Upcoming Appointment Research Articles

Use of the Electronic Health Record to Improve Nursing Chart Preparation.

In a medical specialty clinic located in a rural community, a nursing team identified an opportunity to decrease the time nursing staff spent preparing charts for patients' upcoming clinical appointments. In collaboration with an informaticist, the nursing project team implemented a quality improvement project with a target goal of decreasing the average time spent preparing charts per patient by 20%, without increasing the number of discrepancies in the chart preparation process. The team used the define, measure, analyze, improve, and control framework to identify two interventions that could decrease time for chart preparation. A standardized chart preparation process was developed, and a condensed nursing view was created within the electronic health record. After the quality improvement project, the average time nurses spent on chart preparation per patient decreased by 18% after the standardized process and 16% after the condensed view was implemented.

Abstract 16069: Patient Education and Medication Checklists for Optimization of Guideline-Directed Medical Therapy

Introduction: Despite strong evidence on the benefits of guideline-directed medical therapies (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), the use of GDMT remains suboptimal in clinical practice. Hypothesis: We hypothesized that patient educational videos, coupled with an interactive medication checklist provided to patients, would improve prescription of GDMT in outpatient cardiology clinics. Methods: Patients over the age of 18 years with a diagnosis of HFrEF and a cardiology clinic appointment during the study period were included. Electronic health record communications were sent to patients the week prior to their scheduled cardiology appointments. The communication included (1) short videos on GDMT and (2) a medication checklist to be completed by the patient and brought to their upcoming appointment. The primary outcomes were initiation and uptitration of GDMT. Results: A total of 253 patients (mean age 67 +/- 14 years) were included, of which 69% were male, 10% black, and 11% Hispanic. At baseline, 86% of patients were on an evidence-based beta-blocker, but only 17% were at goal doses (Figure). Additionally, only half of eligible patients were on a mineralocorticoid receptor antagonist (MRA) or sodium-glucose cotransporter-2 inhibitor (SGLT2i). Post-intervention, there was a significant increase in the number of patients on a renin-angiotensin-aldosterone inhibitor (75.9% to 78.3%, p=0.04) and SGLT2i (50.2% to 52.7%, p=0.04). There was also a 0.8% increase in the number of patients on target doses of MRAs, although this did not reach statistical significance. Conclusions: Educational materials and checklists provided to patients prior to clinic appointments were associated with improved initiation and uptitration of GDMT. This intervention may be a scalable and low-cost way of engaging patients in their medical care and encouraging shared decision making, although further study is needed.

EHR-based process to reduce no-shows at the outpatient supportive care clinic at a tertiary cancer center.

263 Background: No-Shows are pervasive across healthcare systems and are associated with interrupted clinical workflows, increased cost, healthcare utilization, and increased morbidity, and mortality. In palliative care, patients who miss their appointments are more likely to have uncontrolled symptoms, frequent Emergency Room visits, and unplanned hospitalization. There is an ongoing need to reduce no-shows to improve patient outcomes. Methods: The aim of this quality improvement (QI) project, launched in September 2022 at the outpatient supportive care center (SCC) at the University of Texas MD Anderson Cancer Center, was to reduce overall no-shows by process improvement in the targeted areas. We developed a process map and Ishikawa diagram to outline workflow and reasons for no-shows. Based on the results of a previous study from our center, 8% of no-shows were due to hospitalization. We used the Plan Do Study Act (PDSA) tool. We developed an electronic query for the Electronic Health Record (EHR) to identify hospitalized patients with an upcoming appointment at SCC in the next 10 days. We redesigned the clinical workflow to generate a daily list of such appointments which were canceled and replaced by patients on the waitlist. We assessed overall no-show rate and rate specific to hospitalizations for our center monthly for eight months. This QI project was approved by the Quality Improvement Assurance Board at the University of Texas MD Anderson Cancer Center. Results: Overall no-show rate was 12% before intervention (BI) and decreased to 8% after intervention (AI), measured at 8 months. No-show rate due to hospitalizations decreased from 9% BI to 2% AI. Telehealth visits had a lower rate of no-shows (5.9%) than in person visits (10.4%). No-show rates did not differ based on days of the week (median 7.4%, SD 0.3%), and the type of visit - consult vs. follow-up (8% vs. 7%). Conclusions: Clinical workflow redesign using EHR at our SCC decreased no-shows due to hospitalization, thereby reducing overall no-show rate by 33% of the original. However, most no-shows are due to reasons other than hospital stays, and more research is needed to identify these patient and system level factors.

