[Show abstract][Hide abstract] ABSTRACT: The disruption in provider continuity caused by medical resident graduation may result in adverse patient outcomes.
Our aim was to investigate whether resident graduation was associated with increased acute care utilization by residents' primary care patients.
This was a retrospective cohort study of patients cared for by junior and senior residents finishing the academic year in 2010, 2011 and 2012.
We compared rates of clinic visits, emergency department (ED) visits, and hospitalizations between transitioning patients whose residents were graduating and non-transitioning patients whose residents were not graduating.
Our study population comprised 90 residents, 4018 unique patients, and 5988 resident-patient dyads that transitioned (n = 3136) or did not transition (n = 2852). For transitioning patients, the clinic visit rate per 100 patients in the 4 months before and after graduation was 129 and 102, respectively; for non-transitioning patients, the clinic visit rate was 119 and 94, respectively (difference-in-differences, +2 per 100 patients; p = 0.12). For transitioning patients, the ED visit rate per 100 patients before and after graduation was 29 and 26, respectively; for non-transitioning patients, the ED visit rate was 28 and 25, respectively (difference-in-differences, 0; p = 0.49). For transitioning patients, the hospitalization rate per 100 patients before and after graduation was 14 and 13, respectively; for non-transitioning patients, the hospitalization rate was 15 and 12, respectively (difference-in-differences, -2; p = 0.20). In multivariable modeling there was no increased risk for transitioning patients for clinic visits (adjusted rate ratio [aRR], 1.03; 95 % confidence interval [CI], 0.97 to 1.10), ED visits (aRR, 1.05; 95 % CI, 0.92 to 1.20), or hospitalizations (aRR, 1.04; 95 % CI, 0.83 to 1.31).
Acute care utilization by residents' patients did not increase or decrease after graduation. Acute care utilization was high before and after graduation. Interventions to decrease the need for acute care should be employed throughout the year.
Journal of General Internal Medicine 04/2015; DOI:10.1007/s11606-015-3305-7 · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To compare antibiotic prescribing among retail clinics, primary care practices, and emergency departments (EDs) for acute respiratory infections (ARIs): antibiotics-may-be-appropriate ARIs (eg, sinusitis) and antibiotics-never-appropriate ARIs (eg, acute bronchitis).
We analyzed retail clinic data from the electronic health records of the 3 largest retail clinic chains in the United States, and data on visits to primary care practices and EDs from the nationally representative National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.
Using multivariate models, we estimated an adjusted antibiotic prescribing rate for each site of care, controlling for differences in patient characteristics and diagnosis.
From 2007 to 2009 in the United States, there were 3 million, 167 million, and 29 million ARI visits at retail clinics, primary care practices, and EDs, respectively. For all ARI visits, the adjusted antibiotic prescribing rate at retail clinics (58%) was similar to the rate at primary care practices (62%; P = .09) and EDs (59%; P = .48). For antibiotics-may-be-appropriate ARI visits, the adjusted antibiotic prescribing rate (95%) at retail clinics was higher than at primary care practices (85%; P < .01) and EDs (83%; P < .01). For antibiotics-never-appropriate ARI visits, the adjusted antibiotic prescribing rate (34%) at retail clinics was lower than at primary care practices (51%; P < .01) and EDs (48%; P < .01).
Compared with primary care practices and EDs, there was no difference at retail clinics in overall ARI antibiotic prescribing. At retail clinics, antibiotic prescribing was more diagnosis-appropriate.
