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Background: Effective shared decision-making (SDM) tools for use during clinical encounters are available, but, outside of study settings, little is known about clinician use of these tools in practice. Objective: To describe real-world use of an SDM encounter tool for statin prescribing, Statin Choice, embedded into the workflow of an electronic health record. Design: Cross-sectional study. Participants: Clinicians and their statin-eligible patients who had outpatient encounters between January 2020 and June 2021 in Cleveland Clinic Health System. Main Measures: Clinician use of Statin Choice was recorded within the Epic record system. We categorized each patient's 10-year atherosclerotic cardiovascular disease risk into low (< 5%), borderline (5–7.5%), intermediate (7.5–20%), and high (≥ 20%). Other patient factors included age, sex, insurance, and race. We used mixed effects logistic regression to assess the odds of using Statin Choice for statin-eligible patients, accounting for clustering by clinician and site. We generated a residual intraclass correlation coefficient (ICC) to characterize the impact of the clinician on Statin Choice use. Key Results: Statin Choice was used in 7% of 68,505 eligible patients. Of 1047 clinicians, 48% used Statin Choice with ≥ 1 patient, and these clinicians used it with a median 9% of their patients (interquartile range: 3–22%). In the mixed effects logistic regression model, patient age (adjusted OR per year: 1.04; 95%CI 1.03–1.04) and 10-year ASVCD risk (aOR for 5–7.5% versus < 5% risk: 1.28; 95%CI: 1.14–1.44) were associated with use of Statin Choice. Black versus White race was associated with a lower odds of Statin Choice use (aOR: 0.83; 95%CI: 0.73–0.95), as was female versus male sex (aOR: 0.83; 95%CI: 0.76–0.90). The model ICC demonstrated that 53% of the variation in use of Statin Choice was clinician-driven. Conclusions: Patient factors, including race and sex, were associated with clinician use of Statin Choice; half the variation in use was attributable to individual clinicians. [ABSTRACT FROM AUTHOR]

Background: As patient-initiated messaging rises, identifying variation in message volume and its relationship to clinician workload is essential. Objective: To describe the association between variation in message volume over time and time spent on the electronic health record (EHR) outside of scheduled hours. Design: Retrospective cohort study. Participants: Primary care clinicians at Cleveland Clinic Health System. Main Measures: We categorized clinicians according to their number of quarterly incoming medical advice messages (i.e., message volume) between January 2019 and December 2021 using group-based trajectory modeling. We assessed change in quarterly messages and outpatient visits between October–December 2019 (Q4) and October–December 2021 (Q12). The primary outcome was time outside of scheduled hours spent on the EHR. We used mixed effects logistic regression to describe the association between incoming portal messages and time spent on the EHR by clinician messaging group and at the clinician level. Key Results: Among the 150 clinicians, 31% were in the low-volume group (206 messages per quarter per clinician), 47% were in the moderate-volume group (505 messages), and 22% were in the high-volume group (840 messages). Mean quarterly messages increased from 340 to 695 (p < 0.001) between Q4 and Q12; mean quarterly outpatient visits fell from 711 to 575 (p = 0.005). While time spent on the EHR outside of scheduled hours increased modestly for all clinicians, this did not significantly differ by message group. Across all clinicians, each additional 10 messages was associated with an average of 12 min per quarter of additional time spent on the EHR (p < 0.001). Conclusions: Message volume increased substantially over the study period and varied by group. While messages were associated with additional time spent on the EHR outside of scheduled hours, there was no significant difference in time spent on the EHR between the high and low message volume groups. [ABSTRACT FROM AUTHOR]

Background: Early recognition and treatment of bacteremia can be lifesaving. Fever is a well-known marker of bacteremia, but the predictive value of temperature has not been fully explored. Objective: To describe temperature as a predictor of bacteremia and other infections. Design: Retrospective review of electronic health record data. Setting: A single healthcare system comprising 13 hospitals in the United States. Patients: Adult medical patients admitted in 2017 or 2018 without malignancy or immunosuppression. Main Measures: Maximum temperature, bacteremia, influenza and skin and soft tissue (SSTI) infections based on blood cultures and ICD-10 coding. Key Results: Of 97,174 patients, 1,518 (1.6%) had bacteremia, 1,392 (1.4%) had influenza, and 3,280 (3.3%) had an SSTI. There was no identifiable temperature threshold that provided adequate sensitivity and specificity for bacteremia. Only 45% of patients with bacteremia had a maximum temperature ≥ 100.4˚F (38˚C). Temperature showed a U-shaped relationship with bacteremia with highest risk above 103˚F (39.4˚C). Positive likelihood ratios for influenza and SSTI also increased with temperature but showed a threshold effect at ≥ 101.0 ˚F (38.3˚C). The effect of temperature was similar but blunted for patients aged ≥ 65 years, who frequently lacked fever despite bacteremia. Conclusions: The majority of bacteremic patients had maximum temperatures below 100.4 ˚F (38.0˚C) and positive likelihood ratios for bacteremia increased with high temperatures above the traditional definition of fever. Efforts to predict bacteremia should incorporate temperature as a continuous variable. [ABSTRACT FROM AUTHOR]

Background: Some antihyperglycemic drugs can reduce cardiovascular events, slow the progression of kidney disease, and prevent death, but they are more expensive than older drugs. Objectives: (1) To estimate trends in use of antihyperglycemic drugs by cost; (2) to examine use of high-cost drugs by race/ethnicity, income, and insurance status Design: Cross-sectional analysis of the 2003–2018 National Health and Nutrition Examination Survey Participants: US adults ≥18 years with type 2 diabetes Exposures: Race/ethnicity, income, and insurance status Main Measures: Low-cost noninsulin medications included any drugs that had at least one generic version approved by the Food and Drug Administration. Human regular, NPH, and premixed NPH/regular 70/30 insulins were classified as low-cost. All other noninsulin medications and insulins were considered high-cost Key Results: The sample included 7,394 patients. Prevalence of use of low-cost noninsulin drugs increased from 37% in 2003–2004 to 52% in 2017–2018. Use of high-cost noninsulin drugs decreased from 2003–2004 to 2013–2014 and then slowly increased. Use of low-cost insulin decreased from 7 to 2% while high-cost insulin rose from 4 to 16%. In multivariable analysis, non-White patients had 25–35% lower odds of receiving high-cost drugs than non-Hispanic Whites. Health insurance was associated with more than twice the odds of having high-cost drugs compared to no insurance. Patients with higher HbA1c or moderate obesity were also more likely to use high-cost drugs. Sex, income, and insurance type were not associated with receipt of high-cost drugs. Conclusions: There was a shift in utilization from high- to low-cost noninsulin drugs, but since 2013–2014 the trend has slowly reversed with increased use of newer, more expensive drug classes. High-cost insulin analogs have almost completely replaced lower cost human insulins. Disparities in receipt of diabetes drugs by race/ethnicity and insurance must be addressed to ensure that cost is not a barrier for disadvantaged populations. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 pandemic has contributed to growing demand for mental health services, but patients face significant barriers to accessing care. Direct-to-consumer(DTC) telemedicine has been proposed as one way to increase access, yet little is known about its pre-pandemic use for mental healthcare. Objective: To characterize patients, providers, and their use of a large nationwide DTC telemedicine platform for mental healthcare. Design: Retrospective cross-sectional study. Setting: Mental health encounters conducted on the American Well DTC telemedicine platform from 2016 to 2018. Participants: Patients and physicians. Main Measures: Patient measures included demographics, insurance report, and number of visits. Provider characteristics included specialty, region, and number of encounters. Encounter measures included wait time, visit length and timing, out-of-pocket payment, coupon use, prescription outcome, referral receipt, where care otherwise would have been sought, and patient satisfaction. Factors associated with five-star physician ratings and prescription receipt were assessed using logistic regression. Key Results: We analyzed 19,270 mental health encounters between 6708 patients and 1045 providers. Visits were most frequently for anxiety (39.1%) or depression (32.5%), with high satisfaction (4.9/5) across conditions. Patients had a median 2.0 visits for psychiatry (IQR 1.0–3.0) and therapy (IQR 1.0–5.0), compared to 1.0 visit (IQR 1.0–1.0) for urgent care. High satisfaction was positively correlated with prescription receipt (OR 1.89, 95% CI 1.54–2.32) and after-hours timing (aOR 1.18, 95% CI 1.02–1.36). Prescription rates ranged from 79.6% for depression to 32.2% for substance use disorders. Prescription receipt was associated with increased visit frequency (aOR 1.95, 95% CI 1.57–2.42 for ≥ 3 visits). Conclusions: As the burden of psychiatric disease grows, DTC telemedicine offers one solution for extending access to mental healthcare. While most encounters were one-off, evidence of some continuity in psychiatry and therapy visits—as well as overall high patient satisfaction—suggests potential for broader DTC telemental health use. [ABSTRACT FROM AUTHOR]

