral weight loss intervention into primary care

OBJECTIVE

To examine patients' perception of how a referral-based online lifestyle intervention contributed to primary care medicine.

METHODS

We invited 50 adults to complete a semi-structured interview after a 1-year online behavioral weight loss intervention (average weight change: -4.79 kg). We developed an iterative codebook using content analysis. Two coders independently coded all transcripts (kappa=0.895). We analyzed responses regarding the integration of the program with primary care.

RESULTS

Among the 35 participants who completed the interview, 46% described a positive experience between the program and their routine medical care; 14% noted it was fine/OK; 9% reported no effect, 3% were negative, 11% said that the program was unrelated to their medical care, and 14% that the only connection was the referral. Factors such as physician feedback and support, coordination with routine health care, and improved cardiovascular risk factors were cited in support of a positive experience. Physician feedback was reported by 89%, and 80% stated that the program helped them to follow their physician's advice.

CONCLUSION

Physician referral to online education and counseling may facilitate the integration of evidence-based behavioral counseling with primary care.

PRACTICE IMPLICATIONS

Internet technology may enable improved access to evidence-based counseling for chronic health problems.

Using the internet to translate an evidence-based lifestyle intervention into practice

Despite evidence-based recommendations for addressing obesity in the clinical setting, lifestyle interventions are lacking in practice. The objective of this study was to translate an evidence-based lifestyle program into the clinical setting by adapting it for delivery via the Internet. We adapted the Diabetes Prevention Program's lifestyle curriculum to an online format, comprising 16 weekly and 8 monthly lessons, and conducted a before-and-after pilot study of program implementation and feasibility. The program incorporates behavioral tools such as e-mail prompts for online self-monitoring of diet, physical activity, and weight, and automated weekly progress reports. Electronic counseling provides further support. Physician referral, automated progress reports, and as-needed communication with lifestyle coaches integrate the intervention with clinical care. We enrolled 50 patients from a large academic general internal practice into a pilot program between November 16, 2006 and February 11, 2007. Patients with a body mass index (BMI) =25 kg/m2, at least one weight-related cardiovascular risk factor, and Internet access were eligible if referring physicians felt the lifestyle goals were safe and medically appropriate. Participants were primarily female (76%), with an average age of 51.94 (standard deviation [SD] 10.82), and BMI of 36.43 (SD 6.78). At 12 months of enrollment, 50% of participants had logged in within 30 days. On average, completers (n = 45) lost 4.79 (SD 8.55) kg. Systolic blood pressure dropped 7.33 (SD 11.36) mm Hg, and diastolic blood pressure changed minimally (+0.44 mm Hg; SD 9.27). An Internet-based lifestyle intervention may overcome significant barriers to preventive counseling and facilitate the incorporation of evidence-based lifestyle interventions into primary care.

Comparison of electronic physician prompts versus waitroom case-finding on clinical trial enrollment

BACKGROUND

Recruiting patients into clinical research protocols is challenging. Electronic medical record (EMR) systems capable of prompting clinicians may facilitate enrollment.

OBJECTIVE

To compare an EMR-based clinician prompt versus a wait-room-based case-finding strategy at enrolling patients into a clinical trial.

DESIGN

Cross-sectional comparison of recruitment data from two trials to treat anxiety disorders in primary care. Both studies utilized similar enrollment criteria, intervention strategies, and the same four practice sites and EMR system.

PARTICIPANTS

Patients referred by their (primary care physicians) PCPs in response to an EMR prompt (recruited 1/2005-10/2006), and patients enrolled by research assistants stationed in practice waiting rooms (7/2000-4/2002).

MEASUREMENTS

Referral counts, patients' baseline sociodemographic and clinical characteristics.

RESULTS

Over a 22-month period, EMR-prompted PCPs referred 794 patients and 176 (22%) met study inclusion criteria and enrolled, compared to 8,095 patients approached by wait room-based recruiters of whom 193 (2.4%) enrolled. Subjects enrolled by EMR-prompted PCPs were more likely to be non-white (23% vs 5%; P < 0.001), male (28% vs 18%; P = 0.03), and have higher anxiety levels than those recruited by wait-room recruiters (P < 0.0001).

CONCLUSIONS

EMR systems prompting clinicians to refer patients with specific characteristics are an efficient recruitment tool with critical implications for increasing minority participation in clinical research.

