Jeffrey A Linder

Harvard University, Cambridge, Massachusetts, United States

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Publications (88)680.21 Total impact

  • Jeffrey A Linder
    Journal of General Internal Medicine 01/2015; DOI:10.1007/s11606-015-3181-1 · 3.42 Impact Factor
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    ABSTRACT: For many surgeries and high-risk medical conditions, higher volume providers provide higher quality care. The impact of volume on more common medical conditions such as acute respiratory infections (ARIs) has not been examined. Using electronic health record data for adult ambulatory ARI visits, we divided primary care physicians into ARI volume quintiles. We fitted a linear regression model of antibiotic prescribing rates across quintiles to assess for a significant difference in trend. Higher ARI volume physicians had lower quality across a number of domains, including higher antibiotic prescribing rates, higher broad-spectrum antibiotic prescribing, and lower guideline concordance. Physicians with a higher volume of cases manage ARI very differently and are more likely to prescribe antibiotics. When they prescribe an antibiotic for a diagnosis for which an antibiotic may be indicated, they are less likely to prescribe guideline-concordant antibiotics. Given that high-volume physicians account for the bulk of ARI visits, efforts targeting this group are likely to yield important population effects in improving quality. © The Author(s) 2015.
    Inquiry: a journal of medical care organization, provision and financing 01/2015; 52. DOI:10.1177/0046958015571130 · 0.56 Impact Factor
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    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; DOI:10.1007/s11606-014-3102-8 · 3.42 Impact Factor
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    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; DOI:10.1001/jamainternmed.2014.6674 · 13.25 Impact Factor
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    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 · 1.74 Impact Factor
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    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; DOI:10.1007/s11606-014-3051-2 · 3.42 Impact Factor
  • JAMA Internal Medicine 10/2014; DOI:10.1001/jamainternmed.2014.5225 · 13.25 Impact Factor
  • Daniella Meeker, Mark W Friedberg, Jeffrey A Linder
    JAMA Internal Medicine 08/2014; 174(8):1419. DOI:10.1001/jamainternmed.2014.1594 · 13.25 Impact Factor
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    Michael L Barnett, Jeffrey A Linder
    JAMA The Journal of the American Medical Association 05/2014; 311(19):2020-2. DOI:10.1001/jama.2013.286141 · 29.98 Impact Factor
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    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. Cross-sectional survey. 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
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    Lipika Samal, Jeffrey A Linder, David W Bates, Adam Wright
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    ABSTRACT: 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.
    BMC Nephrology 05/2014; 15(1):70. DOI:10.1186/1471-2369-15-70 · 1.52 Impact Factor
  • JAMA Internal Medicine 04/2014; 174(6). DOI:10.1001/jamainternmed.2014.662 · 13.25 Impact Factor
  • Rebecca G Mishuris, Jeffrey A Linder
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    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 · 3.57 Impact Factor
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    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 · 13.25 Impact Factor
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    ABSTRACT: Objectives To determine whether clinical decision support (CDS) is associated with improved quality indicators and whether disabling CDS negatively affects these. Study Design/Methods 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). Results 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). Conclusions 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.
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    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
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    Michael L Barnett, Jeffrey A Linder
    JAMA Internal Medicine 10/2013; 174(1). DOI:10.1001/jamainternmed.2013.11673 · 13.25 Impact Factor
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    ABSTRACT: Guidelines and performance measures recommend avoiding antibiotics for acute cough/acute bronchitis and presume visits are straightforward with simple diagnostic decision-making. We evaluated clinician-assigned diagnoses, diagnostic uncertainty, and antibiotic prescribing for acute cough visits in primary care. We conducted a retrospective analysis of acute cough visits -- cough lasting <=21 days in adults 18--64 years old without chronic lung disease -- in a primary care practice from March 2011 through June 2012. Of 56,301 visits, 962 (2%) were for acute cough. Clinicians diagnosed patients with 1, 2, or >= 3 cough-related diagnoses in 54%, 35%, and 11% of visits, respectively. The most common principal diagnoses were upper respiratory infection (46%), sinusitis (10%), acute bronchitis (9%), and pneumonia (8%). Clinicians prescribed antibiotics in 22% of all visits: 65% of visits with antibiotic-appropriate diagnoses and 4% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed diagnostic uncertainty in 16% of all visits: 43% of visits with antibiotic-appropriate diagnoses and 5% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed uncertainty more often when prescribing antibiotics than when not prescribing antibiotics (30% vs. 12%; p < 0.001). As the number of visit diagnoses increased from 1 to 2 to >= 3, clinicians were more likely to express diagnostic uncertainty (5%, 25%, 40%, respectively; p < 0.001) and prescribe antibiotics (16%, 25%, 41%, respectively; p < 0.001). Acute cough may be more complex and have more diagnostic uncertainty than guidelines and performance measures presume. Efforts to reduce antibiotic prescribing for acute cough should address diagnostic complexity and uncertainty that clinicians face.
    BMC Family Practice 08/2013; 14(1):120. DOI:10.1186/1471-2296-14-120 · 1.74 Impact Factor
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    ABSTRACT: Objectives: To evaluate the impact on smoking status documentation of a payer-sponsored pay-for-performance (P4P) incentive that targeted a minority of an integrated healthcare delivery system's patients. Study Design: Three commercial insurers simultaneously adopted P4P incentives to document smoking status of their members with 3 chronic diseases. The healthcare system responded by adding a smoking status reminder to all patients' electronic health records (EHRs). We measured change in smoking status documentation before (2008-2009) and after (2010-2011) P4P implementation by patient P4P eligibility. Methods: The P4P-eligible patients were compared primarily with a subset of non-P4P-eligible patients who resembled P4P-eligible patients and also with all non-P4P-eligible patients. Multivariate models adjusted for patient and provider characteristics and accounted for provider-level clustering and preimplementation trends. Results: Documentation increased from 48% of 207,471 patients before P4P to 71% of 227,574 patients after P4P. Improvement from 56% to 83% occurred among P4P-eligible patients (adjusted odds ratio [AOR], 3.6; 95% confidence interval [CI], 2.9-4.5) and from 56% to 80% among the comparable subset of non-P4P-eligible patients (AOR, 3.0; 95% CI, 2.3-3.9). The difference in improvement between groups was significant (AOR, 1.3; 95% CI, 1.1-1.4; P = .009). Conclusions: A P4P incentive targeting a minority of a healthcare system's patients stimulated adoption of a systemwide EHR reminder and improved smoking status documentation overall. Combining a P4P incentive with an EHR reminder might help healthcare systems improve treatment delivery for smokers and meet "meaningful use" standards for EHRs.
    The American journal of managed care 07/2013; 19(7):554-61. · 2.17 Impact Factor
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    Rebecca G Mishuris, Jeffrey A Linder
    Journal of General Internal Medicine 06/2013; 28(11). DOI:10.1007/s11606-013-2538-6 · 3.42 Impact Factor

Publication Stats

1k Citations
680.21 Total Impact Points

Institutions

  • 2005–2014
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2003–2014
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States
    • Brigham and Women's Hospital
      • • Division of General Internal Medicine and Primary Care
      • • Center for Brain Mind Medicine
      Boston, Massachusetts, United States
  • 2008–2010
    • Partners HealthCare
      • Clinical Informatics Research and Development
      Boston, MA, United States
  • 2001–2002
    • Massachusetts General Hospital
      • Department of Medicine
      Boston, Massachusetts, United States