NHANES and BRFSS/BRFSS-SMART include either the validated Patient Health Questionnaire-9 for depression or its component questions.[19], [20] HRS and MEPS ask about depression symptoms during the prior 12 months or 4 weeks, respectively. BRFSS/BRFSS-SMART and NHIS also ask about sexual behavior (only 2-3 topics each). BRFSS/BRFSS-SMART and NHIS ask about hours of sleep, schedule (NHANES), snoring (BRFSS/BRFSS-SMART, NHANES), and sleep medications (NHIS). [Extracted from the article]

Background: Identifying which patients receive referrals to and which ones attend weight management programs can provide insights into how physicians manage obesity. Objective: To describe patient factors associated with referrals, which primarily reflect physician priorities, and attendance, which reflects patient priorities. We also examine the influence of the individual physician by comparing adjusted rates of referral and attendance across physicians. Design: Retrospective cohort study. Participants: Adults with a body mass index (BMI) ≥ 30 kg/m2 who had a primary care visit between 2015 and 2018 at a large integrated health system Main Measures: Referrals and visits to programs were collected from the EHR in 2019 and analyzed in 2019–2020. Multilevel logistic regression models were used to identify the association between patient characteristics and (1) receiving a referral, and (2) attending a visit after a referral. We compared physicians' adjusted probabilities of referring patients and of their patients attending a visit. Key Results: Our study included 160,163 adults, with a median BMI of 35 kg/m2. Seventeen percent of patients received ≥ 1 referral and 29% of those attended a visit. The adjusted odds of referral increased 57% for patients with a BMI 35–39 (versus 30–34) and 32% for each comorbidity (p < 0.01). Attending a visit was less strongly associated with BMI (aOR 1.18 for 35–39 versus 30–34, 95% CI 1.09–1.27) and not at all with comorbidity. For the physician-level analysis, the adjusted probability of referral had a much wider range (0 to 83%; mean = 19%) than did the adjusted probability of attendance (range 27 to 34%). Conclusions: Few patients attended a weight management program. Physicians vary greatly in their probability of referring patients to programs but not in their patients' probability of attending. [ABSTRACT FROM AUTHOR]

Background: Alcohol use disorder (AUD) imposes a high mortality and economic burden. Effective treatment is available, though underutilized. Objective: Describe trends in AUD pharmacotherapy, variation in prescribing, and associated patient factors. Design: Retrospective cohort using electronic health records from 2010 to 2019. Participants: Primary care patients from 39 clinics in Ohio and Florida with diagnostic codes for alcohol dependence or abuse plus social history indicating alcohol use. PCPs in family or internal medicine with at least 20 AUD patients. Main Measures: Pharmacotherapy for AUD (naltrexone, acamprosate, and disulfiram), abstinence from alcohol, patient demographics, and comorbidities. Generalized linear mixed models were used to identify patient factors associated with prescriptions and the association of pharmacotherapy with abstinence. Key Results: We identified 13,250 patients; average age was 54 years, 66.9% were male, 75.0% were White, and median household income was $51,776 per year. Over 10 years, the prescription rate rose from 4.4 to 5.6%. Patients who were Black (aOR 0.74; 95% CI 0.58, 0.94) and insured by Medicare versus commercial insurance (aOR 0.61; 95% CI 0.48, 0.78) were less likely to be treated. Higher median household income ($10,000 increment, aOR 1.06; 95% CI 1.03, 1.10) and Medicaid versus commercial insurance (aOR 1.52; 95% CI 1.24, 1.87) were associated with treatment. Receiving pharmacotherapy was associated with subsequent documented abstinence from alcohol (aOR 1.60; 95% CI 1.33, 1.92). We identified 236 PCPs. The average prescription rate was 3.6% (range 0 to 24%). The top decile prescribed to 14.6% of their patients. The bottom 4 deciles had no prescriptions. Family physicians had higher rates of pharmacotherapy than internists (OR 1.50; 95% CI 1.21, 1.85). Conclusions: Medications for AUD are infrequently prescribed, but there is considerable variation among PCPs. Increasing the use of pharmacotherapy by non-prescribers may increase abstinence from alcohol. [ABSTRACT FROM AUTHOR]

Background: Over one third of American adults are at high risk for developing diabetes, which can be delayed or prevented using interventions such as medical nutrition therapy (MNT) or metformin. Physicians' self-reported rates of prediabetes treatment are improving, but patterns of actual referral, prescription, and MNT visits are unknown. Objective: To characterize treatment of prediabetes in primary care. Design: We conducted a retrospective cohort study using electronic health record data. We described patterns of treatment and used multivariable logistic regression to evaluate the association of patient factors and PCP-specific treatment rate with patient treatment. Patients: We included overweight or obese outpatients who had a first prediabetes-range hemoglobin A1c (HbA1c) during 2011–2018 and had primary care provider (PCP) follow-up within a year. Main Measures: We collected patient characteristics and the following treatments: metformin prescription; referral to MNT, diabetes education, endocrinology, or bariatric medicine; and MNT visit. We did not capture within-visit physician counseling. Key Results: Of 16,713 outpatients with prediabetes, 20.4% received treatment, including metformin prescriptions (7.8%) and MNT referrals (11.3%), but only 7.4% of referred patients completed a MNT visit. The strongest predictor of treatment was the patient's PCP's treatment rate. Some PCPs never treated prediabetes, but two treated more than half of their patients; 62% had no patients complete a MNT visit. Being younger or female and having higher body mass index or HbA1c were also positively associated with treatment. Compared to white patients, black patients were more likely to receive MNT referral and less likely to receive metformin. Conclusions: Almost 80% of patients with new prediabetes never received treatment, and those who did receive referrals had very poor visit completion. Treatment rates appear to reflect provider rather than patient preferences. [ABSTRACT FROM AUTHOR]