Feasibility of A Brief Workshop on Palliative Care Communication Skills for Medical Interns

OBJECTIVE

This report describes a novel 3-hour workshop on delivering bad news and discussing end-of-life goals of care for internal medicine interns, and its effect on the interns' attitudes, knowledge, and confidence in discussing these topics with patients.

INTERVENTION

Interns participated in a 3-hour workshop involving role-playing, focused on teaching core knowledge, skills, and attitudes associated with delivering bad news and discussing goals of care at the end of life.

MEASUREMENTS

One to 3 weeks before and after the workshop, participants completed a written questionnaire that included 54 knowledge questions, 6 questions eliciting their perceived level of confidence, and 11 questions about attitudes toward delivering bad news or discussing goals of care. Immediately after the workshop, interns answered questions rating their satisfaction with the workshop.

RESULTS

Of 43 interns who took the pretest, 29 completed the posttest. There was a high degree of satisfaction with the workshop. Mean knowledge scores increased by 4 points (from 41.4 to 45.4, p < 0.001). The percentage of interns who expressed confidence increased. There was no change in interns' attitudes.

Objectives for advance care planning

Identifying objectives for advance care planning (ACP) is an important step toward improving care at the end of life. Previous studies of ACP have used many different measures of success. However, there has been no consensus on what should be the objectives for ACP. Lack of attention to specific objectives for ACP may lead to ineffective communication and research. The first step to improving outcomes in ACP is to acknowledge the diversity of objectives that ACP may achieve. Health care providers, patients, and surrogates should identify and agree on common objectives for particular conversations. Various methods, conversations, and forms may be used to achieve these objectives over time. Clarifying objectives from various perspectives is an important step toward achieving the level of understanding necessary to make these difficult decisions. It is time for physicians to reconsider the way in which they think about and discuss ACP with patients. If we are to improve care at the end of life, future patient care, research, and education about ACP should proceed with specific objectives in mind.

Advance care planning

BACKGROUND

Advance directives (AD) with specific treatment preferences can be difficult to apply in actual clinical situations. As an alternative, advance directives that outline patient goals and values have been advocated.

OBJECTIVE

To compare patient reactions to values-based and treatment-based advance directive forms.

SETTING

Two academic general medicine outpatient clinics in Pittsburgh, Pa.

METHODS

Outpatients age 55 or older who did not have an AD and were not demented were randomly assigned to complete either Emanuel's Medical Directive (EMD) or Pearlman's values history (PVH) form.

MEASUREMENTS

Length of time to complete and number of questions asked about the AD forms; proportions of patients discussing the AD with family, designating a surrogate, returning the AD by mail, and desiring to have the AD in the medical record; patient ratings of AD by telephone interview; physician report of patient-initiated AD discussions.

RESULTS

Of the 275 patients approached, 143 refused, 69 already had an AD, 63 patients were enrolled, and 25 in each group completed the telephone interview. A majority of individuals in both groups had conversations with others about the AD (60% EMD, 56% PVH; P = .77). All PVH forms designated a surrogate, whereas 79% of EMD forms did so (P = .02). One patient in each group initiated a conversation with his or her physician about AD following study completion. Both forms were thought to be a good first step in planning care at the end of life (92% EMD vs 84% PVH totally or mostly agree; P = .06). Patients completing the EMD thought it would give them control over the way their doctor cared for them at the end of their lives more than did the PVH group (84% EMD vs 48% PVH totally or mostly agree; P = .02). More patients completing the EMD form worried that it would be difficult to change answers on the form if they later changed their minds (20% EMD vs 4% PVH totally or mostly agree; P = .02).

CONCLUSIONS

Both the values-based and treatment-based AD forms were rated favorably overall. Patients thought the treatment-based directive would give them more control over their care. Patients completing the values history form were more likely to designate a surrogate. Patients are likely to discuss both types of AD with family, but neither form alone is likely to lead to AD conversations with physicians.

Experts practice what they preach: A descriptive study of best and normative practices in end-of-life discussions

BACKGROUND

Advance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected. However, observational studies suggest that these discussions often fail to meet their stated goals.

OBJECTIVES

To explore best practices by describing what physicians who are considered expert in the area of end of-life bioethics or medical communication do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions of ADs with their patients collected as part of an earlier study.

