Index Clinic Visit Research Articles

Therapeutic Hydroxychloroquine Blood Levels Are Associated With Fewer Hospitalizations and Possible Reduction of Health Disparities in Lupus.

Nonadherence to receiving hydroxychloroquine (HCQ) is associated with a three-fold higher risk of lupus-related hospitalization. Monitoring HCQ blood levels could improve adherence to receiving HCQ and efficacy. Yet, HCQ level monitoring is not routinely done partially due to cost and coverage concerns. To establish HCQ level monitoring cost-effectiveness, we reported the following: (1) risk of acute care by HCQ blood levels, and (2) cost of HCQ monitoring versus acute care visits. HCQ blood levels were measured during routine lupus visits. HCQ levels were categorized as follows: (1) subtherapeutic (<750 ng/mL), (2) therapeutic (750-1,200 ng/mL), or (3) supratherapeutic (>1,200 ng/mL). All lupus-related acute care visits (emergency room visits/hospitalizations) after the index clinic visit until next follow-up were abstracted. In our primary analysis, we examined associations between HCQ levels and time to first acute care visit in all patients and subgroups with higher rates of acute care. A total of 39 lupus-related acute care visits were observed in 181 patients. Therapeutic HCQ blood levels were associated with 66% lower rates of acute care. In our cohort, two groups, Black or Hispanic patients and those with public insurance, faced three to four times higher rates of acute care. Levels within 750 to 1,200 ng/mL were associated with 95% lower rates of acute care use in subgroups with higher acute care use. HCQ blood levels within 750 to 1,200 ng/mL are associated with lower rates of acute care in all patients with lupus, including groups with higher rates of acute care. Future clinical trials should establish the causal association between HCQ level monitoring and acute care in patients with lupus.

Treatment patterns of patients with worsening heart failure with reduced ejection fraction.

Patients with HFrEF and worsening HF events (WHFE) are at particularly high risk and urgently need disease-modifying therapy. CHART-HF assessed treatment patterns and reasons for medication decisions among HFrEF patients with and without WHFE. CHART-HF collected retrospective electronic medical records of outpatients with HF and EF<45% between 2017-2019 from a nationwide panel of 238 cardiologists (458 patients) and the Geisinger Health System (GHS) medical record (1000 patients). The index visit in the WHFE cohort was the first outpatient cardiologist visit ≤6months following the WHFE, and in the reference cohort was the last visit in a calendar year without WHFE. Demographic characteristics were similar between patients with and without WHFE in both the nationwide panel and GHS. In the nationwide panel, the proportion of patients with versus without WHFE receiving ≥50% of guideline-recommended dose on index visit was 35% versus 40% for beta blocker, 74% versus 83% for ACEI/ARB/ARNI, and 48% versus 49% for MRA. The proportion of patients receiving ≥50% of guideline-recommended dose was lower in the GHS: 29% versus 34% for beta-blocker, 16% versus 31% for ACEI/ARB/ARNI, and 18% versus 22% for MRA. For patients with and without WHFE, triple therapy on index date was 42% and 44% of patients from the nationwide panel, and 14% and 17% in the GHS. Comparing end of index clinic visit with 12-month follow-up in the GHS, the proportion of patients on no GDMT increased from 14% to 28% in the WHFE cohort and from 14 to 21% in the non-WHFE group. Major gaps in use of GDMT, particularly combination therapy, remain among US HFrEF patients. These gaps persist during longitudinal follow-up and are particularly large among patients with recent WHFE.

Patient- and clinician-directed implementation strategies to improve serious illness communication for high-risk patients with cancer: A cluster-randomized pragmatic trial.