Background: Treating hypertension is important but physicians often do not intensify blood pressure (BP) treatment in the setting of pain. Objective: To identify whether reporting pain is associated with (1) elevated BP at the same visit, (2) medication intensification, and (3) elevated BP at the subsequent visit. Design: Retrospective cohort Setting: Integrated health system Participants: Adults seen in primary care Exposure: Pain status based on numerical scale: mild (1–3), moderate (4–6), or severe (≥ 7). Main Measures: We defined elevated BP as ≥ 140/80 mmHg and medication intensification as increasing the dose or adding a new antihypertensive medication. Multilevel regression models were used to find the association between pain and (1) elevated BP at the index visit; (2) medication intensification at the index visit; and (3) elevated BP at the subsequent visit. Models adjusted for demographics, chronic conditions, and clustering within physician. In the third model, we adjusted for initial systolic BP as well. Key Results: Our population included 56,322 patients; 3155 (6%) reported mild pain, 5050 (9%) reported moderate pain, and 4647 (8%) reported severe pain at the index visit. Compared with no pain, the adjusted odds ratios of elevated BP were 1.38 (95% CI: 1.28–1.48) for severe pain, 1.06 (95% CI: 0.99–1.14) for moderate pain, and 1.02 (95% CI: 0.93–1.12) for mild pain. Adjusted odds ratios of medication intensification at the index visit were 0.65 (95% CI: 0.54–0.80) for mild pain, 0.61 (95% CI: 0.52–0.72) for moderate pain, and 0.55 (95% CI: 0.47–0.64) for severe pain. Among patients with elevated BP at the index visit, reporting pain at the index visit was not associated with elevated BP at the subsequent visit. Conclusions: When patients reported pain, physicians were less likely to intensify antihypertensive treatment; nevertheless, patients reporting pain were not more likely to have elevated BP at the subsequent visit. [ABSTRACT FROM AUTHOR]

To our knowledge, our study is the first to examine differences in APC and physician practice content. As the population ages amid growing shortages in primary care practitioners, expanding the supply of advanced practice clinicians (APC) - nurse practitioners and physician assistants - may offer a low-cost way to increase primary care access.[1] Given differences in training, states have traditionally limited APC scope of practice, with 22 states requiring full physician oversight. [Extracted from the article]

Background: Unless implementation of systematic depression screening is associated with timely treatment, quality measures based on screening are unlikely to improve outcomes. Objective: To assess the impact of integrating systematic depression screening with clinical decision support on depression identification and treatment. Design: Retrospective pre-post study. Participants: Adults with a primary care visit within a large integrated health system in 2016 were included. Adults diagnosed with depression in 2015 or prior to their initial primary care visit in 2016 were excluded. Intervention: Initiation of systematic screening using the Patient Health Questionnaire (PHQ) which began in mid-2016. Main Measures: Depression diagnosis was based on ICD codes. Treatment was defined as (1) antidepressant prescription, (2) referral, or (3) evaluation by a behavioral health specialist. We used an adjusted linear regression model to identify whether the percentage of visits with a depression diagnosis was different before versus after implementation of systematic screening. An adjusted multilevel regression model was used to evaluate the association between screening and odds of treatment. Key Results: Our study population included 259,411 patients. After implementation, 59% of patients underwent screening. Three percent scored as having moderate to severe depression. The rate of depression diagnosis increased by 1.2% immediately after systematic screening (from 1.7 to 2.9%). The percent of patients with diagnosed depression who received treatment within 90 days increased from 64% before to 69% after implementation (p < 0.01) and the adjusted odds of treatment increased by 20% after implementation (AOR 1.20, 95% CI 1.12–1.28, p < 0.01). Conclusions: Implementing systematic depression screening within a large health care system led to high rates of screening and increased rates of depression diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Background: Patient satisfaction measures have important implications for physicians. Patient bias against non-White physicians may impact physician satisfaction ratings, but this has not been widely studied. Objective: To assess differences in patient satisfaction by physician race/ethnicity. Design: A cross-sectional observational study. Participants: Patients seeking care on a large nationwide direct to consumer telemedicine platform between July 2016 and July 2018 and their physicians. Main Measures: Patient satisfaction was ascertained immediately following the encounter on scales of 1 to 5 stars and scored two ways: (1) top-box satisfaction (5 stars versus fewer) and (2) dissatisfaction (2 or fewer stars versus 3 or more). To approximate the information patients would use to make assumptions about physician race/ethnicity, four reviewers classified physicians into categories based on physician name and photo. These included White American, Black American, South Asian, Middle Eastern, Hispanic, and East Asian. Mixed effects logistic regression was used to assess differences in patient top-box satisfaction and patient dissatisfaction by physician race/ethnicity, controlling for patient characteristics, prescription receipt, physician specialty, and whether the physician trained in the USA versus internationally. Key Results: The sample included 119,016 encounters with 390 physicians. Sixty percent were White American, 14% South Asian, 7% Black American, 7% Hispanic, 6% Middle Eastern, and 6% East Asian. Encounters with South Asian physicians (aOR 0.70; 95% CI 0.54–0.91) and East Asian physicians (aOR 0.72; 95% CI 0.53–0.99) were significantly less likely than those with White American physicians to result in top-box satisfaction. Compared to encounters with White American physicians, those with Black American physicians (aOR 1.72; 95% CI 1.12–2.64), South Asian physicians (aOR 1.77; 95% CI 1.23–2.56), and East Asian physicians (aOR 2.10; 95% CI 1.38–3.20) were more likely to result in patient dissatisfaction. Conclusions: In our study, patients reported lower satisfaction with some groups of non-White American physicians, which may have implications for their compensation, professional reputation, and job satisfaction. [ABSTRACT FROM AUTHOR]

Background: Medical educators need valid, reliable, and efficient tools to assess evidence-based medicine (EBM) knowledge and skills. Available EBM assessment tools either do not assess skills or are laborious to grade.Objective: To validate a multiple-choice-based EBM test-the Resident EBM Skills Evaluation Tool (RESET).Design: Cross-sectional study.Participants: A total of 304 medicine residents from five training programs and 33 EBM experts comprised the validation cohort.Main Measures: Internal reliability, item difficulty, and item discrimination were assessed. Construct validity was assessed by comparing mean total scores of trainees to experts. Experts were also asked to rate importance of each test item to assess content validity.Key Results: Experts had higher total scores than trainees (35.6 vs. 29.4, P < 0.001) and also scored significantly higher than residents on 11/18 items. Cronbach's alpha was 0.6 (acceptable), and no items had a low item-total correlation. Item difficulty ranged from 7 to 86%. All items were deemed "important" by > 50% of experts.Conclusions: The proposed EBM assessment tool is a reliable and valid instrument to assess competence in EBM. It is easy to administer and grade and could be used to guide and assess interventions in EBM education. [ABSTRACT FROM AUTHOR]

Importance: Inappropriate antibiotic use for upper respiratory tract infections (URTIs) is an ongoing problem in primary care. There is extreme variation in the prescribing practices of individual physicians, which cannot be explained by clinical factors.Objective: To identify factors associated with high and low prescriber status for management of URTIs in primary care practice.Design and Participants: Exploratory sequential mixed-methods design including interviews with primary care physicians in a large health system followed by a survey. Twenty-nine physicians participated in the qualitative interviews. Interviews were followed by a survey in which 109 physicians participated.Main Measures: Qualitative interviews were used to obtain perspectives of high and low prescribers on factors that influenced their decision making in the management of URTIs. A quantitative survey was created based on qualitative interviews and responses compared to actual prescribing rates. An assessment of self-prescribing pattern relative to their peers was also conducted.Results: Qualitative interviews identified themes such as clinical factors (patient characteristics, symptom duration, and severity), nonclinical factors (physician-patient relationship, concern for patient satisfaction, preference and expectation, time pressure), desire to follow evidence-based medicine, and concern for adverse effects to influence prescribing. In the survey, reported concern regarding antibiotic side effects and the desire to practice evidence-based medicine were associated with lower prescribing rates whereas reported concern for patient satisfaction and patient demand were associated with high prescribing rates. High prescribers were generally unaware of their high prescribing status.Conclusions and Relevance: Physicians report that nonclinical factors frequently influence their decision to prescribe antibiotics for URTI. Physician concerns regarding antibiotic side effects and patient satisfaction are important factors in the decision-making process. Changes in the health system addressing both physicians and patients may be necessary to attain desired prescribing levels. [ABSTRACT FROM AUTHOR]

