Linking Primary Care Patients to Mental Health Care via Behavioral Health Social Workers: A Stepped-Wedge Study

OBJECTIVE

Demand for systematic linkage of patients to behavioral health care has increased because of the widespread implementation of depression screening. This study assessed the impact of deploying behavioral health social workers (BHSWs) in primary care on behavioral health visits for depression or anxiety.

METHODS

This quasi-experimental, stepped-wedge study included adults with a primary care visit between 2016 and 2019 at Cleveland Clinic, a large integrated health system. BHSWs were deployed in 40 practices between 2017 and 2019. Patients were allocated to a control group (diagnosed before BHSW deployment) and an intervention group (diagnosed after deployment). Data were collected on behavioral health visits (i.e., to therapists and psychiatrists) within 30 days of the diagnosis. Multilevel logistic regression models identified associations between BHSW deployment period and behavioral health visit, adjusted for demographic variables and clustering within each group.

RESULTS

Of 68,659 persons with a diagnosis, 21% had a depression diagnosis, 49% an anxiety diagnosis, and 31% both diagnoses. In the period after BHSW deployment, the proportion of patients with depression who had a behavioral health visit increased by 10 percentage points, of patients with anxiety by 9 percentage points, and of patients with both disorders by 11 percentage points. The adjusted odds of having a behavioral health visit was higher in the postdeployment period for patients with depression (adjusted odds ratio [AOR]=4.35, 95% confidence interval [CI]=3.50-5.41), anxiety (AOR=4.27, 95% CI=3.57-5.11), and both (AOR= 3.26, 95% CI=2.77-3.84).

CONCLUSIONS

Integration of BHSWs in primary care was associated with increased behavioral health visits.

Implementing Behavioral Health Social Workers' Increased Mental Health Care Among Older Adults

Depression is underdiagnosed and undertreated among older adults. Health systems can screen patients to identify depression, but systemic linkages to treatment are required to ensure care. We used a retrospective stepped-wedge study to identify the impact of implementing behavioral health social workers (BHSWs) on receipt of treatment after a new depression diagnosis. We included adults over 65 years of age with a primary care visit between 2016 and 2019 at a large integrated health system. We excluded patients who were diagnosed with or treated for depression in 2015. Patients were categorized into control (diagnosed before implementation) and intervention (diagnosed after implementation) groups. From our electronic health record, we collected prescriptions for pharmacotherapy and behavioral health visits. Patients were considered treated if they received pharmacotherapy or had a behavioral health visit within 30 days of diagnosis. We used multilevel logistic regression models to identify the association between implementation period (pre versus post) and treatment, adjusted for demographic variables and clustering within site. Our population included 4,475 people. The percent of patients that received treatment increased from 47% to 54% after implementation and the percent of patients with ≥1 behavioral health visit within 30 days increased from 3% to 8% (p<0.01, respectively). The adjusted odds ratio of receiving treatment (AOR: 4.13, 95%CI: 2.84-6.01) and having a behavioral health visit (AOR: 3.12, 95%CI: 2.31-4.24) was significantly higher in the post-implementation period. In conclusion, implementation of BHSWs was associated with increased treatment for older patients with depression.

Personalized predictions of patient outcomes during and after hospitalization using artificial intelligence

Hospital systems, payers, and regulators have focused on reducing length of stay (LOS) and early readmission, with uncertain benefit. Interpretable machine learning (ML) may assist in transparently identifying the risk of important outcomes. We conducted a retrospective cohort study of hospitalizations at a tertiary academic medical center and its branches from January 2011 to May 2018. A consecutive sample of all hospitalizations in the study period were included. Algorithms were trained on medical, sociodemographic, and institutional variables to predict readmission, length of stay (LOS), and death within 48-72 h. Prediction performance was measured by area under the receiver operator characteristic curve (AUC), Brier score loss (BSL), which measures how well predicted probability matches observed probability, and other metrics. Interpretations were generated using multiple feature extraction algorithms. The study cohort included 1,485,880 hospitalizations for 708,089 unique patients (median age of 59 years, first and third quartiles (QI) [39, 73]; 55.6% female; 71% white). There were 211,022 30-day readmissions for an overall readmission rate of 14% (for patients ≥65 years: 16%). Median LOS, including observation and labor and delivery patients, was 2.94 days (QI [1.67, 5.34]), or, if these patients are excluded, 3.71 days (QI [2.15, 6.51]). Predictive performance was as follows: 30-day readmission (AUC 0.76/BSL 0.11); LOS > 5 days (AUC 0.84/BSL 0.15); death within 48-72 h (AUC 0.91/BSL 0.001). Explanatory diagrams showed factors that impacted each prediction.