1514 Background: Early serious illness conversations (SICs) elicit patients’ values, goals, and care preferences and have been shown to improve outcomes and reduce end-of-life healthcare utilization for patients with cancer. However, most patients with cancer die without a documented SIC. Given prior evidence that strategies informed by behavioral economics (“nudges”) increase SIC rates, our objective was to test the independent and additive effects of clinician- and patient-directed nudges to increase SIC completion. Methods: We conducted a 2 × 2 factorial, cluster-randomized pragmatic trial (NCT04867850) to test the effects of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Usual care was an active control consisting of clinician-directed text messages sent before routine clinic sessions, identifying patients at high risk of 6-month mortality as predicted by a validated machine-learning prognostic algorithm. The clinician nudge additionally included weekly peer comparisons on clinician-level SIC completion rates. The patient nudge consisted of a patient-facing message sent electronically before an index clinic visit, asking a 3-question survey designed to prime patients for an SIC with their oncology team. Participants included medical/gynecologic oncologists and advanced practice providers (APPs) within a large academic health system and their high-risk patients. We independently randomized oncologist/APP clusters and patients to receive nudges vs. usual care. The primary outcome was a documented SIC in the electronic health record within 6 months of enrollment. Using a Cox proportional hazards model with cluster robust standard errors, we performed a time-to-event analysis and tested for heterogeneity of effect across prespecified subgroups. Results: From September 2021 to March 2022, the study accrued 4,450 patients (median age 67, 52.9% female, 17.3% Black, 2.7% Hispanic) seen by 166 clinicians across 4 hospitals and 6 community sites, randomized to clinician nudge (n=1,179), patient nudge (n=997), both (n=1,270), or active control (n=1,004). Overall patient-level rates of 6-month SIC completion were: 11.5% (clinician nudge), 11.5% (patient nudge), 14.1% (both), and 11.2% (active control). Compared to the active control, participants in the combination nudge arm were more likely to engage in SICs (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.00-2.40), whereas those in the clinician (HR 0.95, 95% CI 0.64-1.41) and patient (HR 0.99, 95% CI 0.73-1.33) nudge arms were not. There was no effect heterogeneity across age and race subgroups. Conclusions: Clinician- and patient-directed nudges may be synergistic in promoting serious illness communication at scale and equitably in routine cancer care. Effects on end-of-life care among decedents are forthcoming. Clinical trial information: NCT04867850 .

Correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) measures with unplanned healthcare resources utilization (HRU) among patients with epilepsy (PWE): a retrospective cohort study (P6-1.001)

<h3>Objective:</h3> To evaluate whether PROMIS scores correlate with unplanned HRU among PWE. <h3>Background:</h3> Mental, physical, and social health determinants have a significant effect on quality of life with sparse data on their effect on unplanned HRU. <h3>Design/Methods:</h3> We utilized the PROMIS-16 questionnaire to assess patients’ mental, physical, and social health. Patients completed the questionnaire as part of routine medical care at outpatient neurology clinic visits. We performed a retrospective analysis of the PROMIS measures completed between June 2018, and August 2022. PROMIS data was combined with Health Plan claims data on utilization at 7, 30 and 90-day from the index clinic visit and analyzed using a logit model. A pathologic score in each of the 8 PROMIS measures (Anxiety&gt;62, Depression&gt;60, Fatigue &gt;65, Pain&gt;65, Sleep Disturbance&gt;65, Cognition&lt;35, Physical function&lt;35, Social scores&lt;35) was analyzed as an independent predictor of unplanned HRU in each of 4 domains (Mortality all causes, Hospitalization all causes, ED treat and release all causes and Urgent care all causes). <h3>Results:</h3> The cohort included 6485 unique PWE (13159 encounters; 53.1% females, 10.1% black, median age 46.4-years). The following statistically significant correlations emerged: 1) pathological Physical Function and Social Scores were associated with 90-day mortality; 2) pathological Fatigue, Pain, Sleep Disturbance, Physical Function, and Social Scores were associated with 7-day Hospitalization, 3) Pathological Anxiety, Depression, Fatigue, Pain, Physical Function, and Social Scores were associated with 7-day ED visits, 4) Pathological scores on each of the 8 measures correlated with 90-day Hospitalization (7 measures with a 30-day) and ED visits (5 measures with a 30-day), and 5) Pathological Fatigue scores correlated with 90-day urgent care utilization. <h3>Conclusions:</h3> PROMIS scores are associated with unplanned HRU at short index times from outpatient neurology clinic visits among PWE. This prognostic utility supports the routine collection of patient-reported health measures in clinical practice along with developing timely interventions. <b>Disclosure:</b> Dr. Urban has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Neuropace. The institution of Dr. Kirkpatrick has received research support from American Academy of Neurology. The institution of Dr. Kirkpatrick has received research support from Academic Pediatric Association. The institution of Dr. Kirkpatrick has received research support from American Academy of Pediatrics. The institution of Dr. Kirkpatrick has received research support from Society of Family Planning. The institution of Dr. Kirkpatrick has received research support from North American Society for Pediatric and Adolescent Gynecology. Dr. Rajasekaran has a non-compensated relationship as a PI with UCB Drug study that is relevant to AAN interests or activities. Dr. Rajasekaran has a non-compensated relationship as a PI with Engrail Drug study that is relevant to AAN interests or activities. Dr. Fong has nothing to disclose. Dr. Hanmer has nothing to disclose. Dr. Bagic has nothing to disclose. The institution of Dr. Thirumala has received research support from University of Pittsburgh.