Background: Ketogenic diets have been highlighted as a way to lose weight while experiencing reduced hunger. The protein-sparing modified fast (PSMF) induces ketosis but may be difficult to maintain.Objective: To track weight loss for individuals initiating PSMF versus all other diets (e.g., balanced, high protein) for up to 5 years.Design: Retrospective cohort study PARTICIPANTS: Adults who discussed the PSMF with a clinician between 2007 and 2014 INTERVENTION: Initiating the PSMF diet versus other diets MEASURES: The main outcome was percent weight change up to 5 years. Demographic and health data were collected using electronic health records. We fit regression models including age, sex, race, insurance, new medication prescriptions, and specialist visit to identify the effect of PSMF diet on percent weight change. We grouped patients by percent weight change at each year (≥ 5% loss, 4% loss to 4% gain, ≥ 5% gain) and used Pearson χ2 tests to compare proportions.Results: Of 1,403 eligible patients, 879 (63%) started the PSMF. The PSMF group was slightly younger (52 vs. 54 years, p < 0.01) and had a higher body mass index (41.9 kg/m2 vs. 40.4 kg/m2, p < 0.001). In the adjusted analysis, the PSMF group averaged 3% more weight loss than the other group over the 5-year follow-up (95% CI - 3.5, - 2.0, p < 0.001). PSMF patients lost more weight initially, but by year 4, there was no difference between diets (1.6% versus 1.3%, PSMF versus other diets, p = 0.12). Patients starting the PSMF were more likely to experience ≥ 5% weight loss at 1 year (55% vs 20%, p < 0.001) and 3 years (33% vs. 23% p < 0.05), but not 5 years (34% vs 29%, p = 0.16, PSMF versus other diets, respectively).Conclusions: In clinical practice, the PSMF achieves rapid weight loss in the first 6 months, but only a small percentage of patients maintained significant weight loss long term. [ABSTRACT FROM AUTHOR]

Background: Urinary tract infections (UTI) are a common reason for seeking care via direct to consumer (DTC) telemedicine, yet patterns of care, including antibiotic prescribing, have not been reported.Objective: To describe management of UTI in a large nationwide DTC telemedicine platform.Design: Cross-sectional observational study.Participants: Patients seeking care for or diagnosed with UTI via DTC telemedicine between July 2016 and July 2018.Main Measures: Patient measures included age, sex, geographic region, satisfaction with care, and patient-reported call reason. High-risk patients were defined as males, patients over 65 years, or those diagnosed with pyelonephritis. Physician measures included specialty and geographic region. Antibiotic prescription was assessed overall and by antibiotic type. Variation in antibiotic prescriptions was assessed by patient and physician factors, including geographic region of both parties.Key Results: Of the 20,600 patients diagnosed with a UTI during the study period, 96% were female. Most (84%) stated their call reason was a UTI. Overall, 94% of UTI patients received an antibiotic; 56% got nitrofurantoin, 29% got trimethoprim-sulfamethoxazole, and 10% got a quinolone. Receipt of an antibiotic was associated with higher satisfaction with care (p < 0.001). While nitrofurantoin was the most common antibiotic for all physician regions, antibiotic type varied by physician region. Of the 6% of the study population defined as high risk, 69% received an antibiotic: 72% of males, 91% of women over 65, and 21% of patients diagnosed with pyelonephritis.Conclusions: Management of UTI via DTC telemedicine appears to be appropriate for average-risk patients, and most are able to self-diagnose. Most patients received guideline-concordant care, but over half of high-risk patients received antibiotics. DTC telemedicine offers convenient, low-cost care that is generally appropriate. Efforts should be made to ensure high-risk patients get proper follow-up. [ABSTRACT FROM AUTHOR]

The prevalence of diagnosed and undiagnosed diabetes reached 9.4% of US adults in 2015.[1] Obesity is a strong risk factor for diabetes and appears to be occurring at younger ages.[1] Consequently, diabetes may also occur earlier. For patients with previously undiagnosed diabetes, we assigned their age at the interview as age at diagnosis, but also conducted sensitivity analysis including only previously diagnosed patients. Also, since time from diabetes onset to diagnosis is unknown,[5] we could not confirm when diabetes developed. [Extracted from the article]

Background: One widely cited study suggested a link between physician empathy and laboratory outcomes in patients with diabetes, but its findings have not been replicated. While empathy has a positive impact on patient experience, its impact on other outcomes remains unclear.Objective: To assess associations between physician empathy and glycosylated hemoglobin (HgbA1c) as well as low-density lipoprotein (LDL) levels in patients with diabetes.Design: Retrospective cross-sectional study.Participants: Patients with diabetes who received care at a large integrated health system in the USA between January 1, 2011, and May 31, 2014, and their primary care physicians.Main Measures: The main independent measure was physician empathy, as measured by the Jefferson Scale of Empathy (JSE). The JSE is scored on a scale of 20-140, with higher scores indicating greater empathy. Dependent measures included patient HgbA1c and LDL. Mixed-effects linear regression models adjusting for patient sociodemographic characteristics, comorbidity index, and physician characteristics were used to assess the association between physician JSE scores and their patients' HgbA1c and LDL.Key Results: The sample included 4176 primary care patients who received care with one of 51 primary care physicians. Mean physician JSE score was 118.4 (standard deviation (SD) = 12). Median patient HgbA1c was 6.7% (interquartile range (IQR) = 6.2-7.5) and median LDL concentration was 83 (IQR = 66-104). In adjusted analyses, there was no association between JSE scores and HgbA1c (β = - 0.01, 95%CI = - 0.04, 0.02, p = 0.47) or LDL (β = 0.41, 95%CI = - 0.47, 1.29, p = 0.35).Conclusion: Physician empathy was not associated with HgbA1c or LDL. While interventions to increase physician empathy may result in more patient-centered care, they may not improve clinical outcomes in patients with diabetes. [ABSTRACT FROM AUTHOR]

Background: Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care.Objective: To identify practice setting components contributing to uptake of new team-based care models.Design: Convergent mixed-methods design.Participants: Employees and patients of primary care practices implementing two team-based models in a large, integrated health system.Main Measures: Field observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team.Key Results: Based on analysis of observations and interviews, the 9 practices were categorized into 3 groups-high, partial, and low uptake of new team-based models. Uptake was related to (1) practices' responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices' ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices.Conclusion: Uptake of new team-based care delivery models is related to practices' ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices. [ABSTRACT FROM AUTHOR]