Implementing Shared Decision-Making for Multiple Sclerosis: The MS-SUPPORT Tool

BackgroundDisease modifying therapies (DMTs) offer opportunities to improve the course of multiple sclerosis (MS), but decisions about treatment are difficult. People with multiple sclerosis (pwMS) want more involvement in decisions about DMTs, but new approaches are needed to support shared decision-making (SDM) because of the number of treatment options and the range of outcomes affected by treatment. We designed a patient-centered tool, MS-SUPPORT, to facilitate SDM for pwMS. We sought to evaluate the feasibility and impact of MS-SUPPORT on decisions about disease modifying treatments (DMTs), SDM processes, and quality-of-life. MethodsThis multisite randomized controlled trial compared the SDM intervention (MS-SUPPORT) to control (usual care) over a 12-month period. English-speaking adults with relapsing MS were eligible if they had an upcoming MS appointment and an email address. To evaluate clinician perspectives, participants’ MS clinicians were invited to participate. Patients were referred between November 11, 2019 and October 23, 2020 by their MS clinician or a patient advocacy organization (the Multiple Sclerosis Association of America). MS-SUPPORT is an online, interactive, evidence-based decision aid that was co-created with pwMS. It clarifies patient treatment goals and values and provides tailored information about MS, DMTs, and adherence. Viewed by patients before their clinic appointment, MS-SUPPORT generates a personalized summary of the patient's treatment goals and preferences, adherence, DMT use, and clinical situation to share with their MS clinician. Outcomes (DMT utilization, adherence, quality-of-life, and SDM) were assessed at enrollment, post-MS-SUPPORT, post-appointment, and quarterly for 1 year. ResultsParticipants included 501 adults with MS from across the USA (84.6% female, 83% white) and 34 of their MS clinicians (47% neurologists, 41% Nurse Practitioners, 12% Physician Assistants). Among the 203 patients who completed MS-SUPPORT, most (88.2%) reported they would recommend it to others and that it helped them talk to their doctor (85.2%), understand their options (82.3%) and the importance of taking DMTs as prescribed (82.3%). Among non-users of DMTs at baseline, the probability ratio of current DMT use consistently trended higher over one-year follow-up in the MS-SUPPORT group (1.30 [0.86-1.96]), as did the cumulative probability of starting a DMT within 6-months, with shorter time-to-start (46 vs 90 days, p=0.24). Among the 222 responses from 34 participating clinicians, more clinicians in the MS-SUPPORT group (vs control) trended towards recommending their patient start a DMT (9 of 108 (8%) vs 5 of 109 (5%), respectively, p=0.26). Adherence (no missed doses) to daily-dosed DMTs was higher in the MS-SUPPORT group (81.25% vs 56.41%, p=.026). Fewer patients forgot their doses (p=.046). The MS-SUPPORT group (vs control) reported 1.7 fewer days/month of poor mental health (p=0.02). ConclusionsMS-SUPPORT was strongly endorsed by patients and is feasible to use in clinical settings. MS-SUPPORT increased the short-term probability of taking and adhering to a DMT, and improved long-term mental health. Study limitations include selection bias, response bias, social desirability bias, and recall bias. Exploring approaches to reinforcement and monitoring its implementation in real-world settings should provide further insights into the value and utility of this new SDM tool.

Intraday dynamic rescheduling under patient no-shows.

Patient no-shows are a major source of uncertainty for outpatient clinics. A common approach to hedge against the effect of no-shows is to overbook. The trade-off between patient's waiting costs and provider idling/overtime costs determines the optimal level of overbooking. Existing work on appointment scheduling assumes that appointment times cannot be updated once they have been assigned. However, advances in communication technology and the adoption of online (as opposed to in-person) appointments make it possible for appointments to be flexible. In this paper, we describe an intraday dynamic rescheduling model that adjusts upcoming appointments based on observed no-shows. We formulate the problem as a Markov Decision Process in order to compute the optimal pre-day schedule and the optimal policy to update the schedule for every scenario of no-shows. We also propose an alternative formulation based on the idea of 'atomic' actions that allows us to apply a shortest path algorithm to solve for the optimal policy more efficiently. Based on a numerical study using parameter estimates from existing literature, we find that intraday dynamic rescheduling can reduce expected cost by 15% compared to static scheduling.