Burden of Glaucoma in the United Kingdom: A Multicenter Analysis of United Kingdom Glaucoma Services

To determine the spectrum of glaucoma-associated health care resource utilization among outpatients attending National Health Service (NHS) hospital glaucoma clinics and the costs of managing glaucoma in this setting. Retrospective observational cohort study using electronic medical record data. Patients aged ≥ 18 years attending 5 NHS glaucoma clinics in the United Kingdom (2013‒2018) with ≥ 12 months of continuous electronic medical record data. Deidentified Medisoft Ophthalmology electronic medical record data (January 2013‒December 2018) from 43 742 eligible patients were categorized by year of clinic visit. Extracted information included patient demographics, glaucoma diagnoses, topical glaucoma medication prescription start/stop dates, types/numbers of glaucoma clinic visits, glaucoma investigations (visual acuity, intraocular pressure, visual field, and OCT), and glaucoma procedures received over 12 months after the first ("index") visit of the specified year. Direct glaucoma-related health care costs (clinic visits, investigations, procedures, and ongoing glaucoma medication initiated in the clinic) were estimated from event volumes and unit costs (UK national tariffs) and expressed from the direct-payer perspective. Glaucoma diagnoses and topical glaucoma medication use at the index clinic visit; numbers of glaucoma clinic visits, investigations and procedures; and glaucoma-related health care costs over 12 months postindex. For the 2016 cohort (n= 21 719), the estimated average total cost of NHS-provided glaucoma care over 12 months was £405 per patient (medical staff services £209, glaucoma investigations £126, glaucoma medication £40, glaucoma procedures £26). Among this cohort, 40.8% had ocular hypertension/suspected glaucoma, 70% had 0-to-mild visual field impairment, and 14% had undergone a glaucoma procedure. Over 12 months, patients received (mean) 2.0 glaucoma clinic visits and 1.5 visual field tests, and 7% underwent glaucoma procedure(s). Results were similar for the other years examined. Cost estimates for managing patients with glaucoma in the UK are required for effective service planning. Appreciable proportions of patients managed in NHS glaucoma clinics may be considered at low risk of blindness (glaucoma suspects and those with ocular hypertension with mild visual field loss) and may be more appropriately managed with alternative, more affordable models of care.

Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: A case-control study.

Present guidelines recommend a multidisciplinary team (MDT) approach to diabetic foot ulcer (DFU) care, but relevant data from Asia are lacking. We aim to evaluate the clinical and economic outcomes of an MDT approach in a lower extremity amputation prevention programme (LEAPP) for DFU care in an Asian population. We performed a case‐control study of 84 patients with DFU between January 2017 and October 2017 (retrospective control) vs 117 patients with DFU between December 2017 and July 2018 (prospective LEAPP cohort). Comparing the clinical outcomes between the retrospective cohort and the LEAPP cohort, there was a significant decrease in mean time from referral to index clinic visit (38.6 vs 9.5 days, P < .001), increase in outpatient podiatry follow‐up (33% vs 76%, P < .001), decrease in 1‐year minor amputation rate (14% vs 3%, P = .007), and decrease in 1‐year major amputation rate (9% vs 3%, P = .05). Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86m (SGD $2.5m) for patients within the LEAPP cohort. In conclusion, similar to the data from Western societies, an MDT approach in an Asian population, via a LEAPP for patients with DFU, demonstrated a significant reduction in minor and major amputation rates, with annualised cost avoidance of USD $1.86m.