The American journal of managed care 04/2015; 21(4):294-302. · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute respiratory infections (ARIs) are a major burden on healthcare systems. ARIs—including non-specific upper respiratory infections (the common cold), otitis media, sinusitis, pharyngitis, acute bronchitis, influenza, and pneumonia—are the number-one symptomatic reason for seeking medical care. In the United States, ARIs account for about 10 % of all ambulatory visits.Among ARIs, the diagnosis and management of acute bronchitis should be particularly straightforward. Acute bronchitis is a cough-predominant respiratory infection of less than 3 weeks’ duration in a patient without chronic cardiopulmonary disease who has normal vital signs and a normal lung examination. Forty years of randomized controlled trials, as well as more recent guidelines and performance measures, indicate that antibiotics are not beneficial for acute bronchitis and that the right antibiotic prescribing rate is zero.Despite clear evidence, guidelines, and measures indicating that physicians should avoid prescr ...
Journal of General Internal Medicine 01/2015; 30(4). DOI:10.1007/s11606-015-3181-1 · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Collection of data on race, ethnicity, and language preference is required as part of the "meaningful use" of electronic health records (EHRs). These data serve as a foundation for interventions to reduce health disparities.
Our aim was to compare the accuracy of EHR-recorded data on race, ethnicity, and language preference to that reported directly by patients.
Data collected as part of a tobacco cessation intervention for minority and low-income smokers across a network of 13 primary care clinics (n = 569).
Patients were more likely to self-report Hispanic ethnicity (19.6 % vs. 16.6 %, p < 0.001) and African American race (27.0 % vs. 20.4 %, p < 0.001) than was reported in the EHR. Conversely, patients were less likely to complete the survey in Spanish than the language preference noted in the EHR suggested (5.1 % vs. 6.3 %, p < 0.001). Thirty percent of whites self-reported identification with at least one other racial or ethnic group, as did 37.0 % of Hispanics, and 41.0 % of African Americans. Over one-third of EHR-documented Spanish speakers elected to take the survey in English. One-fifth of individuals who took the survey in Spanish were recorded in the EHR as English-speaking.
We demonstrate important inaccuracies and the need for better processes to document race/ ethnicity and language preference in EHRs.
Journal of General Internal Medicine 12/2014; 30(6). DOI:10.1007/s11606-014-3102-8 · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Widening socioeconomic disparities in mortality in the United States are largely explained by slower declines in tobacco use among smokers of low socioeconomic status (SES) than among those of higher SES, which points to the need for targeted tobacco cessation interventions. Documentation of smoking status in electronic health records (EHRs) provides the tools for health systems to proactively offer tobacco treatment to socioeconomically disadvantaged smokers.
To evaluate a proactive tobacco cessation strategy that addresses sociocontextual mediators of tobacco use for low-SES smokers.
This prospective, randomized clinical trial included low-SES adult smokers who described their race and/or ethnicity as black, Hispanic, or white and received primary care at 1 of 13 practices in the greater Boston area (intervention group, n = 399; control group, n = 308).
We analyzed EHRs to identify potentially eligible participants and then used interactive voice response (IVR) techniques to reach out to them. Consenting patients were randomized to either receive usual care from their own health care team or enter an intervention program that included (1) telephone-based motivational counseling, (2) free nicotine replacement therapy (NRT) for 6 weeks, (3) access to community-based referrals to address sociocontextual mediators of tobacco use, and (4) integration of all these components into their normal health care through the EHR system.
Self-reported past-7-day tobacco abstinence 9 months after randomization ("quitting"), assessed by automated caller or blinded study staff.
The intervention group had a higher quit rate than the usual care group (17.8% vs 8.1%; odds ratio, 2.5; 95% CI, 1.5-4.0; number needed to treat, 10). We examined whether use of intervention components was associated with quitting among individuals in the intervention group: individuals who participated in the telephone counseling were more likely to quit than those who did not (21.2% vs 10.4%; P < .001). There was no difference in quitting by use of NRT. Quitting did not differ by a request for a community referral, but individuals who used their referral were more likely to quit than those who did not (43.6% vs 15.3%; P < .001).
Proactive, IVR-facilitated outreach enables engagement with low-SES smokers. Providing counseling, NRT, and access to community-based resources to address sociocontextual mediators among smokers reached in this setting is effective.
clinicaltrials.gov Identifier: NCT01156610.