Optimizing the social engagement of persons with mild cognitive impairment: insight from a process evaluation of an empowerment‐based psycho‐behavioral program

AbstractBackgroundEnhancing social engagement has been suggested as a promising approach to enhance the quality of life and prevent the progression to dementia among older adults with mild cognitive impairment (MCI). However, their cognitive deficits and the concomitant neuropsychiatric symptoms, particularly depression and apathy, may not only mass their incompetency and inadequacy to engage in social events, but also lead to withdrawal from leisure activities and social interaction. Therefore, a randomized controlled trial of an empowerment‐based psycho‐behavioral program was conducted among persons with MCI, and its process evaluation may provide insight into optimizing social engagement among this preclinical cohort.MethodA qualitative process evaluation was conducted for a 13‐week, group‐based, psycho‐behavioral program focused on promoting knowledge enhancement, cognitive coping, and stress adaptation among persons with MCI and was guided by empowerment model through a goal‐setting approach. A purposive sample of 22 participants who reported differential changes on NPS after completing the program attended an individual, semi‐structured, face‐to‐face interview from December 2020 to October 2021. A semi‐structured interview guide was developed to elicit their views on the engagement experience and perceived effects of the program. All interviews were audio‐taped, transcribed verbatim, and analyzed by thematic analysis.ResultThree themes emerged: (1) barriers to social engagement, (2) environmental factors to increase social engagement, and (3) psychosocial context to increase social engagement. The participants identified fear of social rejection, lack of available social activities, and perceived difficulties in keeping appointments as barriers to social engagement. As supported by the empowering environment of the program, the participants received a clear roadmap and protocol to overcome their cognitive deficits and enhance their participation in social activities. The memory aids provided by the program, such as whiteboards and memos, were highly useful in tracking upcoming appointments and social events. The program also offered them a platform to develop new friendships and interact with peers facing similar challenges.ConclusionThis study highlighted the effects of a psycho‐behavioral program on improving cognitive and psycho‐social well‐being among persons with MCI. The findings also underscored the potential of the empowerment approach to optimize cognitive coping and social engagement in this preclinical cohort.

Neonatal Outcomes Associated With Personalized Text Messages for Diabetes Self-Management in Pregnancy [ID: 1373396

INTRODUCTION: The objective was to determine whether providing individualized text messages regarding diabetes management improved compliance with care and pregnancy outcomes. METHODS: Institutional review board committee approval was obtained for the study. Pregnant women with type 2 (T2) and gestational diabetes (GDM) were randomized into two groups. The “contact-control” group was enrolled in the Text4baby program, which provides nonpersonalized educational text messages throughout pregnancy. The intervention group (Text4diabetes) received individualized text messages regarding upcoming appointments, current insulin regimen, and encouragement to keep and submit glucose logs for review. The primary outcome is compliance (data not yet analyzed). This analysis assesses neonatal outcomes, including perinatal loss (>24 weeks), delivery gestational age (GA), arterial cord pH less than 7.1, 5-minute Apgar less than 7, large-for-gestational-age (LGA) status, need for glucose supplementation, intubation, and surfactant administration. RESULTS: One hundred forty-four women with T2 or GDM were randomized. Both groups had similar numbers of women with T2 diabetes (33% and 31%) and history of GDM in prior pregnancy (21% and 19%). The Text4diabetes group had fewer deliveries less than 35 weeks, fewer LGA infants, and fewer surfactant administrations. A composite of adverse neonatal outcomes, including LGA status, delivery less than 35 weeks GA, arterial cord pH less than 7.1, and need for surfactant administration, showed fewer adverse outcomes in the Text4diabetes group. No findings, however, reached statistical significance. CONCLUSION: Text messages aimed at improving compliance with diabetes care in pregnancy did not significantly affect neonatal outcomes. Correlation with compliance results is needed to see whether improved compliance improved neonatal outcomes.

Online Dental Appointment Booking System

In today’s fast-paced world, patients are seeking more efficient and convenient ways to schedule appointments with healthcare providers. With the increasing demand for convenient and efficient healthcare services, online appointment booking systems have become essential for dental practices. In response to this need, we have designed and implemented an online dental appointment website using ASP .Net and SQL Server. This paper discusses the features of online appointment booking systems, how they can enhance the overall experience for patients and dental clinics, and the website's design and implementation, including the database schema, user interface, and server-side scripting. The website allows patients to schedule appointments, view their appointment history, view and download their medical reports and update their personal information. Dentists can view their upcoming appointments, update their schedules, generate the patient’s medical reports and manage their patient database. Key Word: Online Dental Booking, Managing schedules, Download the reports, Sql Server.