Abstract 16784: Under-Enrollment of Real-World Heart Failure With Preserved Ejection Fraction Patients in Major HFpEF Clinical Trials

Introduction: Inclusion criteria for enrollment in HFpEF clinical trials vary considerably and often exclude patients with co-morbidities such as obesity. We tested the hypotheses that: 1) a large number of patients with clinical and hemodynamic evidence of HFpEF are excluded from major HFpEF clinical trials; and 2) there is no difference in clinical outcomes between patients excluded versus those who met enrollment criteria by evaluating reasons for exclusion from HFpEF clinical trials and comparing clinical outcomes in a real-world HFpEF cohort. Methods: Patients referred to the Johns Hopkins HFpEF Clinic with clinical and hemodynamic evidence of HFpEF (pulmonary capillary wedge pressure [PCWP] ≥ 12 mmHg on a loop diuretic or PCWP ≥ 15 mmHg) were assessed for inclusion into 4 major HFpEF trials (TOPCAT, I-PRESERVE, PARAGON-HF, and RELAX). Cumulative hazard of HF hospitalization or death at 2 years from index clinic visit was compared between patients included and excluded by each trial. Results: Of 132 HFpEF patients, the median PCWP was 19 mmHg (IQR: 15-22 mmHg). Forty-four (33%) of patients met enrollment criteria for TOPCAT, 39 (29%) for I-PRESERVE, 21 (16%) for PARAGON-HF, and 50 (38%) for RELAX. The top 5 criteria that would have excluded patients included low natriuretic peptide level, obesity, elevated blood pressure, young age, and low hemoglobin (Figure 1A) . There was no difference in HF burden (hospitalizations, diuretic dosing, or NYHA class), or in clinical outcomes including HF hospitalization or death between patients who did or did not meet inclusion criteria for each clinical trial (Figure 1B ). Conclusion: We demonstrate that in a real-world cohort of hemodynamically-proven HFpEF few patients would have met criteria for enrollment in major HFpEF clinical trials, yet HF burden and outcomes were no different. Given the lack of proven therapies in HFpEF, consideration should be given to unifying and broadening enrollment criteria in HFpEF clinical trials.

Corticosteroid choice and clinical outcomes for asthma exacerbations in the primary care setting

Objective To evaluate clinical outcomes in young children with acute asthma exacerbations treated with prednisone/prednisolone versus dexamethasone in the primary care setting. Methods Retrospective cohort study of children ages 3-9 years with a primary care clinic visit for asthma and an associated oral corticosteroid (OCS) prescription fill in the Colorado All Payers Claim Database between 2/2013-3/2019. This was a secondary analysis of a dataset extracted to analyze risk of future development of asthma in younger children. The primary outcome was subsequent ED visit or hospital admission for asthma within 2-14 days after the index clinic visit. Demographics and asthma health services characteristics were assessed. Multivariable logistic regression was used to estimate the association between type of OCS prescription filled within 1 day of the index clinic visit and the primary outcome. Results There were 3236 index clinic visits for asthma for 1918 children during the study period. Sixty-two percent were male and 66% were 3-4 years old. Prednisone/prednisolone accounted for 84% of OCS prescriptions fills within 1 day of the index clinic visit. One percent visited the ED and 1% required hospital admission within 2-14 days. In multivariate analysis, there was no statistical association between type of OCS prescribed and the primary outcome (OR 0.82; 95% CI: 0.37-1.8). Conclusions There are no differences in clinical outcomes by type of OCS prescribed for acute asthma exacerbations in the primary care setting. Due to better adherence and side effect profile, primary care providers may consider to use dexamethasone as the preferred OCS.

Does Undergoing Outpatient Hand Surgery Lead to Prolonged Opioid Use? A Comparison of Surgical and Nonsurgical Patients.

Orthopedic surgical patients in general have been found to be at higher risk for developing opioid dependence in the postoperative period. However, there is conflicting evidence in the literature whether opioid exposure after hand surgery leads to prolonged use. In the absence of a nonoperative control group, it is not clear whether prolonged opioid use in hand surgical patients is related to undergoing a surgical intervention. The purpose of our study to compare opioid prescription fulfillment patterns in surgical and nonoperative patients in a hand surgery practice. We retrospectively compared 320 patients that underwent elbow, wrist, and hand surgery procedures with 741 nonoperative patients treated by 2 hand surgeons. The Pennsylvania Drug Monitoring Program (PDMP), a mandatory statewide database, was used to evaluate the primary outcomes of filling more than one opioid prescription and filling opioid prescriptions beyond 6 months of the index surgery or clinic visit. Bivariate and multivariable logistic regression analysis was performed using the following variables: surgery, prior benzodiazepine use, and prior opioid use. There was no difference in prior opioid use (15.2% vs 16.9%, P = .51) or prior benzodiazepine (10.4% vs 8.4%, P = .33) use between the nonoperative and operative groups. Patients that underwent surgery had a higher incidence of filling more than one opioid prescription (20.9% vs 8.8%, P < .001). However, continued opioid use was not statistically different between nonoperative and operative patients (2.8% vs 5%, P = .08). Bivariate analysis demonstrated that prior opioids (odds ratio [OR] = 12.94, P < .001) and prior benzodiazepines (OR = 1.95, P < .001) were significant independent risk factors for prolonged opioid use. Multivariable analysis demonstrated prior opioid use to be the only independent risk factor for prolonged opioid use (OR = 12.58, P < .001). Undergoing outpatient hand surgery do not appear to be an independent risk factor for filling opioid prescriptions beyond 6 months. Significant risk factors for prolonged opioid use include prior use of controlled substances, particularly prior opioid use.