Bilateral giant parathyroid adenoma in the absence of multiple endocrine neoplasia type 1

INTRODUCTION

Bilateral giant parathyroid adenoma in the absence of multiple endocrine neoplasia (MEN) type 1 is extremely rare and literature on this subject is limited.

CASE HISTORY

A 79-year-old man presented with acute kidney injury secondary to hypercalcaemia. Blood test results indicated primary hyperparathyroidism. Ultrasonography revealed bilateral parathyroid adenomas measuring 19.4mm x 19.5mm x 18.8mm (left) and 15.2mm x 18.3mm x 19.6mm (left) whereas on computed tomography, the measurements were 31mm x 20mm (left) and 30mm x 14mm (right). Intraoperatively, giant adenomas measuring 50mm x 25mm x 12mm (left, weighing 8.101g) and 48mm x 22mm x 10mm (right, weighing 7.339g) were identified and excised. Parathyroid hormone level dropped from 44.6pmol/l preoperatively to 8.9pmol/l postoperatively (normal range 1.3-7.6pmol/l). The patient was discharged with no complications.

CONCLUSIONS

We report a rare phenomenon where bilateral giant parathyroid adenoma occurred in the absence of MEN type 1. It highlights the importance of cross-sectional imaging in delineating the anatomy of adenomas as their size can be grossly underestimated by ultrasonography alone.

Impact of a system-wide quality improvement initiative on blood pressure control: a cohort analysis

OBJECTIVE

To assess the impact of a quality improvement programme on blood pressure (BP) control and determine whether medication intensification or repeated measurement improved control.

DESIGN

Retrospective cohort comparing visits in 2015 to visits in 2016 (when the programme started).

SUBJECTS

Adults with ≥1 primary care visit between January and June in 2015 and 2016 and a diagnosis of hypertension in a large integrated health system.

MEASURES

Elevated BP was defined as a BP ≥140/90 mm Hg. Physician response was defined as: nothing; BP recheck within 30 days; or medication intensification within 30 days. Our outcome was BP control (<140/90 mm Hg) at the last visit of the year. We used a multilevel logistic regression model (adjusted for demographic and clinical variables) to identify the effect of the programme on the odds of BP control.

RESULTS

Our cohort included 111 867 adults. Control increased from 72% in 2015 to 79% in 2016 (p<0.01). The average percentage of visits with elevated blood pressure was 31% in 2015 and 25% in 2016 (p<0.01). During visits with an elevated BP, physicians were more likely to intensify medication in 2016 than in 2015 (43% vs 40%, p<0.01) and slightly more likely to obtain a BP recheck (15% vs 14%, p<0.01). Among patients with ≥1 elevated BP who attained control by the last visit in the year, there was 6% increase from 2015 to 2016 in the percentage of patients who received at least one medication intensification during the year and a 1% increase in BP rechecks. The adjusted odds of the last BP reading being categorised as controlled was 59% higher in 2016 than in 2015 (95% CI 1.54 to 1.64).

CONCLUSION

A system-wide initiative can improve BP control, primarily through medication intensification.

P30 A PRISMA systematic review and meta-analysis of open and novel ‘minimally invasive’ techniques for mesial temporal lobe epilepsy (MTLE)

Objectives

One third of patients with focal epilepsy fail to achieve seizure freedom despite best medical therapy. Surgery may provide seizure freedom if the epileptogenic zone can be safely remove. We compare the outcomes following open surgery, laser interstitial thermal therapy (LITT), radiofrequency ablation (RFA) and radiosurgery (RS).