JAMA Internal Medicine 12/2014; 175(2). DOI:10.1001/jamainternmed.2014.6674 · 13.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Clinicians prescribe antibiotics to over 65% of adults with acute bronchitis despite guidelines stating that antibiotics are not indicated.Methods
To identify and understand primary care clinician perceptions about antibiotic prescribing for acute bronchitis, we conducted semi-structured interviews with 13 primary care clinicians in Boston, Massachusetts and used thematic content analysis.ResultsAll the participants agreed with guidelines that antibiotics are not indicated for acute bronchitis and felt that clinicians other than themselves were responsible for overprescribing. Barriers to guideline adherence included 6 themes: (1) perceived patient demand, which was the main barrier, although some clinicians perceived a recent decrease; (2) lack of accountability for antibiotic prescribing; (3) saving time and money; (4) other clinicians¿ misconceptions about acute bronchitis; (5) diagnostic uncertainty; and (6) clinician dissatisfaction in failing to meet patient expectations. Strategies to decrease inappropriate antibiotic prescribing included 5 themes: (1) patient educational materials; (2) quality reporting; (3) clinical decision support; (4) use of an over-the-counter prescription pad; and (5) pre-visit triage and education by nurses to prevent visits.Conclusions
Clinicians continued to cite patient demand as the main reason for antibiotic prescribing for acute bronchitis, though some clinicians perceived a recent decrease. Clinicians felt that other clinicians were responsible for inappropriate antibiotic prescribing and that better pre-visit triage by nurses could prevent visits and change patients¿ expectations.
BMC Family Practice 12/2014; 15(1):194. DOI:10.1186/s12875-014-0194-5 · 1.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Healthcare professionals are rapidly adopting electronic health records (EHRs). Within EHRs, seemingly innocuous menu design configurations can influence provider decisions for better or worse.
Journal of General Internal Medicine 11/2014; 30(3). DOI:10.1007/s11606-014-3051-2 · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives:
To determine whether clinical decision support (CDS) is associated with improved quality indicators and whether disabling CDS negatively affects these.
Using the 2006-2009 National Ambulatory and National Hospital Ambulatory Medical Care Surveys, we performed logistic regression to analyze adult primary care visits for the association between the use of CDS (problem lists, preventive care reminders, lab results, lab range notifications, and drug-drug interaction warnings) and quality measures (blood pressure control, cancer screening, health education, influenza vaccination, and visits related to adverse drug events).
There were an estimated 900 million outpatient primary care visits to clinics with EHRs from 2006-2009; 97% involved CDS, 77% were missing at least 1 CDS, and 15% had at least 1 CDS disabled. The presence of CDS was associated with improved blood pressure control (86% vs 82%; OR 1.3; 95% CI, 1.1-1.5) and more visits not related to adverse drug events (99.9% vs 99.8%; OR 3.0; 95% CI, 1.3-7.3); these associations were also present when comparing practices with CDS against practices that had disabled CDS. Electronic problem lists were associated with increased odds of having a visit with controlled blood pressure (86% vs 80%; OR 1.4; 95% CI, 1.3-1.6). Lab result notification was associated with increased odds of ordering cancer screening (15% vs 10%; OR 1.5; 95% CI, 1.03-2.2).
The use of CDS was associated with improvement in some quality indicators. Not having at least 1 CDS was common; disabling CDS was infrequent. This suggests that meaningful use standards may improve national quality indicators and health outcomes, once fully implemented.
The American journal of managed care 10/2014; 20(10):e445-52. · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Individuals involved with the criminal justice system have increased health needs and poor access to primary care.
To examine hospital and emergency department (ED) utilization and related costs by individuals with recent criminal justice involvement.
Non-institutionalized, civilian U.S. adult participants (n = 154,356) of the National Survey on Drug Use and Health (2008-2011).