Effect of a clinical evidence technology on patient skin disease outcomes in primary care: a cluster-randomized controlled trial.

ObjectiveProviders’ use of clinical evidence technologies (CETs) improves their diagnosis and treatment decisions. Despite these benefits, few studies have evaluated the impact of CETs on patient outcomes. The investigators evaluated the effect of one CET, VisualDx, on skin problem outcomes in primary care.MethodsA cluster-randomized controlled pragmatic trial was conducted in outpatient clinics at an academic medical center in the northeastern United States. Participants were primary care providers (PCPs) and their adult patients seen for skin problems. The intervention was VisualDx, as used by PCPs. Outcomes were patient-reported time from index clinic visit to problem resolution, and the number of follow-up visits to any provider for the same problem. PCPs who were randomly assigned to the intervention agreed to use VisualDx as their primary evidence source for skin problems. Control group PCPs agreed not to use VisualDx. Investigators collected outcome data from patients by phone at thirty-day intervals. Cox proportional hazards models assessed time to resolution. Wilcoxon-rank sum tests and logistic regression compared the need for return appointments.ResultsThirty-two PCPs and 433 patients participated. In proportional hazards modelling adjusted for provider clusters, the time from index visit to skin problem resolution was similar in both groups (hazard ratio=0.92; 95% confidence interval [CI]=0.70, 1.21; p=0.54). Patient follow-up appointments did not differ significantly between groups (odds ratio=1.26; CI=0.94, 1.70; p=0.29).ConclusionThis pragmatic trial tested the effectiveness of VisualDx on patient-reported skin disease outcomes in a generalizable clinical setting. There was no difference in skin problem resolution or number of follow-up visits when PCPs used VisualDx.

Clinical evaluation and surveillance imaging of children with myelomeningocele and shunted hydrocephalus: a follow-up study.

OBJECTIVEThe majority of children with myelomeningocele undergo implantation of CSF shunts. The efficacy of adding surveillance imaging to clinical evaluation during routine follow-up as a means to minimize the hazard associated with future shunt failure has not been thoroughly studied.METHODSA total of 300 spina bifida clinic visits during the calendar years between 2012 and 2016 were selected for this study (defined as the index clinic visit). Each index visit was preceded by a 6-month period during which no shunt evaluation of any kind was performed. At the index clinic visit, all patients were evaluated by a neurosurgeon. Seventy-four patients underwent previously scheduled surveillance CT or shunt series scans in addition to clinical evaluation (surveillance imaging group), and 226 patients did not undergo surveillance imaging (clinical evaluation group). Subsequent unexpected events, defined as emergency department visits, caregiver-requested clinic visits, and shunt revision surgeries were reviewed. The timing and likelihood of an unexpected event in each of the 2 groups were compared using Cox proportional hazard survival analysis. The rate of shunt revision surgery in the follow-up period as well as the associated outcomes and rate of complications were analyzed.RESULTSThe clinical characteristics of the 2 groups were similar. In the clinical evaluation group, 4 of 226 (1.8%) patients underwent shunt revision based on clinical findings during the index visit, compared to 8 of 74 (10.8%) patients in the surveillance imaging group who underwent shunt revision based on clinical and imaging findings at that visit (p < 0.05). In the subsequent follow-up period, there were 74 unexpected events resulting in 10 shunt revisions in the clinical evaluation group, for an event rate of 33% and operation rate of 13.5%. In the surveillance imaging group there were 23 unexpected events resulting in 2 shunt revisions, for an event rate of 34.8% and an operation rate of 8.7%; neither difference was statistically significant. The complication rate for shunt revision surgery was also not different between the groups.CONCLUSIONSObtaining predecided, routine surveillance imaging in children with myelomeningocele and shunted hydrocephalus resulted in more shunt revisions in asymptomatic patients. For patients who had negative results on surveillance imaging, the rate of shunt revision in the follow-up period was not significantly decreased compared to patients who underwent clinical examination only at the index visit.