DESIGN

Nonexperimental, descriptive study of audiotaped discussions.

SETTING

Outpatient primary care practices in the United States.

PARTICIPANTS

Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 locations-Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously discussed ADs with their physician. Expert clinicians had discretion regarding patient selection, while the internists chose patients according to a predetermined protocol.

MEASUREMENTS

Coders applied the Roter Interaction Analysis System (RIAS) to audiotapes of the medical visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician performance in specific skills related to AD discussions.

RESULTS

Experts spent close to twice as much time (14.7 vs 8.1 minutes, P<.001) and were less verbally dominant (P<.05) than other physicians during AD discussions. When length of visit was controlled statistically, the expert physicians gave less information about treatment procedures and biomedical issues (P<.05) and asked fewer related questions (P<. 05) but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building (P<.05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P<.001), and more positive talk (P<.05) than patients of community physicians. Expert physicians scored higher on the 21 items reflecting AD-specific skills (P<.001).

CONCLUSIONS

Best practices as reflected in the performance of expert physicians reflect differences in measures of communication style and in specific AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains. Arch Intern Med. 2000;160:3477-3485.

Talking to the older adult about advance directives

Discussing advance care plans with elderly patients can improve the experience of end-of-life care for patients, families, and health care teams. Specific goals for any particular discussion should be based on patients' particular clinical circumstances. Physicians should focus on patients' overall values and goals and should provide emotional support during the discussion. Decisions made during the advance care planning process should be documented.

Influence of pathogenicity islands and the minor leuX-encoded tRNA5Leu on the proteome pattern of the uropathogenic Escherichia coli strain 536

The uropathogenic Escherichia coli strain 536 (O6:K15:H31) carries four distinct DNA regions in its chromosome, termed pathogenicity islands (PAIs I536 to IV536). Each of these PAIs encodes at least one virulence factor. All four PAIs are associated with tRNA genes. PAI I536 and PAI II536 can be spontaneously deleted from the chromosome by homologous recombination between flanking direct repeats. The deletion of PAI II536 results in the truncation of the associated gene leuX encoding the tRNALeu. This tRNA influences the expression of various virulence traits. In order to get a deeper insight into the role of PAI I536/II536 and of the tRNA5LeU for the protein expression, the protein expression patterns of Escherichia coli 536 and different derivatives were studied. Differences in the protein expression patterns of the wild-type strain Escherichia coli 536, its mutants 536-21 (PAI I536-, PAI II536-, leuX-), 536delta102 (PAI I536+, PAI II536+, leuX-) as well as of the strain 536R3 (PAI I536-, PAI II536-, leuX+) were analyzed by two-dimensional polyacrylamide gel electrophoresis and MALDI-TOF mass spectrometry. We identified about 39 different intracellular proteins whose expression is markedly altered in the different strain backgrounds. These differences can be linked either to the presence or absence of the PAI I536 and PAI II536 or to that of the tRNA gene leuX. The identities of 34 proteins have been determined by MALDI-TOF-MS. The identification of five proteins was not possible. The results suggest that proteome analysis is an efficient approach to study differences in global gene expression. The comparison of protein expression patterns of the uropathogenic E. coli strain 536 and different derivatives revealed that in this strain the expression of various proteins including those encoded by many housekeeping genes is affected by the presence of PAI I536 and Pai II536 or by that of the tRNA5Leu.

Opening the black box: how do physicians communicate about advance directives?

BACKGROUND

The quality of communication that leads to the completion of written advance directives may influence the usefulness of these documents, but the nature of that communication remains relatively unexplored.

OBJECTIVE

To describe how physicians discuss advance directives with patients.

DESIGN

Prospective study.

SETTING

Five outpatient primary care medicine practices in Durham, North Carolina, and Pittsburgh, Pennsylvania.

PARTICIPANTS

56 attending internists and 56 of their established patients. Eligible patients were at least 65 years of age or had a serious medical illness.

MEASUREMENTS

Two raters coded transcripts of audiotaped discussions about advance directives to document how physicians introduced the topic of advance directives, discussed scenarios and treatments, provided information, elicited patient values, and identified surrogate decision makers.