Design

PRISMA systematic review and meta-analysis.

Subjects

MTLE

Methods

Structured searchs of PubMed, Embase and Cochrane databases. Random effects meta-analysis to calculate effects sizes and a pooled estimate of the probability of remaining seizure free at one year following intervention.

Results

From 1212 screened publications, 57 articles were included in the quantitative analysis. Open surgery included anterior temporal lobectomy as well as transcortical, subtemporal and transsylvian selective amygdalohippocampectomy. The probability of remaining seizure free at one year was 0.89 (95% CI 0.83–0.93) with open surgery based on Level 1 and 2 evidence. RS resulted in 0.88 (95% CI 0.84–0.90) probability and a single RCT revealed RS was less efficacious than open surgery. Follow up duration and study sizes were limited with LITT and RFA providing a probability of remaining seizure free at one year of 0.71 (95% CI 0.65–0.76) and 0.86 (95% CI 0.76–0.92) respectively.

Conclusions

There is no evidence supporting novel ‘minimally invasive’ approaches as being as efficacious as open surgery. Secondary outcome measures such as neuropsychological outcome and intervention morbidity are poorly reported.

TP3-4 Changes in whole brain connectomes with simulated laser interstitial thermal therapy (LITT) using seizure free and non-seizure free ablation cavities in mesial temporal sclerosis: a graph theory approach

Objectives

LITT is a novel means of focal lesioning. Improved seizure free outcome has been associated with the extent to which the mesial hippocampal head is ablated, but not overall ablation volume. We question whether specific changes in structural network connectivity exist in patients that achieve seizure freedom.

Design

Retrospective

Subjects

25 MTS patients after LITT with 2 year outcome.

Methods

Ablation cavities from 11 seizure free and 14 non-seizure free patients were combined to generate group masks. In 12 separate pre-operative patients with MTS (6 right), weighted normalized connectomes were generated with 1 × 10^7 streamlines. To simulate ablations the group cavity masks were excluded from the connectomes prior to normalization. Differences in connectomes were assessed by graph theory metrics.

Results

Greater node strength (str) in non-seizure free patients were present in the ipsilateral basal temporo-occipital cortices in both right and left MTS. Str and local efficiency were relatively maintained in the ipsilateral thalamus of seizure free cavities. Betweenness centrality in non-seizure free cavities were greater in ipsilateral temporal poles in right and left MTS.

Conclusions

Differences in network connectivity are present following simulated LITT for MTS between seizure free and non-seizure free ablation cavities. LiTT ablation cavities may be pre-operatively modelled to ensure the ablation cavity includes important structures and non-essential or inhibitory connectivity is spared. Prospective validation is required.

Use of Visual Decision Aids in Physician-Patient Communication: A Pilot Investigation

INTRODUCTION

A risk calculator paired with a personalized decision aid (RC&DA) may foster shared decision-making in primary care. We assessed the feasibility of using an RC&DA with patients in a primary care outpatient clinic and patients' experiences regarding communication and decision-making.

METHODS

This pilot study was conducted with 15 patients of 3 primary care physicians at a clinic within a tertiary medical center. An atherosclerotic cardiovascular disease (ASCVD) risk calculator was used to generate a personalized RC&DA that displayed absolute 10-year risk information as an icon array graphic. Patient perceptions of utility of the RC&DA, preferences for decision-making, and uncertainty with risk reduction decisions were measured with a semi-structured interview.

RESULTS

Patients reported that the RC&DA was easy to understand and knowledge gained was useful to modify their ASCVD risk. Patients used the RC&DA to make decisions and reported low uncertainty with those decisions.

CONCLUSIONS

Our findings demonstrate the feasibility of, and positive patient experiences related to using, an RC&DA to facilitate shared decision-making between physicians and patients in an outpatient primary care setting.

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients

SUMMIT PARTICIPANTS

ORGANIZATIONS REPRESENTED

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.

Quantifying the defensive medicine contribution to primary care costs

BACKGROUND

Defensive medicine represents one cause of economic losses in healthcare. Studies that measured its cost have produced conflicting results.

OBJECTIVE

To directly measure the proportion of primary care costs attributable to defensive medicine.