What convinces parents of children with asthma to adhere to maintenance inhaled corticosteroids?

ABSTRACTBACKGROUND: Although daily inhaled corticosteroids (ICS) are the cornerstone of therapy, treatment adherence remains suboptimal in children with asthma.OBJECTIVE: We aimed to identify modifiable factors during the medical visit that may lead children and parents to adhere to prescribed ICS.METHODS: We conducted a cross-sectional mixed-method study including comprehensive qualitative interviews, with a pilot quantitative survey of 20–30 children with asthma and their parents followed in a tertiary care asthma clinic. Patients were eligible if they were aged 1–17 years, had a physician's diagnosis of asthma, had taken less than 7 days of ICS in the preceding month, and were prescribed maintenance daily ICS at the index clinic visit. Subjects were approached prior to the medical visit to ascertain their admissibility and were interviewed immediately after. The data collection including a semi-structured individual interview to assess intention, barriers and facilitators to adherence to daily ICS, followed a quantitative survey with several validated questionnaires to explore their feasibility of use to assess satisfaction with the medical visit, perception of medications, physician facilitation of parents' involvement, information exchange, shared decision-making and medication intake responsibility.RESULTS: Of the 24 adults who completed the qualitative, most (54%) were parents of preschoolers, and 21% and 25% were parents of children aged 6–8 years and 8 years and older, respectively. Six children (8 years or more) were interviewed: most were female (66%) with a median (25%, 75%) age was 12.5 (12, 14) years. All parents and children indicated that they intended to give the prescribed ICS daily as recommended. Yet, they reported that their intention to adhere to daily ICS depended on personal patient factors as well as medical visit-related factors. Personal patient factors centred around three categories: cognitive (knowledge, beliefs, fears), practical implementation, as well as motivation, attitude and preference. Medical-visit-related factors included 5 categories: the content discussed, objectivation of disease progression, conflict resolution techniques, communication techniques (e.g. communication aids and clear explanations) and trust in the physician as a professional. Several medical visit-related factors served as barriers or facilitators to enhance or overcome personal patient barriers. All parents answered the 4 questionnaires (P-MISS, PPICS, BMQ and SURE). A total of 87% (21) completed the P-MISS in its entirety and were included in the analysis. They were satisfied with the medical visit, the parent or child's proposed involvement and the information exchange, and reported no decisional conflict; however, participants' involvement in decision-making was rated as low.CONCLUSION: Participants' intention to adhere to daily ICS is centered on modifiable personal patient-related (e.g. cognitive, practice implementation, motivation) and medical visit-related factors, the latter often influencing the former. While patients arrive with a baggage of perceptions, motivations, attitudes and preferences, the medical visit appears as an important opportunity to positively influence the parent/child's intention to take daily ICS.PRACTICE IMPLICATION: The medical visit appears as a key opportunity for physicians to positively influence the patient's intention to take daily ICS, primarily by building patient trust as medical experts providing sufficient information, using good communication skills conflict and resolution techniques, and requesting lung function testing to objectivate disease progression.

Clinical decision support directed to primary care patients and providers reduces cardiovascular risk: a randomized trial.

To test the hypothesis that use of a clinical decision support (CDS) system in a primary care setting can reduce cardiovascular (CV) risk in patients. Twenty primary care clinics were randomly assigned to usual care (UC) or CDS. For CDS clinic patients identified algorithmically with high CV risk, rooming staff were prompted by the electronic health record (EHR) to print CDS that identified evidence-based treatment options for lipid, blood pressure, weight, tobacco, or aspirin management and prioritized them based on potential benefit to the patient. The intention-to-treat analysis included 7914 adults who met high CV risk criteria at an index clinic visit and had at least one post-index visit, accounted for clustering, and assessed impact on predicted annual rate of change in 10-year CV risk over a 14-month period. The CDS was printed at 75% of targeted visits, and providers reported 85% to 98% satisfaction with various aspects of the intervention. Predicted annual rate of change in absolute 10-year CV risk was significantly better in CDS clinics than in UC clinics (-0.59% vs. +1.66%, -2.24%; P < .001), with difference in 10-year CV risk at 12 months post-index favoring the CDS group (UC 24.4%, CDS 22.5%, P < .03). Deploying to both patients and providers within primary care visit workflow and limiting CDS display and print burden to two mouse clicks by rooming staff contributed to high CDS use rates and high provider satisfaction. This EHR-integrated, web-based outpatient CDS system significantly improved 10-year CV risk trajectory in targeted adults.