Background: Despite its rapid expansion, little is known about use of direct to consumer (DTC) telemedicine.Objective: To characterize telemedicine patients and physicians and correlates of patient satisfaction DESIGN: Cross-sectional study PARTICIPANTS: Patients and physicians of a large nationwide DTC telemedicine service MAIN MEASURES: Patient characteristics included demographics and whether or not they reported insurance information. Physician characteristics included specialty, board certification, and domestic versus international medical training. Encounter characteristics included time of day, wait time, length, coupon use for free or reduced-cost care, diagnostic outcome, prescription receipt, and patient/physician geographic concordance. Patients rated satisfaction with physicians on scales of 0 to 5 stars and reported where they would have sought care had they not used telemedicine. Logistic regression was used to assess factors associated with 5-star physician ratings.Key Results: The analysis included 28,222 encounters between 24,040 patients and 277 physicians completed between January 2013 and August 2016. Sixty-five percent of patients were under 40 years and 32% did not report insurance information. Family medicine was the most common physician specialty (47%) and 16% trained at a non-US medical school. Coupons were used in 24% of encounters. Respiratory infections were diagnosed in 35% of encounters and 69% resulted in a prescription. Had they not used telemedicine, 43% of patients reported they would have used urgent care/retail clinic, 29% would have gone to the doctor's office, 15% would have done nothing, and 6% would have gone to the emergency department. Eighty-five percent of patients rated their physician 5 stars. High satisfaction was positively correlated with prescription receipt (OR 2.98; 95%CI 2.74-3.23) and coupon use (OR 1.47; 95%CI 1.33-1.62).Conclusions: Patients were largely satisfied with DTC telemedicine, yet satisfaction varied by coupon use and prescription receipt. The impact of telemedicine on primary care and emergency department use is likely to be small under present usage patterns. [ABSTRACT FROM AUTHOR]

Attention-deficit/hyperactivity disorder (ADHD) is increasingly prevalent.[1], [2] Commonly a childhood-onset disorder, its symptoms frequently persist into adulthood.[2] Untreated ADHD is associated with significant impairment, and there is growing unmet need for treatment - especially among adults.[3] Although stimulants are the mainstay of pediatric therapy, management of ADHD in adults is less well-established, with studies suggesting roles for stimulants, non-stimulants, and therapy.[1], [4] Internists' limited comfort with ADHD and the dearth of behavioral health providers represent significant barriers to treatment for patients transitioning to adult care or moving residence.[3], [5] Innovative care models are needed. Little is known about how patients with ADHD use DTC telemedicine. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. [Extracted from the article]

Prediabetes affects 84 million US adults, more than 50% of whom will develop diabetes in 15 years.[1] Once patients develop diabetes, up to 75% will have nonalcoholic fatty liver disease (NAFLD), and many of these will develop nonalcoholic steatohepatitis (NASH) and advanced fibrosis.[2] However, the burden of NAFLD and associated comorbidities in patients with prediabetes is less well understood. We aimed to estimate the population-based trends in prevalence of concurrent suspected NAFLD, advanced fibrosis and NASH cirrhosis in US adults with prediabetes. In this population-based study, we found that between 44 and 62% of US adults with prediabetes had concurrent suspected NAFLD, equivalent to 27-38 million patients, and similar to the numbers of prediabetic patients with hypertension or dyslipidemia. [Extracted from the article]

Background: The Advisory Committee on Immunization Practices recommends a single dose of herpes zoster (HZ) vaccine in persons aged 60 years or older, but the efficacy decreases to zero after approximately 10 years. A booster dose administered after 10 years might extend protection, but the cost-effectiveness of a booster strategy has not been examined.Objective: We aimed to determine the optimal schedule for HZ vaccine DESIGN: We built a Markov model to follow patients over their lifetime. From the societal perspective, we compared costs and quality-adjusted life years (QALYs) saved of 11 strategies to start and repeat HZ vaccine at different ages.Subjects: Adults aged 60 years.Intervention: HZ vaccine.Main Measures: Costs, quality-adjusted life years (QALYs), and incremental costs per QALY saved.Key Results: At a $100,000/QALY threshold, "vaccination at 70 plus one booster" was the most cost-effective strategy, with an incremental cost-effectiveness ratio (ICER) of $36,648/QALY. "Vaccination at 60 plus two boosters" was more effective, but had an ICER of $153,734/QALY. In deterministic sensitivity analysis, "vaccination at 60 plus two boosters" cost < $100,000/QALY if compliance rate was > 67 % or vaccine cost was < $156 per dose. In probabilistic sensitivity analysis, "vaccination at 70 plus one booster" was preferred at a willingness-to-pay of up to $135,000/QALY.Conclusions: Under current assumptions, initiating HZ vaccine at age 70 years with one booster dose 10 years later appears optimal. Future data regarding compliance with or efficacy of a booster could affect these conclusions. [ABSTRACT FROM AUTHOR]

Background: Understanding resource utilization patterns among high-cost patients may inform cost reduction strategies.Objective: To identify patterns of high-cost healthcare utilization and associated clinical diagnoses and to quantify the significance of hot-spotters among high-cost users.Design: Retrospective analysis of high-cost patients in 2012 using data from electronic medical records, internal cost accounting, and the Centers for Medicare and Medicaid Services. K-medoids cluster analysis was performed on utilization measures of the highest-cost decile of patients. Clusters were compared using clinical diagnoses. We defined "hot-spotters" as those in the highest-cost decile with ≥4 hospitalizations or ED visits during the study period.Participants and Exposure: A total of 14,855 Medicare Fee-for-service beneficiaries identified by the Medicare Quality Resource and Use Report as having received 100 % of inpatient care and ≥90 % of primary care services at Cleveland Clinic Health System (CCHS) in Northeast Ohio. The highest-cost decile was selected from this population.Main Measures: Healthcare utilization and diagnoses.Key Results: The highest-cost decile of patients (n = 1486) accounted for 60 % of total costs. We identified five patient clusters: "Ambulatory," with 0 admissions; "Surgical," with a median of 2 surgeries; "Critically Ill," with a median of 4 ICU days; "Frequent Care," with a median of 2 admissions, 3 ED visits, and 29 outpatient visits; and "Mixed Utilization," with 1 median admission and 1 ED visit. Cancer diagnoses were prevalent in the Ambulatory group, care complications in the Surgical group, cardiac diseases in the Critically Ill group, and psychiatric disorders in the Frequent Care group. Most hot-spotters (55 %) were in the "frequent care" cluster. Overall, hot-spotters represented 9 % of the high-cost population and accounted for 19 % of their overall costs.Conclusions: High-cost patients are heterogeneous; most are not so-called "hot-spotters" with frequent admissions. Effective interventions to reduce costs will require a more multi-faceted approach to the high-cost population. [ABSTRACT FROM AUTHOR]

Background: Cervical cancer screening guidelines for women aged ≥30 years allow for co-testing or primary cytology testing. Our objective was to determine the test characteristics and costs associated with Cytology, HPV and Co-testing screening strategies.Main Methods: Retrospective cohort study of women undergoing cervical cancer screening with both cytology and HPV (Hybrid Capture 2) testing from 2004 to 2010 in an integrated health system. The electronic health record was used to identify women aged ≥30 years who had co-testing. Unsatisfactory or unavailable test results and incorrectly ordered tests were excluded. The main outcome was biopsy-proven cervical intraepithelial neoplasia grade 3 or higher (CIN3+).Key Results: The final cohort consisted of 99,549 women. Subjects were mostly white (78.4 %), married (70.7 %), never smokers (61.3 %) and with private insurance (86.1 %). Overall, 5121 (5.1 %) tested positive for HPV and 6115 (6.1 %) had cytology ≥ ASCUS; 1681 had both and underwent colposcopy and 310 (0.3 %) had CIN3+. Sensitivity for CIN3+ was 91.9 % for Primary Cytology, 99.4 % for Co-testing, and 94.8 % for Primary HPV; specificity was 97.3 % for Co-testing and Primary Cytology and 97.9 % for Primary HPV. Over a 3-year screening interval, Primary HPV detected more cases of CIN3+ and was less expensive than Primary Cytology. Co-testing detected 14 more cases of CIN3+ than Primary HPV, but required an additional 100,277 cytology tests and 566 colposcopies at an added cost of $2.38 million, or $170,096 per additional case detected.Conclusions: Primary HPV was more effective and less expensive than Primary Cytology. Primary HPV screening appears to represent a cost-effective alternative to Co-testing. [ABSTRACT FROM AUTHOR]