Creating a Guardrail System to Ensure Appropriate Activation of Adolescent Portal Accounts.

The parent of an adolescent patient noticed an upcoming appointment in the patient's portal account that should have remained confidential to the parent. As it turned out, this parent was directly accessing their child's adolescent patient portal account instead of using a proxy account. After investigation of this case, it was found that the adolescent account had been activated with the parent's demographic (i.e., phone/email) information. This case illustrates the challenges of using adult-centric electronic health record (EHR) systems and how our institution addressed the problem of incorrect portal account activations.Confidentiality is fundamental to providing healthcare to adolescents. To comply with the 21st Century Cures Act's information blocking rules, confidential information must be released to adolescent patients when appropriate while also remaining confidential from their guardians. While complying with this national standard, systems of care must also account for interstate variability in which services allow for confidential adolescent consent. Unfortunately, there are high rates of guardian access to adolescent portal accounts which may lead to unintended disclosure of confidential information. Therefore, measures must be taken to minimize the risk of inadvertent confidentiality breaches via adolescent patient portals.Our institution implemented a guardrail system that checks the adolescent patient's contact information against the contact information of their parent/guardian/guarantor. This guardrail reduced the rate of account activation errors after implementation. However, the guardrail can be bypassed when demographic fields are missing. Thus, ongoing efforts to create pediatric-appropriate demographic fields, clearly distinguishing patient from proxy, in the EHR and workflows for registration of proxy accounts in the patient portal are needed.

Implementation-effectiveness trial of systematic family health history based risk assessment and impact on clinical disease prevention and surveillance activities

BackgroundSystematically assessing disease risk can improve population health by identifying those eligible for enhanced prevention/screening strategies. This study aims to determine the clinical impact of a systematic risk assessment in diverse primary care populations.MethodsHybrid implementation-effectiveness trial of a family health history-based health risk assessment (HRA) tied to risk-based guideline recommendations enrolling from 2014–2017 with 12 months of post-intervention survey data and 24 months of electronic medical record (EMR) data capture. Setting:19 primary care clinics at four geographically and culturally diverse U.S. healthcare systems. Participants: any English or Spanish-speaking adult with an upcoming appointment at an enrolling clinic. Methods: A personal and family health history based HRA with integrated guideline-based clinical decision support (CDS) was completed by each participant prior to their appointment. Risk reports were provided to patients and providers to discuss at their clinical encounter. Outcomes: provider and patient discussion and provider uptake (i.e. ordering) and patient uptake (i.e. recommendation completion) of CDS recommendations. Measures: patient and provider surveys and EMR data.ResultsOne thousand eight hundred twenty nine participants (mean age 56.2 [SD13.9], 69.6% female) completed the HRA and had EMR data available for analysis. 762 (41.6%) received a recommendation (29.7% for genetic counseling (GC); 15.2% for enhanced breast/colon cancer screening). Those with recommendations frequently discussed disease risk with their provider (8.7%-38.2% varied by recommendation, p-values ≤ 0.004). In the GC subgroup, provider discussions increased referrals to counseling (44.4% with vs. 5.9% without, P < 0.001). Recommendation uptake was highest for colon cancer screening (provider = 67.9%; patient = 86.8%) and lowest for breast cancer chemoprevention (0%).ConclusionsSystematic health risk assessment revealed that almost half the population were at increased disease risk based on guidelines. Risk identification resulted in shared discussions between participants and providers but variable clinical action uptake depending upon the recommendation. Understanding the barriers and facilitators to uptake by both patients and providers will be essential for optimizing HRA tools and achieving their promise of improving population health.Trial registrationClinicaltrials.gov number NCT01956773, registered 10/8/2013.