Estimated proportion of adults who reported past year 1) hospitalization or 2) ED utilization according to past year criminal justice involvement, defined as 1) parole or probation, 2) arrest without subsequent correctional supervision, or 3) no criminal justice involvement; estimated annual expenditures using unlinked data from the Medical Expenditure Panel Survey.
An estimated 5.7 million adults reported parole or probation and an additional 3.9 million adults reported an arrest in the past year. Adults with recent parole or probation and those with a recent arrest, compared with the general population, had higher rates of hospitalization (12.3 %, 14.3 %, 10.5 %; P < 0.001) and higher rates of ED utilization (39.3 %, 47.2 %, 26.9 %; P < 0.001). Recent parole or probation was an independent predictor of hospitalization (adjusted odds ratio [AOR], 1.21; 95 % confidence interval [CI], 1.02-1.44) and ED utilization (AOR, 1.35; 95 % CI, 1.12-1.63); Recent arrest was an independent predictor of hospitalization (AOR, 1.26; 95 % CI, 1.08-1.47) and ED utilization (AOR, 1.81; 95 % CI, 1.53-2.15). Individuals with recent criminal justice involvement make up 4.2 % of the U.S. adult population, yet account for an estimated 7.2 % of hospital expenditures and 8.5 % of ED expenditures.
Recent criminal justice involvement is associated with increased hospital and ED utilization and costs. The criminal justice system may offer an important point of contact for efforts to improve the healthcare utilization patterns of a large and vulnerable population.
Journal of General Internal Medicine 05/2014; 29(9). DOI:10.1007/s11606-014-2877-y · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Chronic kidney disease (CKD) is increasingly common and under-recognized in primary care clinics, leading to low rates of stage-appropriate monitoring and treatment. Our objective was to determine whether electronic problem list documentation of CKD is associated with monitoring and treatment.
This is a cross-sectional observational study of patients with stage 3 or 4 CKD, defined as two past estimated glomerular filtration rates (eGFR) 15-60 mL/min/1.73 m2 separated by 90 days and collected between 2007-2008. We examined the association of problem list documentation with: 1) serum eGFR monitoring test, 2) urine protein or albumin monitoring test, 3) an angiotensin converting enzyme inhibitor or angiotensin receptor blocker (ACE/ARB) prescription, 4) mean systolic blood pressure (BP), and 5) BP control.
Out of 3,149 patients with stage 3 or 4 CKD, only 16% of patients had CKD documented on the problem list. After adjustment for eGFR, gender, and race/ethnicity and after clustering by physician, problem list documentation of CKD was associated with serum eGFR testing (97% with problem list documentation vs. 94% without problem list documentation, p = 0.02) and urine protein testing (47% with problem list documentation vs. 40% without problem list documentation, p = 0.04). After adjustment, problem list documentation was not associated with ACE/ARB prescription, mean systolic BP, or BP control.
Documentation of CKD on the electronic problem list is rare. Patients with CKD documentation have better stage-appropriate monitoring of the disease, but do not have higher rates of blood pressure treatment or better blood pressure control. Interventions aimed at increasing documentation of CKD on the problem list may improve stage-appropriate monitoring, but may not improve clinical outcomes.
[Show abstract][Hide abstract] ABSTRACT: Health information technology (HIT) can increase preventive care. There are hopes and fears about the impact of HIT on racial disparities in cancer screening.
To determine whether electronic health records (EHRs) or electronic preventive care reminders (e-reminders) modify racial differences in cancer screening order rates.
Using the 2006-2010 National Ambulatory and National Hospital Ambulatory Medical Care Surveys, we measured (1) visit-based differences in rates of age-appropriate breast, cervical and colon cancer screening orders between white and non-white subjects at primary care visits with and without EHRs, and, at visits with EHRs, with and without e-reminders, and (2) whether EHRs or e-reminders modified these differences.