RESULTS

Conversations about advance directives averaged 5.6 minutes; physicians spoke for two thirds of this time. In 91% of cases, physicians discussed dire scenarios in which most patients would not want to be treated, and 48% asked patients about their preferences in reversible scenarios. Fifty-five percent of physicians discussed scenarios involving uncertainty, typically using vague language. Patients' values were rarely explored in detail. In 88% of cases, physicians discussed surrogate decision making and documents to aid in advance care planning.

CONCLUSIONS

Although they accomplished the goal of introducing patients to advance directives, discussions infrequently dealt with patients' values and attitudes toward uncertainty. Physicians may not have addressed the topic in a way that would be of substantial use in future decision making, and these discussions did not meet the standards proposed in the literature.

Patient knowledge and physician predictions of treatment preferences after discussion of advance directives

OBJECTIVE

To determine patient knowledge about life-sustaining treatments and physician understanding of patient preferences for proxies and treatments after outpatient discussions about advance directives.

DESIGN

Cross-sectional interview-based and questionnaire-based survey.

SETTING

Two university general internal medicine practices, two Department of Veterans Affairs general internal medicine practices, and one university-based geriatrics practice, in two different cities.

PATIENTS

Fifty-six patients of primary care internists.

INTERVENTION

Physicians discussed "advance directives" (ADs) with one randomly selected patient during an outpatient visit.

MEASUREMENTS AND MAIN RESULTS

After the discussions, physicians identified the patient's proxy and predicted the patient's preferences for treatment in 20 scenarios. Patients provided treatment preferences in the 20 scenarios, the name of their preferred surrogate decision maker, and their understanding of cardiopulmonary resuscitation and mechanical ventilation. Of the 39 patients who discussed resuscitation, 43% were able to identify two important characteristics; 26% identified none; 66% did not know that most patients need mechanical ventilation after undergoing resuscitation. None of the 43 patients who had a discussion about mechanical ventilation had a good understanding of it; 67% did not know that patients generally cannot talk while on ventilators; 46% expressed serious misconceptions about ventilators. There was poor agreement between physicians and their patients regarding treatment preferences in 18 of 20 scenarios (kappa -0.04 to 0.31). Physicians correctly identified the proxy 89% of the time (kappa 0.78).

CONCLUSIONS

Patients leave routine AD discussions with serious misconceptions about life-sustaining treatments. Physicians are unable to predict treatment preferences but do learn about patients' preferences for surrogate decision makers.

Can goals of care be used to predict intervention preferences in an advance directive?

BACKGROUND

Some have suggested that advance directives elicit goals of care from patients, instead of or in addition to specific intervention preferences, but little is known about whether goals of care can be used in a meaningful way on documents or whether they can predict preferences for specific interventions.

METHODS

Attending physicians (n = 716) at the Massachusetts General Hospital in Boston were surveyed to elicit general goals of care (eg, treat everything or comfort measures only) along with specific preferences for 11 medical, interventions in 6 scenarios. In each scenario, each goal was classified as an adequate predictor of acceptance or rejection of an intervention if its predictive value of the preference for that intervention was at least 80%.

RESULTS

Goals varied with scenarios (P < .001) in a predictable manner. The goal treat everything was an adequate predictor of acceptance of each intervention, and comfort was an adequate predictor of rejection for nearly every intervention. Attempt cure adequately predicted acceptance of almost every nonaggressive intervention, but did not predict acceptance of aggressive interventions. Quality of life predicted rejection of aggressive interventions in 3 scenarios, but was not useful in other cases. When goals were predictors of preferences, the mean range of 95% confidence intervals for their predictive values was generally 20% or less.

CONCLUSIONS

Goals have a valid role in advance directives, since the goal choices had a logical relationship to scenarios and intervention choices. However, the 2 goals attempt cure and choose quality of life were not predictive in many instances. If these findings hold true for more general populations of patients, then advance directive documents will need to rely on more than these general goal statements if they are to adequately represent patient preferences.

Psychometric analysis of an advance directive

OBJECTIVES

Reliability and validity are as necessary for predrafted advance directive forms as they are for all clinical assessment instruments. Performance of predrafted advance directive forms with both lay persons and clinicians is relevant. Evidence relating to test- retest reliability, content validity, and criterion-related validity of one form, the Medical Directive, has been documented for outpatients. The authors investigated construct validity and external validity among outpatients, physicians, and the general public.