Background: Extending medical assistants and nursing roles to include in-visit documentation is a recent innovation in the age of electronic health records. Despite the use of these clinical scribes, little is known regarding interactions among and perspectives of the involved parties: physicians, clinical scribes, and patients.Objective: The purpose of this project is to describe perspectives of physicians, clinical scribes, and patients regarding clinical scribes in primary care.Design: We used qualitative content analysis, using Interpretive Description of semi-structured audio-recorded in-person and telephone interviews.Participants: Participants included 18 physicians and 17 clinical scribes from six healthcare systems, and 36 patients from one healthcare system.Key Results: Despite physician concerns regarding terminology within notes, physicians, clinical scribes, and patients perceived more detailed notes because of real-time documentation by scribes. Most patients were comfortable with the scribe's presence and perceived increased attention from their physicians. Clinical scribes also performed more active roles during a patient visit, leading to formation of positive scribe-patient relationships. The resulting shift in workflow, however, led to stress. Our theoretical model for successful physician-scribe teams emphasizes the importance of interpersonal aspects such as communication, mutual respect, and adaptability, as well as system level support such as training and staffing.Conclusions: Both interpersonal fit between physician and scribe, and system level support including adequate training, transition time, and staffing support are necessary for successful use of clinical scribes. Future directions for research regarding clinical scribes include study of care continuity, scribe medical knowledge, and scribe burnout. [ABSTRACT FROM AUTHOR]

The article offers information to assess differences in Respiratory Tract Infections (RTI) coding for particular diagnoses by physician antibiotic prescribing rates. It mentions in order to avoid scrutiny when prescribing inappropriate antibiotics, physicians may diagnose a cold as sinusitis; and also mentions Physicians' overall antibiotic prescribing rate was associated with the frequency of diagnosing a specific RTI.

Background: Many employers offer worksite wellness programs, including financial incentives to achieve goals. Evidence supporting such programs is sparse.Objective: To assess whether diabetes and cardiovascular risk factor control in employees improved with financial incentives for participation in disease management and for attaining goals.Design: Retrospective cohort study using insurance claims linked with electronic medical record data from January 2008-December 2012.Participants: Employee patients with diabetes covered by the organization's self-funded insurance and propensity-matched non-employee patient comparison group with diabetes and commercial insurance.Intervention: Financial incentives for employer-sponsored disease management program participation and achieving goals.Main Measures: Change in glycosylated hemoglobin (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SBP), and weight.Results: A total of 1092 employees with diabetes were matched to non-employee patients. With increasing incentives, employee program participation increased (7 % in 2009 to 50 % in 2012, p < 0.001). Longitudinal mixed modeling demonstrated improved diabetes and cardiovascular risk factor control in employees vs. non-employees [HbA1c yearly change -0.05 employees vs. 0.00 non-employees, difference in change (DIC) p <0.001]. In their first participation year, employees had larger declines in HbA1c and weight vs. non-employees (0.33 vs. 0.14, DIC p = 0.04) and (2.3 kg vs. 0.1 kg, DIC p < 0.001), respectively. Analysis of employee cohorts corresponding with incentive offerings showed that fixed incentives (years 1 and 2) or incentives tied to goals (years 3 and 4) were not significantly associated with HbA1c reductions compared to non-employees. For each employee cohort offered incentives, SBP and LDL also did not significantly differ in employees compared with non-employees (DIC p > 0.05).Conclusions: Financial incentives were associated with employee participation in disease management and improved cardiovascular risk factors over 5 years. Improvements occurred primarily in the first year of participation. The relative impact of specific incentives could not be discerned. [ABSTRACT FROM AUTHOR]

Background: Skilled physician communication is a key component of patient experience. Large-scale studies of exposure to communication skills training and its impact on patient satisfaction have not been conducted.Objective: We aimed to examine the impact of experiential relationship-centered physician communication skills training on patient satisfaction and physician experience.Design: This was an observational study.Setting: The study was conducted at a large, multispecialty academic medical center.Participants: Participants included 1537 attending physicians who participated in, and 1951 physicians who did not participate in, communication skills training between 1 August 2013 and 30 April 2014.Intervention: An 8-h block of interactive didactics, live or video skill demonstrations, and small group and large group skills practice sessions using a relationship-centered model.Main Measures: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), Jefferson Scale of Empathy (JSE), Maslach Burnout Inventory (MBI), self-efficacy, and post course satisfaction.Key Results: Following the course, adjusted overall CGCAHPS scores for physician communication were higher for intervention physicians than for controls (92.09 vs. 91.09, p < 0.03). No significant interactions were noted between physician specialty or baseline CGCAHPS and improvement following the course. Significant improvement in the post-course HCAHPS Respect domain adjusted mean was seen in intervention versus control groups (91.08 vs. 88.79, p = 0.02) and smaller, non-statistically significant improvements were also seen for adjusted HCAHPS communication scores (83.95 vs. 82.73, p = 0.22). Physicians reported high course satisfaction and showed significant improvement in empathy (116.4 ± 12.7 vs. 124 ± 11.9, p < 0.001) and burnout, including all measures of emotional exhaustion, depersonalization, and personal accomplishment. Less depersonalization and greater personal accomplishment were sustained for at least 3 months.Conclusions: System-wide relationship-centered communication skills training improved patient satisfaction scores, improved physician empathy, self-efficacy, and reduced physician burnout. Further research is necessary to examine longer-term sustainability of such interventions. [ABSTRACT FROM AUTHOR]

Background: Rates of preventable admissions will soon be publicly reported and used in calculating performance-based payments. The current method of assessing preventable admissions, the Agency of Healthcare Research and Quality (AHRQ) Preventable Quality Indicators (PQI) rate, is drawn from claims data and was originally designed to assess population-level access to care.Objective: To identify the prevalence and causes of preventable admissions by attending physician review and to compare its performance with the PQI tool in identifying preventable admissions.Design: Cross-sectional survey.Setting: General medicine service at an academic medical center.Participants: Consecutive inpatient admissions from December 1-15, 2013.Main Measures: Survey of inpatient attending physicians regarding the preventability of the admissions, primary contributing factors and feasibility of prevention. For the same patients, the PQI tool was applied to determine the claims-derived preventable admission rate.Key Results: Physicians rated all 322 admissions and classified 122 (38 %) as preventable, of which 31 (25 %) were readmissions. Readmissions were more likely to be rated preventable than other admissions (49 % vs. 35 %, p = 0.04). Application of the AHRQ PQI methodology identified 75 (23 %) preventable admissions. Thirty-one admissions (10 %) were classified as preventable by both methods, and the majority of admissions considered preventable by the AHRQ PQI method (44/78) were not considered preventable by physician assessment (K = 0.04). Of the preventable admissions, physicians assigned patient factors in 54 (44 %), clinician factors in 36 (30 %) and system factors in 32 (26 %).Conclusions: A large proportion of admissions to a general medicine service appeared preventable, but AHRQ's PQI tool was unable to identify these admissions. Before initiation of the PQI rate for use in pay-for-performance programs, further study is warranted. [ABSTRACT FROM AUTHOR]