Impact of provision of time in therapeutic range value on anticoagulation management in atrial fibrillation patients on warfarin

IntroductionThe importance of time in therapeutic range (TTR) in patients prescribed warfarin therapy for stroke prevention in atrial fibrillation (AF) cannot be overemphasised.AimTo evaluate the impact of provision of TTR...

Elevated preoperative blood pressures in adult surgical patients are highly predictive of elevated home blood pressures

Blood pressure (BP) measurement during the presurgical assessment has been suggested as a way to improve longitudinal detection and treatment of hypertension. The relationship between BP measured during this assessment and home blood pressure (HBP), a better indicator of hypertension, is unknown. The purpose of the present study was to determine the positive predictive value of presurgical BP for predicting elevated HBP. We prospectively enrolled 200 patients at a presurgical evaluation clinic with clinic blood pressures (CBPs) ≥130/85 mm Hg, as measured using a previously validated automated upper-arm device (Welch Allyn Vital Sign Monitor 6000 Series), to undergo daily HBP monitoring (Omron Model BP742N) between the index clinic visit and their day of surgery. Elevated HBP was defined, per American Heart Association guidelines, as mean systolic HBP ≥135 mm Hg or mean diastolic HBP ≥85 mm Hg. Of the 200 participants, 188 (94%) returned their home blood pressure monitors with valid data. The median number of HBP recordings was 10 (interquartile range, 7–14). Presurgical CBP thresholds of 140/90, 150/95, and 160/100 mm Hg yielded positive predictive values (95% confidence interval) for elevated HBP of 84.1% (0.78–0.89), 87.5% (0.81–0.92), and 94.6% (0.87–0.99), respectively. In contrast, self-reported BP control, antihypertensive treatment, availability of primary care, and preoperative pain scores demonstrated poor agreement with elevated HBP. Elevated preoperative CBP is highly predictive of longitudinally elevated HBP. BP measurement during presurgical assessment may provide a way to improve longitudinal detection and treatment of hypertension.

Impact of an Electronic Pain and Opioid Risk Assessment Program: Are There Improvements in Patient Encounters and Clinic Notes?

A comprehensive electronic self-report assessment, called PainCAS® (Clinical Assessment System), was developed and implemented in three clinics. PainCAS captures demographic information, pain assessment, quality-of-life variables, and contains validated, electronic versions of screeners for risk of aberrant opioid-related behaviors (the SOAPP and COMM). This investigation sought to determine the impact of PainCAS on documentation of pain and opioid risk evaluations. Exploratory hypotheses examined changes in the content of the patient-provider interaction and any impact on outcome. In study 1, chart reviews were conducted between pain patients who completed the electronic program (N = 89) and controls who represented standard of care (N = 120). In study 2, two groups of chronic pain patients (treatment-as-usual Control condition = 75, PainCAS Experimental condition = 72) were interviewed after completing their index clinic visit and completed mailed questionnaires 3 months later. Results revealed significantly more key, pain-relevant chart elements documented in charts of patients who completed the PainCAS than those using a traditional paper questionnaire (Study 1; <0.001). In Study 2, the Experimental group reported more discussion about legal issues, substance use history, and medication safety compared with the Control group (p < 0.05). Satisfaction questionnaire responses supported provider and patient perceived benefit from using PainCAS. However, as expected, no differences were found between conditions on outcome measures of pain, mood, and function. Results indicate that use of the PainCAS electronic pain assessment improves documentation of chart elements in clinic notes and is associated with increased discussion of key, pain-relevant topics during the clinical visit.

A primary care, electronic health record-based strategy to promote safe drug use: study protocol for a randomized controlled trial.