METHODS

Four hundred ninety-five outpatients, 513 physicians, and 102 members of the general public were surveyed with the Medical Directive. Preference for 11 specific treatments in four to six illness scenarios were recorded. Mokken modeling of responses was used to produce a psychometric scale of receptiveness-to-treatment and desirability of treatments. The Kuder Richardson-20 statistic, Friedman's procedure for analysis of variance, and the Kruskall-Wallis test were used, respectively, to measure inter-item reliability, the relation with scenarios, and the relation between physicians' general goals for care and their scaled preferences.

RESULTS

All model diagnostic tests indicated a close-fitting scale for all three respondent groups. Kuder Richardson-20 for outpatients (.98), physicians (.97), and the public (.93) demonstrated high inter-item reliability. Treatment desirabilities were related to invasiveness. Receptiveness-to-treatment was related to prognoses and disabilities of described illness scenarios among each group and to physicians' goals for care.

CONCLUSIONS

The Medical Directive has construct validity in relations among specific treatment preferences and between treatment preferences, illness scenarios, and goals for care. External validity is supported by study of separate outpatient, physician, and general public populations. The treatment items constitute a highly reliable scale that can be used in further empirical research regarding life-sustaining treatment.

Elevator talk: observational study of inappropriate comments in a public space

OBJECTIVES

We conducted a study to determine the type and frequency of inappropriate comments made by hospital employees while riding hospital elevators.

METHODS

Four observers rode in elevators at five hospitals, listening for any comments made by hospital employees that might be deemed inappropriate. All potentially inappropriate comments were reviewed by the research team and were classified as inappropriate if they met at least one of the following criteria: violated patient confidentiality, raised concerns about the speaker's ability or desire to provide high-quality patient care, raised concerns about poor quality of care in the hospital (by persons other than the speaker), or contained derogatory remarks about patients or their families.

RESULTS

We observed 259 one-way elevator trips offering opportunity for conversation. We overheard a total of 39 inappropriate comments, which took place on 36 rides (13.9% of the trips). The most frequent comments (18) were violations of patients confidentiality. Next most frequent (10 comments) were unprofessional remarks in which clinicians talked about themselves in ways that raised questions about their ability or desire to provide high-quality patient care. Other comments included derogatory statements about the general quality of hospital care (8) and derogatory remarks about patients (5). Physicians were involved in 15 of the comments, nurses in 10, and other hospital employees in the remainder.

CONCLUSION

Inappropriate comments took place with disturbing frequency in the elevator rides we sampled. These comments did not exclusively involve violations of patient confidentiality, but encompassed a range of discussions that health care employees must be careful to avoid.

Evaluation of NCS rapid plasma reagin card test, a new screening kit for syphilis

Agreements in qualitative and quantitative test results between the recently marketed NCS rapid plasma reagin card test (NCS Diagnostics Corp.) and the Macro-Vue rapid plasma reagin 18-mm circle card test (Hynson, Westcott and Dunning) were 99.2 and 99.1%, respectively, indicating the NCS RPR card test to be an acceptable alternative procedure for the serodiagnosis of syphilis.

Comparison of MYCOPLASMELISA with complement fixation test for measurement of antibodies to Mycoplasma pneumoniae

The MYCOPLASMELISA test kit was compared with the complement fixation test for detection of Mycoplasma pneumoniae antibody in single sera and evaluation of acute- and convalescent-phase serum pairs for significant rises in antibody titers. Agreement between the two assays was 96.6% (85 of 88) for antibody detection and 93.9% (92 of 98) for evaluation of paired sera. Sensitivity and specificity of MYCOPLASMELISA, relative to complement fixation, for the serodiagnosis of recent M. pneumoniae infection was 92.2% (59 of 64) and 95% (19 of 20), respectively.

Reactivity of Dade rapid plasma reagin card test with low-titer sera

Of 105 sera having reagin titers of 1 dilution as determined by the rapid plasma reagin 18-mm circle card test (Hynson, Westcott and Dunning, Baltimore, Md.), 103 (98.1%) were reactive with the Dade rapid plasma reagin card test (Biokit Laboratories, Barcelona, Spain), indicating that the two procedures are comparable in their ability to detect low levels of nontreponemal syphilitic antibody, or reagin.