Feasibility, acceptability, and limited efficacy of health system-led familial risk notification: protocol for a mixed-methods evaluation

BackgroundGenetic testing for pathogenic variants associated with hereditary breast and ovarian cancer risk can improve cancer outcomes through enhanced preventive care in both people with known variants and their biologic relatives. Cascade screening—the process of case-finding in relatives by notifying and inviting them to consider testing—currently relies on the patient to notify their own at-risk relatives. However, many of these relatives never learn they might be at risk. We developed and implemented a new health system-led familial genetic risk notification process where the care team offers to contact at-risk relatives directly. This protocol describes a study to assess the feasibility, acceptability, and limited efficacy of this intervention.MethodsThis feasibility study will use a single-arm, nonrandomized, mixed-methods prospective design.We will enroll two groups of participants: probands and relatives of probands. Eligible probands are currently enrolled Kaiser Permanente Washington (KPWA) members with an upcoming appointment for pre-test genetic counseling for hereditary Lynch syndrome, breast, or ovarian cancer. Eligible relatives, who do not have to be KPWA members, are first-and second-degree relatives of probands. During the appointment with the proband, the genetic counselor will determine whether the proband is appropriate for genetic testing and if so, which relatives might benefit from cascade testing. The genetic counselor then will offer to contact any or all identified relatives directly to discuss genetic risk and testing. The primary outcome of this study is the feasibility of the implemented familial notification process, which we will measure using quantitative and qualitative data on intervention reach, intervention acceptability, and limited efficacy. Analyses will be primarily descriptive and exploratory, with the intent of preparing for a future, larger trial of direct contact interventions.DiscussionOur findings will provide new, foundational evidence for the creation of US-based familial notification systems that directly address logistical and ethical challenges while prioritizing the preferences of patients and families.

Remote genetic counselling provision for heart failure patients at a UK transplant centre

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiomyopathy has been highlighted as one of the key drivers of heart failure, particularly dilated cardiomyopathy (DCM) (5,1). Finding the correct diagnosis for patients is not only important to their health, but to that of their family members (2). European guidelines recommend genetic counselling and testing for all patients with a cardiomyopathy diagnosis (3). Genetic counselling involves communicating complex information and providing support to patients and families with inherited conditions. It is recommended that patients undergo genetic counselling alongside genetic testing (6). Purpose historically, the heart failure team had no formal pathway in place for genetic testing. We set to establish a remote provision for genetic counselling and testing. We hoped to increase access to genetic services, without additional trips to the hospital in this already burdened patient group. Methods A genetic counsellor (GC) attended the weekly team meeting to raise awareness of the genetic service and help identify eligible patients. Eligibility was determined using criteria from the national genomic test directory (4). Eligible patients had appointments via video or phone call. Outpatients who consented to genetic testing had blood samples arranged locally or at an upcoming hospital appointment. Inpatients had blood samples taken during their hospital stay. Forty-one eligible patients were identified, the majority had DCM (n=40) and one had arrhythmogenic right ventricular cardiomyopathy (ARVC). Genetic testing was performed using a diagnostic DCM or ARVC panel. Results were classified as positive, i.e. pathogenic or likely pathogenic variant identified; negative, i.e. no pathogenic variant identified; or inconclusive, i.e. variant of unknown significance identified. Results were fed back to patients by virtual genetic counselling appointment. GCs facilitated screening of family members as appropriate. Results In the period, July 2020 to January 2022, 41 patients attended virtual genetic counselling appointments and consented to genetic testing. Of these, 19 received a positive genetic result, 4 an inconclusive result, and 18 a negative result. The majority of positive results were identified in the TTN gene (n=9) (see Figure 1). To date, six family members have been identified as gene positive and requiring ongoing screening, whilst six have now been discharged on the basis of a gene negative result. These are preliminary figures and expected to grow as more family members are able to access genetic counselling Conclusion Heart failure patients represent an underserved population who may benefit from genetic testing alongside genetic counselling. Remote genetic counselling is an effective service delivery model. A significant proportion of patients (46.3%) received a positive genetic result. This has potential benefits, not only to the patient but to family members.

Targeted Electronic Patient Portal Messaging Increases Hepatitis C Virus Screening in Primary Care: a Randomized Study.