RESEARCH DESIGN AND METHODS

Six-week prospective study of primary care physicians from four outpatient practices. On 3 distinct days, participants were asked to rate each order placed the day before on the extent to which it represented defensive medicine, using a 5-point scale from 0 (not at all defensive) to 4 (entirely defensive).

MAIN OUTCOME MEASURES

This study calculated the order defensiveness score for each order (the defensiveness/4) and the physician defensive score (the mean of all orders defensiveness scores). Each order was assigned a weighted cost by multiplying the total cost of that order (based on Medicare reimbursement rates) by the order defensiveness score. The proportion of total cost attributable to defensive medicine was calculated by dividing the weighted cost of defensive orders by the total cost of all orders.

RESULTS

Of 50 eligible physicians, 23 agreed to participate; 21 returned the surveys and rated 1234 individual orders on 347 patients. Physicians wrote an average of 3.6 ± 1.0 orders/visit with an associated total cost of $72.60 ± 18.5 per order. Across physicians, the median physician defensive score was 0.018 (IQR = [0.008, 0.049]) and the proportion of costs attributable to defensive medicine was 3.1% (IQR = [0.5%, 7.2%]). Physicians with defensive scores above vs below the median had a similar number of orders and total costs per visit. Physicians were more likely to place defensive orders if trained in community hospitals vs academic centers (OR = 4.29; 95% CI = 1.55-11.86; p = 0.01).

CONCLUSIONS

This study describes a new method to directly quantify the cost of defensive medicine. Defensive medicine appears to have minimal impact on primary care costs.

Meaningful measurement: developing a measurement system to improve blood pressure control in patients with chronic kidney disease

OBJECTIVES

To develop an electronic registry of patients with chronic kidney disease (CKD) treated in a nephrology practice in order to provide clinically meaningful measurement and population management to improve rates of blood pressure (BP) control.

METHODS

We combined data from multiple electronic sources: the billing system, structured fields in the electronic health record (EHR), and free text physician notes using natural language processing (NLP). We also used point-of-care worksheets to capture clinical rationale.

RESULTS

Nephrologist billing accurately identified patients with CKD. Using an algorithm that incorporated multiple BP readings increased the measured rate of control (130/80 mm Hg) from 37.1% to 42.3%. With the addition of NLP to capture BP readings from free text notes, the rate was 52.6%. Data from point-of-care worksheets indicated that in 52% of visits in which patients were identified as not having controlled BP, patients were actually at goal based on BP readings taken at home or on that day in the office.

CONCLUSIONS

Building a method for clinically meaningful continuous performance measurement of BP control is possible, but will require data from multiple sources. Electronic measurement systems need to grow to be able to capture and process performance data from patients as well as in real-time from physicians.

Development and application of a multiple typing system for Clostridium difficile

A combination of bacteriocin, bacteriophage, and plasmid typing techniques was used to differentiate strains of Clostridium difficile. A typing set of 20 bacteriocin-producing strains was established after 400 isolates of C. difficile were screened for the ability to produce bacteriocin. These strains were used to type a collection of 114 isolates of C. difficile. Forty-six (40%) of the 114 isolates were typeable, and 31 typing patterns were distinguishable. Plasmid typing of the same 114 isolates of C. difficile showed that 67 (59%) of the isolates carried up to four plasmids ranging from 7 to 60 kb in size, although most strains contained only one or two plasmids. Twenty different plasmid typing patterns were observed among the isolates. A combination of bacteriocin and plasmid typing provided 77% typeability. Fifteen (13%) of the 114 strains were typeable with five bacteriophages isolated in our laboratory, but the increase in typeability of strains over that obtainable by plasmid and bacteriocin typing was only 1.8%. Isolates that were nontypeable by bacteriocins, plasmids, or phages could be divided into two groups on the basis of positive or negative cytotoxin production. This further division of strains would increase the typeability potential by 7%; i.e., the ability to differentiate strains would rise from 77 to 84%, or perhaps 86%, if phage typing were included. We conclude that more than one of the techniques reported in this paper must be used to achieve an acceptable level of typeability of this species.