BackgroundThe Northwestern University Center for Education and Research on Therapeutics (CERT), funded by the Agency for Healthcare Research and Quality, is one of seven such centers in the USA. The thematic focus of the Northwestern CERT is ‘Tools for Optimizing Medication Safety.’ Ensuring drug safety is essential, as many adults struggle to take medications, with estimates indicating that only half of adults take drugs as prescribed. This report describes the methods and rationale for one innovative project within the CERT: the ‘Primary Care, Electronic Health Record-Based Strategy to Promote Safe and Appropriate Drug Use’.Methods/DesignThe overall objective of this 5-year study is to evaluate a health literacy-informed, electronic health record-based strategy for promoting safe and effective prescription medication use in a primary care setting. A total of 600 English and Spanish-speaking patients with diabetes will be consecutively recruited to participate in the study. Patients will be randomized to receive either usual care or the intervention; those in the intervention arm will receive a set of print materials designed to support medication use and prompt provider counseling and medication reconciliation. Participants will be interviewed in person after their index clinic visit and again one month later. Process outcomes related to intervention delivery will be recorded. A medical chart review will be performed at 6 months. Patient outcome measures include medication understanding, adherence and clinical measures (hemoglobin A1c, blood pressure, and cholesterol; exploratory outcomes only).DiscussionThrough this study, we will be able to examine the impact of a health literacy-informed, electronic health record-based strategy on medication understanding and adherence among diabetic primary care patients. The measurement of process outcomes will help inform how the strategy might ultimately be refined and disseminated to other sites. Strategies such as these are needed to address the multifaceted challenges related to medication self-management among patients with chronic conditions.Trial registrationClinicaltrials.gov NCT01669473.

Relationship between social cognitive theory constructs and self-reported condom use: assessment of behaviour in a subgroup of the Safe in the City trial

ObjectivesPrevious studies have found social cognitive theory (SCT)-framed interventions are successful for improving condom use and reducing sexually transmitted infections (STIs). We conducted a secondary analysis of behavioural data from...

Association of Patient Recall, Satisfaction, and Adherence to Content of an Electronic Health Record (EHR)-Generated After Visit Summary: A Randomized Clinical Trial

Most electronic health record (EHR) systems have the capability of generating a printed after-visit summary (AVS), but there has been little research on optimal content. We conducted a qualitative study and a randomized trial to understand the effect of AVS content on patient recall and satisfaction. Adult primary care patients (n = 272) with at least 1 chronic condition were randomly assigned to 4 AVS content conditions: minimum, intermediate, maximum, or standard AVS. Demographics and health literacy were measured at an index clinic visit. Recall and satisfaction were measured by telephone 2 days and 2 to 3 weeks after the clinic visit. Average age was 52 years; 75% of patients were female, 61% were Hispanic, and 21% were African American, and 64% had adequate health literacy. Average medication recall accuracy was 53% at 2 days and 52% at 3 weeks, with no significant difference among groups at either time. Satisfaction with AVS content was high and did not differ among groups. Recall of specific content categories was low and unrelated to group assignment. Health literacy was unrelated to recall and satisfaction. Primary care patients like to receive an AVS, but the amount of information included does not affect content recall or satisfaction with the information.

The Association of Clinical Follow-Up Intervals in HIV-Infected Persons with Viral Suppression on Subsequent Viral Suppression

The recommendation for the frequency for routine clinical monitoring of persons with well-controlled HIV infection is based on evidence that relies on observed rather than intended follow-up intervals. We sought to determine if the scheduled follow-up interval is associated with subsequent virologic failure. Participants in this 6-clinic retrospective cohort study had an index clinic visit in 2008 and HIV viral load (VL) ≤400 c/mL. Univariate and multivariate tests evaluated if scheduling the next follow-up appointment at 3, 4, or 6 months predicted VL >400 c/mL at 12 months (VF). Among 2171 participants, 66%, 26%, and 8% were scheduled next follow-up visits at 3, 4, and 6 months, respectively. With missing 12-month VL considered VF, 25%, 25%, and 24% of persons scheduled at 3, 4, and 6 months had VF, respectively (p=0.95). Excluding persons with missing 12-month VL, 7.1%, 5.7%, and 4.5% had VF, respectively (p=0.35). Multivariable models yielded nonsignificant odds of VF by scheduled follow-up interval both when missing 12-month VL were considered VF and when persons with missing 12-month VL were excluded. We conclude that clinicians are able to make safe decisions extending follow-up intervals in persons with viral suppression, at least in the short-term.