Electronic health record (EHR) tools such as direct-to-patient messaging and automated lab orders are effective at improving uptake of preventive health measures. It is unknown if patient engagement in primary care impacts efficacy of such messaging. To determine whether more engaged patients, defined as those who have an upcoming visit scheduled, are more likely to respond to a direct-to-patient message with an automated lab order for hepatitis C virus (HCV) screening. Randomized trial PARTICIPANTS: One thousand six hundred randomly selected Stanford Primary Care patients, 800 with an upcoming visit within 6 months and 800 without, born between 1945 and 1965 who were due for HCV screening. Each group was randomly divided into cohorts of 400 subjects each. Subjects were followed for 1 year. One 400 subject cohort in each group received a direct-to-patient message through the EHR portal with HCV antibody lab order. The EHR was queried on a monthly basis for 6 months after the intervention to monitor which subjects completed HCV screening. For any subjects screened positive for HCV, follow-up through the cascade of HCV care was monitored, and if needed, scheduled by the study team. Of 1600 subjects, 538 (34%) completed HCV screening. In the stratum without an upcoming appointment, 18% in the control group completed screening compared to 26% in intervention group (p<0.01). Similarly, in the stratum with an upcoming appointment, 34% in the control group completed screening compared to 58% in the intervention group (p<0.01). Direct-to-patient messaging coupled with automated lab orders improved HCV screening rates compared to standard of care, particularly in more engaged patients. Including this intervention in primary care can maximize screening with each visit, which is particularly valuable in times when physical throughput in the healthcare system may be low.

Do Hispanic Patients Who Require a Medical Interpreter Understand the Severity of Their Glaucoma Diagnosis?

Background and Hypothesis: Glaucoma is a group of progressive optic neuropathies characterized by a degeneration of retinal ganglion cells with characteristic changes in the visual field. The Los Angeles Latino Eye Study (LALES) is the largest and most recent study to determine the prevalence of open-angle glaucoma in Hispanics; reported at nearly 5%. Between 2010 – 2019, Hispanic patients accounted for more than half of the United States population growth, reaching a record of 60.6 million Hispanics living in the United States. With an influx of Hispanic’s migrating to the United States, there is an increased need for medical interpreters to assist medical professionals in encounters with Hispanic patients. The success of a medical encounter relies on a multitude of factors, but when a medical interpreter is involved, the stakes are even higher. We hypothesize that Hispanic speaking patients will have lower rates of understanding their glaucoma diagnosis and severity, in comparison to English speaking patients due to gaps in translation provided by medical interpreters. &#x0D; Project Methods: Native Spanish and native English-speaking patients from the Eskenazi Health Eye Clinic were recruited via phone, reminding them of their upcoming eye appointment and their eligibility to participate in the study. Interested patients were provided with information regarding the study and consent materials at the start of the medical encounter. Participants who consented were administered the survey at the end of their medical encounter, in their preferred language, in person, at the clinic. &#x0D; Results: This is an ongoing prospective study. &#x0D; Potential Impact: This study will determine if medical interpreters successfully relay all the necessary information regarding a Hispanic patient’s glaucoma diagnosis. This study could also provide a partial explanation as to why there is a high no show rate and high medication noncompliance rate within the Eskenazi Health Eye Clinic Hispanic population.

Abstract 13155: Validation of a Decision Aid for Familial Hypercholesterolemia

Introduction: We validated the “Familial Hypercholesterolemia (FH) Decision Aid” to promote shared decision making (SDM) about lipid lowering therapy, based on patient-clinician encounters. Methods: Validation of the DA included an assessment of whether the content and design of the tool facilitated SDM and patient engagement and to determine how well the tool integrated with clinical workflow. Validation was conducted during patient-clinician encounters in the Mayo preventive cardiology clinic. As inclusion criteria we considered an upcoming appointment in the clinic, an LDL-C level ≥ ~160 mg/dL, and no prior diagnosis of FH. Prior to the encounters, each clinician viewed a demonstration of the online, interactive DA. During the encounters, the DA was shared with patients using the clinic room computer screen, either in-person or virtually. Patient-clinician encounters were video recorded for further analysis by two design researchers and experts in SDM. Results: Ten patients were enrolled in the study (7 male; average age 51 years). The average patient LDL-C level was 207 mg/dL, range 157 - 248 mg/dL. Review and qualitative analysis of the encounter recordings yielded 4 key findings: i) clinicians primarily used the cardiovascular risk estimate in the DA to guide conversation with patients; ii) highly trained specialists needed to change their usual approach to care and conversation to integrate the DA with their clinical workflows; iii) as clinicians became more familiar with the DA, they moved through the tool at a more efficient pace; and iv) each clinician developed his/her own style of navigating the DA, either moving through it one screen at a time or focusing on one specific section for the duration of the conversation. The DA effectively guided conversation and facilitated active patient engagement in 6 of 10 encounters. Social distancing and use of telemedicine encounters, due to the COVID-19 pandemic, limited patient engagement in 2 of 10 encounters. Overall, the DA promoted SDM regarding FH management in 9 of 10 encounters. Conclusion: Using patient-clinician encounters, we found the FH DA to facilitate SDM regarding lipid-lowering therapy. The tool has potential to improve care of FH patients and increase patient engagement and knowledge.