Mammography (N=45 380); Pap smears (N=73 348); and sigmoidoscopy/colonoscopy (N=50 955) orders.
Among an estimated 2.4 billion US adult primary care visits, orders for screening for breast, cervical or colon cancer did not differ between clinics with and without EHRs or e-reminders. There was no difference in screening orders between non-white and white patients for breast (aOR=1.1; 95% CI 0.9 to 1.4) or cervical cancer (aOR=1.2; 95% CI 1.0 to 1.3). For colon cancer, non-white patients were more likely to receive screening orders than white patients overall (aOR=1.5; 95% CI 1.1 to 2.0), at visits with EHRs (aOR=1.8; 95% CI 1.1 to 2.8) and at visits with e-reminders (aOR=2.1; 95% CI 1.2 to 3.7). EHRs or e-reminders did not modify racial differences in cancer screening rates.
In this visit-based analysis, non-white patients had higher colon cancer screening order rates than white patients. Despite hopes and fears about HIT, EHRs and e-reminders did not ameliorate or exacerbate racial differences in cancer screening order rates.
Journal of the American Medical Informatics Association 03/2014; 21(E2). DOI:10.1136/amiajnl-2013-002439 · 3.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE "Nudges" that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice. OBJECTIVE To investigate the use of a behavioral "nudge" based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention). INTERVENTIONS The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs. MAIN OUTCOMES AND MEASURES Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status. RESULTS Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time. CONCLUSIONS AND RELEVANCE Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01767064.
JAMA Internal Medicine 01/2014; 174(3). DOI:10.1001/jamainternmed.2013.14191 · 13.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Fatigue and stress may deplete clinicians’ capacity to resist prescribing antibiotics for acute respiratory infections (ARIs). We hypothesized that primary care clinicians would be less likely to prescribe antibiotics for ARIs at the beginning and more likely to prescribe antibiotics for ARIs at the end of clinic sessions.
Methods: We compared the antibiotic prescribing rates for all ARIs, antibiotic-appropriate diagnoses (e.g., sinusitis or pneumonia), and non-antibiotic-appropriate diagnoses (e.g., acute bronchitis) for the first visit of a half-day clinic session and the last hour of a half-day clinic session (i.e., the 11 am and 4 pm hours) to the remaining visits. We used multivariable generalized estimating equations to identify independent predictors of antibiotic prescribing after adjusting for patient demographics, antibiotic-appropriateness of diagnosis, and clustering by clinician.
Results: There were 678,982 total visits and 31,838 ARI visits scheduled from 8 am to 5 pm, Monday to Friday, by patients aged 18 to 64 years old without chronic lung disease to 561 clinicians in 23 Boston-area primary care practices, between May 2011 and September 2012. The antibiotic prescribing rate for the first visit of the session was significantly lower than later visits for all ARIs (55.2% vs. 58.7%; p<0.001), antibiotic-appropriate diagnoses (74.2% vs. 77.4%; p=0.008), and non-antibiotic-appropriate diagnoses (45.1% vs. 48.8%; p<0.001). The antibiotic prescribing rate was significantly higher during the last hour of each session compared to the remainder of the session for all ARIs (60.3% vs. 57.6%; p<0.001), antibiotic-appropriate diagnoses (78.8% vs. 76.4%; p=0.01), and non-antibiotic-appropriate diagnoses (50.6% vs. 47.6%; p<0.001). In multivariable modeling, clinicians were less likely to prescribe antibiotics at the first visit of the session (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.81 to 0.96) and more likely to prescribe antibiotics in the last hour of a clinic session (OR, 1.12; 95% CI, 1.04 to 1.19).
Conclusion: Primary care clinicians are slightly, but significantly less likely to prescribe antibiotics at the beginning of a clinic session and more likely to prescribe antibiotics at the end of a clinic session.
IDWeek 2013 Meeting of the Infectious Diseases Society of America; 10/2013