Even CAPSTONE-2, which compared baloxavir, oseltamivir, and placebo for high-risk patients with uncomplicated influenza, was underpowered to detect differences in hospitalizations, with an overall hospitalization rate of only 1%.[2] Perhaps more concerning, there are no randomized trials of patients hospitalized with influenza. Although the authors intended to enroll only high-risk patients, after 1 month, they expanded enrollment to include all patients with influenza, highlighting the challenge of studying high-risk patients. All patients had influenza diagnosed by PCR and at least 2 moderately severe influenza symptoms which had been present for < 48 h. [Extracted from the article]

Background: Statins are prescribed to lower cholesterol, but also have anti-inflammatory properties. Some observational studies suggest that statins may reduce mortality from sepsis.Methods: Using a highly detailed administrative database, we conducted an observational cohort study of all patients aged ≥18 years who received a discharge diagnosis of pneumonia from 2003-2005 at 376 hospitals. Patients with contraindications to statins, and those unable to take oral medications or discharged within 2 days were excluded. We used multivariable logistic regression and propensity matching to compare mortality among patients who did and did not receive statins on hospital day 1 or 2.Results: Of the 121,254 patients who met the inclusion criteria, median age was 74; 56% were female and 70% were white; 19% received a statin on day 1 or 2. Compared to patients who did not receive statins, statin-treated patients were less likely to be admitted to intensive care (15.7% vs 18.1%, p < 0.001), require mechanical ventilation (6.9% vs. 9.3%, p < 0.001), or die in hospital (3.9% vs 5.7%, p < 0.001). After multivariable adjustment, including the propensity for statin treatment and severity at presentation, mortality was lower in statin-treated patients [OR for propensity-adjusted 0.86 (95% CI 0.79 to 0.93) OR for propensity-matched 0.90, (0.82 to 0.99)]. For patients admitted to intensive care the adjusted odds ratio for mortality with statins was 0.93 (95% CI 0.81 to 1.06), whereas outside intensive care it was 0.79 (95% CI 0.71 to 0.87).Conclusions: Inpatient treatment with statins is associated with a modest reduction in pneumonia mortality outside of intensive care. [ABSTRACT FROM AUTHOR]

Background: Internet-based social networking tools that allow users to share content have enabled a new form of public reporting of physician performance: the physician-rating website.Objective: To describe the structure and content of physician-rating websites and to assess the extent to which a patient might find them valuable.Methods: We searched Google for websites that allowed patients to review physicians in the US. We included websites that met predetermined criteria, identified common elements of these websites, and recorded website characteristics. We then searched the websites for reviews of a random sample of 300 Boston physicians. Finally, we separately analyzed quantitative and narrative reviews.Results: We identified 33 physician-rating websites, which contained 190 reviews for 81 physicians. Most reviews were positive (88%). Six percent were negative, and six percent were neutral. Generalists and subspecialists did not significantly differ in number or nature of reviews. We identified several narrative reviews that appeared to be written by the physicians themselves.Conclusion: Physician-rating websites offer patients a novel way to provide feedback and obtain information about physician performance. Despite controversy surrounding these sites, their use by patients has been limited to date, and a majority of reviews appear to be positive. [ABSTRACT FROM AUTHOR]

Background: Chemoprophylaxis is recommended for medical patients at moderate to high risk of venous thromboembolism (VTE) and is now a requirement of the Joint Commission on Accreditation of Healthcare Organizations. To see who receives prophylaxis and how far hospitals will need to go to meet this requirement, we examined VTE prophylaxis patterns at US hospitals.Methods: We conducted a retrospective cohort study of adult patients with seven medical diagnoses considered to carry moderate to high risk of VTE at 376 acute care facilities in 2004-2005. We excluded patients on warfarin or with hospital stays of <2 days. VTE prophylaxis was assessed by billing codes for any heparin or compression device. We classified patient risk using a VTE risk prediction model.Results: Of 351,535 patients included, 36% received prophylaxis by hospital day 2. Prophylaxis rates were highest among patients with certain VTE risk factors, including mechanical ventilation (67%), restraints (57%), central lines (55%), obesity (46%), and prior VTE (44%). The median hospital rate was 31% (IQR 19% to 42%); only 3% of hospitals had rates >70%. Compared to patients at low risk of VTE (<0.05%), patients at high risk (>1.0%) were more likely to receive prophylaxis (52% vs. 34%, p < 0.001). Hospitals with high rates of prescribing for high-risk patients also had high rates for low-risk patients.Conclusions: VTE prophylaxis rates at US hospitals are substantially below Joint Commission targets, even for patients at highest risk of VTE. [ABSTRACT FROM AUTHOR]

Background: Chronic kidney disease (CKD) is a growing problem among the elderly. Early detection is considered essential to ensure proper treatment and to avoid drug toxicity, but detection is challenging because elderly patients with CKD often have normal serum creatinine levels. We hypothesized that most cases of CKD in the elderly would go undetected, resulting in inappropriate prescribing.Objective: To determine whether recognition of CKD is associated with more appropriate treatmentDesign: Retrospective chart reviewParticipants: All patients aged >/=65 years with a measured serum creatinine in the past 3 years at 2 inner city academic health centers.Measurements: Estimated glomerular filtration rate (eGFR) calculated using the Modified Diet in Renal Disease equation, and for patients with eGFR < 60, documentation of CKD by the provider, diagnostic testing, nephrology referral and prescription of appropriate or contraindicated medications.Results: Of 814 patients with sufficient information to estimate eGFR, 192 (33%) had moderate (eGFR < 60 mL/min) and 5% had severe (eGFR < 30 mL/min) CKD. Providers identified 38% of moderate and 87% of severe CKD. Compared to patients without recognized CKD, recognized patients were more likely to receive an ACE/ARB (80% vs 61%, p = .001), a nephrology referral (58% vs 2%, p < .0001), or urine testing (75% vs 47%, p < .0001), and less likely to receive contraindicated medications (26% vs 40%, p = .013).Conclusions: Physicians frequently fail to diagnose CKD in the elderly, leading to inappropriate treatment. Efforts should focus on helping physicians better identify patients with low GFR. [ABSTRACT FROM AUTHOR]

Background: Although vaginitis is a common outpatient problem, only 60% of patients can be diagnosed at the initial office visit of a primary care provider using the office procedures of pH testing, whiff tests, normal saline, and potassium hydroxide preps.Objective: To determine the most cost-effective diagnostic and treatment approach for the medical management of vaginitis.Design: Decision and cost-effectiveness analyses.Participants: Healthy women with symptoms of vaginitis undiagnosed after an initial pelvic exam, wet mount preparations, pH, and the four criteria to diagnose bacterial vaginosis.Setting: General office practice.Methods: We evaluated 28 diagnostic strategies comprised of combinations of pH testing, vaginal cultures for yeast and Trichomonas vaginalis, Gram's stain for bacterial vaginosis, and DNA probes for Neisseria gonorrhoeae and Chlamydia. Data sources for the study were confined to English language literature.Measurement: The outcome measures were symptom-days and costs.Results: The least expensive strategy was to perform yeast culture, gonorrhoeae and Chlamydia probes at the initial visit, and Gram's stain and Trichomonas culture only when the vaginal pH exceeded 4.9 (330 dollars, 7.30 symptom days). Other strategies cost 8 dollars to 76 dollars more and increased duration of symptoms by up to 1.3 days. In probabilistic sensitivity analysis, this strategy was always the most effective strategy and was also least expensive 58% of the time.Conclusions: For patients with vaginitis symptoms undiagnosed by pelvic examination, wet mount preparations and related office tests, a comprehensive, pH-guided testing strategy at the initial office visit is less expensive and more effective than ordering tests sequentially. [ABSTRACT FROM AUTHOR]