Improving Patient Outreach by Defining Telehealth Suitability in a Tertiary Huntington's Disease Clinic.

The COVID-19 pandemic has increased the need for remote healthcare options among patients with Huntington's disease (HD). However, since not every HD patient is suitable for telehealth, it is important to differentiate who can be seen virtually from who should remain as in-person. Unfortunately, there are no clinical guidelines on how to evaluate HD patients for telehealth eligibility. To standardize the teleneurology selection process in HD by implementing a screening tool that accounts for patient-specific factors. We organized various indications and contraindications to teleneurology into a flowchart. If any indications or contraindications were met, patients were assigned to telehealth or maintained as in-person, respectively. If no indications or contraindications were met, patients were given the option of telehealth or in-person for their upcoming appointments. In two implementation cycles, we tested this screening tool among all HD patients scheduled for clinic visits, aided by chart review and phone interview. In a cohort of 81 patients, telehealth acceptance among eligible patients increased from 45.0%to 83.3%. Frequency of telehealth visits increased from a pre-intervention baseline of 12.8%to 28.2%. Teleneurology utilization among HD patients more than doubled across our study. Our intervention promotes consistency and patient-centeredness in HD clinical care and streamlines the overall telehealth selection process. Future studies can seek to reduce telehealth no-shows and also evaluate the utility of the motor and psychiatric criteria included in our screening tool.

Preparing Patients with Early Stage Prostate Cancer to Participate in Clinical Appointments Using a Shared Decision Making Training Video.

BackgroundRates of shared decision making (SDM) are relatively low in early stage prostate cancer decisions, as patients’ values are not well integrated into a preference-sensitive treatment decision. The study objectives were to develop a SDM training video, measure usability and satisfaction, and determine the effect of the intervention on preparing patients to participate in clinical appointments.MethodsA randomized controlled trial was conducted to compare a plain-language decision aid (DA) to the DA plus a patient SDM training video. Patients with early stage prostate cancer completed survey measures at baseline and after reviewing the intervention materials. Survey items assessed patients’ knowledge, beliefs related to SDM, and perceived readiness/intention to participate in their upcoming clinical appointment.ResultsOf those randomized to the DA + SDM video group, most participants (91%) watched the video and 93% would recommend the video to others. Participants in the DA + SDM video group, compared to the DA-only group, reported an increased desire to participate in the decision (mean = 3.65 v. 3.39, P < 0.001), less decision urgency (mean = 2.82 v. 3.39, P < 0.001), and improved self-efficacy for communicating with physicians (mean = 4.69 v. 4.50, P = 0.05). These participants also reported increased intentions to seek a referral from a radiation oncologist (73% v. 51%, P = 0.004), to take notes (mean = 3.23 v. 2.86, P = 0.004), and to record their upcoming appointments (mean = 1.79 v. 1.43, P = 0.008).ConclusionsA novel SDM training video was accepted by patients and changed several measures associated with SDM. This may be a scalable, cost-effective way to prepare patients with early stage prostate cancer to participate in their clinical appointments.HighlightsThis study describes the development of a novel shared decision making training video, which was found to be well received and highly used by patients.The shared decision making video combined with a decision aid was more effective at improving several measures of shared decision making outcomes (e.g., increased desire to participate, self-efficacy) compared to receipt of the decision aid alone.Videos may be an ideal low-resource format to deliver shared decision making training to patients facing preference-sensitive decisions.

Early objective adherence to hypoglossal nerve stimulation therapy.

To assess early adherence to therapy with hypoglossal nerve stimulation therapy. This is a prospective study of consecutive patients with moderate to severe obstructive sleep apnea who underwent implantation of hypoglossal nerve stimulation therapy within a single academic practice and attended a follow-up appointment after greater than 30 days of therapy use. Objective adherence data were extracted from an objective monitoring database and compared to patient characteristics. The study population was 79 participants who were 29.1% female with a mean age of 58.7 ± 12.8 years old, body mass index of 28.9 ± 3.4 kg/m2, and baseline apnea-hypopnea index of 33.8 ± 17.6 events/h. In the first 7 days after device activation, average use was 7.8 h/night, with 91.9% of nights with greater than 4 hours of therapy use and an average of 0.2 pauses in therapy per night. These figures remained stable after 30 days of use: 7.7 h/night, 91.0% of nights longer than 4 hours, and 0.3 pauses per night. Objective evidence of difficulty with acclimatization was associated with age less than 60 years (odds ratio 2.8, 95% confidence interval 1.1-7.1, P = .03) and a history of prior upper airway surgery (3.9, 1.2-11.9, P = .015). Insomnia was present in 31 patients and was not associated with objective evidence of difficulty tolerating therapy. Early adherence to hypoglossal nerve stimulation is excellent (92.4% >4 hours on >70% of nights), suggesting that the acclimatization period is straightforward in most. Younger age and a history of prior upper airway surgery appear to be associated with an increased risk of difficulty with acclimatization. Huyett P. Early objective adherence to hypoglossal nerve stimulation therapy. J Clin Sleep Med. 2022;18(2):631-636.

Pilot study of a brief provider and EMR-based intervention for overweight teens with asthma

IntroductionAsthma-related morbidity is increased in overweight patients, yet providers are given little guidance on how to discuss weight and asthma management with overweight teens.ObjectiveWe piloted an electronic medical record (EMR)-based tailored discussion guide (TDG) and a brief provider training, to address weight management in overweight teens with asthma. The primary outcome was intervention impact on patient-reported asthma outcomes (e.g., asthma control and morbidity). Secondary outcomes included change in BMI, patient-centeredness, and change in healthy behaviors.MethodsTeens aged 13–18 years with persistent asthma and a body mass index ≥ 85th percentile for their age and sex were eligible. Parents of eligible teens were contacted before an upcoming appointment to allow teen enrollment during the clinic visit. Providers reviewed Motivational Interviewing (MI) concepts and were trained in the TDG for support of conversations around weight and asthma management. Measures included asthma outcomes retrieved from the EMR at 6- and 12-month post-baseline, teen impressions of patient-provider communication at 6-week post-enrollment, and teen report of healthy behaviors at 6- and 12-month post-baseline.ResultsOf 44 teens enrolled (77% African-American, 63% female), mean BMI for intervention (n=25) and control groups (n=19) at baseline were similar. Thirty participants (68%) completed a 6-week questionnaire. Compared to controls, at 6 months, intervention teens reported fewer days of limited activity and “uncontrolled asthma,” but at 12 months, only restricted activity remained lower, and BMI was not reduced. Intervention teens reported clinic visits that were more patient-centered than controls, including discussion of asthma treatment options with provider, feeling ready to follow an asthma treatment routine, and receiving helpful tips about reaching a healthy weight. The healthy behavior “dinner with family” showed improvement for intervention teens at 6 and 12 months. The feasibility study also revealed a need to improve recruitment strategies and to streamline intervention delivery.ConclusionModest improvements in patient-reported asthma outcomes and health behaviors were observed. There was strong evidence that the TDG supports provider discussion of weight and asthma to create a more patient-centered conversation from the perspective of participating teens. Challenges to recruitment and clinic adaptation must be addressed before advancing to a full-scale trial.Trial registrationNCT02575326 Teen Asthma Control Encouraging a Healthier Lifestyle, www.cllinicaltrials.gov

Opportunities for successful de-escalation of proton pump inhibitors at a federally qualified health center

BackgroundA Proton Pump Inhibitor (PPI) de-escalation initiative was piloted at a Family Medicine Federally Qualified Health Center (FQHC) after a needs assessment showed that PPIs were prescribed inappropriately. The objective was to evaluate implementation of a PPI de-escalation program for an urban, underinsured patient population at a (FQHC).MethodsPatients receiving PPI with an upcoming appointment with their primary care provider (PCP) were evaluated by a pharmacist for the appropriateness of therapy. The pharmacist administered a questionnaire to patients to assess PPI usage patterns and then evaluated for appropriate PPI therapy which included diagnoses, risk factors for gastrointestinal bleed, symptom control, and duration of PPI therapy. For consenting patients, de-escalation was implemented per pharmacist protocol.ResultsA total of 36 patients were evaluated for appropriate PPI use, among those, 21 (58%) were eligible for de-escalation, and 19 agreed to de-escalation. Fifteen patients (15/19) had successful PPI de-escalation after 4 weeks without discomfort or symptoms which disrupted daily activities.ConclusionsThis pharmacist led initiative in collaboration with PCPs resulted in successful de-escalation of PPIs in an underserved primary care setting.