Objective: To determine the cost-effectiveness of management strategies for dysuria in different office settings.Design: Decision and cost-effectiveness analyses, assuming the payer's perspective. Data on disease prevalence, test characteristics, treatment efficacy, and adverse effects were drawn from the English language literature using medline searches and bibliographies.Setting: Hypothetical primary care practice.Patients: Otherwise healthy, nonpregnant women with symptoms of dysuria, urgency, and frequency.Interventions: All reasonable combinations of urinalysis, urine culture, pelvic examination, chlamydia and gonorrhea cultures, and empiric treatment with trimethoprim-sulfamethoxazole.Results: The cost-effectiveness of strategies varied substantially among different patient settings. In all settings, empiric trimethoprim-sulfamethoxazole for all patients was least expensive and least effective. Most testing increased both cost and effectiveness. Compared to empiric antibiotics, performing pelvic examination and urine culture for women with normal urinalyses had a marginal cost-effectiveness ratio of $4 to $32 per symptom-day avoided (SDA). Adding urine culture for patients with pyuria had a marginal cost of $34 to $107 per SDA, which fell to $40/SDA when the prevalence of resistance to trimethoprim-sulfamethoxazole exceeded 40%. Pelvic examination and urine culture for all patients regardless of urinalysis results achieved the greatest benefit but at the highest cost (>$300 per SDA).Conclusions: In otherwise healthy women with symptoms of dysuria and no vaginal complaints, performing pelvic exam and urine culture based on urinalysis offers a reasonable alternative to empiric therapy. Other testing may be warranted, depending on antibiotic resistance and the value of avoiding a day of dysuria. [ABSTRACT FROM AUTHOR]

To determine the cost-effectiveness of management strategies for dysuria in different office settings. Decision and cost-effectiveness analyses, assuming the payer's perspective. Data on disease prevalence, test characteristics, treatment efficacy, and adverse effects were drawn from the English language literature using medline searches and bibliographies. Hypothetical primary care practice. Otherwise healthy, nonpregnant women with symptoms of dysuria, urgency, and frequency. All reasonable combinations of urinalysis, urine culture, pelvic examination, chlamydia and gonorrhea cultures, and empiric treatment with trimethoprim-sulfamethoxazole. The cost-effectiveness of strategies varied substantially among different patient settings. In all settings, empiric trimethoprim-sulfamethoxazole for all patients was least expensive and least effective. Most testing increased both cost and effectiveness. Compared to empiric antibiotics, performing pelvic examination and urine culture for women with normal urinalyses had a marginal cost-effectiveness ratio of $4 to $32 per symptom-day avoided (SDA). Adding urine culture for patients with pyuria had a marginal cost of $34 to $107 per SDA, which fell to $40/SDA when the prevalence of resistance to trimethoprim-sulfamethoxazole exceeded 40%. Pelvic examination and urine culture for all patients regardless of urinalysis results achieved the greatest benefit but at the highest cost (>$300 per SDA). In otherwise healthy women with symptoms of dysuria and no vaginal complaints, performing pelvic exam and urine culture based on urinalysis offers a reasonable alternative to empiric therapy. Other testing may be warranted, depending on antibiotic resistance and the value of avoiding a day of dysuria. J GEN INTERN MED 2004;19:433–443. [ABSTRACT FROM AUTHOR]

Objective: To determine the cost-effectiveness of rapid diagnostic testing and empiric antiviral therapy for healthy adults with symptoms of influenza.Design: Cost-effectiveness analysis using a decision model based on previously published data. Outcome measures included costs and quality-adjusted life expectancy.Setting: Physician's office.Patients/participants: Hypothetically healthy, working adults < 65 years of age presenting with cough and fever during the influenza season.Interventions: Rapid testing or clinical diagnosis followed by treatment with amantadine, rimantadine, oseltamivir, or zanamivir compared with no antiviral therapy.Results: Base-case analysis: not giving antiviral therapy is the most expensive and least effective strategy, costing 471 dollars per patient, mostly owing to time lost from work. Amantadine treatment increases life expectancy by 0.0014 quality-adjusted life years (QALYs) while saving 108 dollars per patient relative to no antiviral therapy. Zanamivir is slightly more effective than amantadine, adding 0.0002 QALYs at an incremental cost of 31 dollars, or 133,000 dollars per QALY saved. All other strategies, including testing strategies, are both less effective and more expensive. SENSITIVITY ANALYSIS: The model is sensitive to the probability of influenza infection, proportion of influenza caused by type B, the relative efficacy of the various drugs, and the value of a workday. At a clinical probability of influenza infection > 20%, antiviral therapy is favored. As the proportion of influenza B increases, zanamivir is favored over amantadine. Testing is rarely indicated. Ignoring the costs of lost workdays, amantadine treatment costs 1,200 dollars/QALY saved.Conclusions: Antiviral therapy with either amantadine or zanamivir is cost-effective for healthy, young patients with influenza-like illness during the influenza season, depending on the prevalence of influenza B. [ABSTRACT FROM AUTHOR]

To determine the cost-effectiveness of rapid diagnostic testing and empiric antiviral therapy for healthy adults with symptoms of influenza. Cost-effectiveness analysis using a decision model based on previously published data. Outcome measures included costs and quality-adjusted life expectancy. Physician's office. Hypothetically healthy, working adults < 65 years of age presenting with cough and fever during the influenza season. Rapid testing or clinical diagnosis followed by treatment with amantadine, rimantadine, oseltamivir, or zanamivir compared with no antiviral therapy. Base-case analysis: not giving antiviral therapy is the most expensive and least effective strategy, costing $471 per patient, mostly owing to time lost from work. Amantadine treatment increases life expectancy by 0.0014 quality-adjusted life years (QALYs) while saving $108 per patient relative to no antiviral therapy. Zanamivir is slightly more effective than amantadine, adding 0.0002 QALYs at an incremental cost of $31, or $133,000 per QALY saved. All other strategies, including testing strategies, are both less effective and more expensive. The model is sensitive to the probability of influenza infection, proportion of influenza caused by type B, the relative efficacy of the various drugs, and the value of a workday. At a clinical probability of influenza infection > 20%, antiviral therapy is favored. As the proportion of influenza B increases, zanamivir is favored over amantadine. Testing is rarely indicated. Ignoring the costs of lost workdays, amantadine treatment costs $1,200/QALY saved. Antiviral therapy with either amantadine or zanamivir is cost-effective for healthy, young patients with influenza-like illness during the influenza season, depending on the prevalence of influenza B. [ABSTRACT FROM AUTHOR]

Background: Serum folic acid tests are routinely ordered by physicians for evaluating anemia and sometimes ordered for evaluating dementia and altered mental status.Objective: To determine the utility of routine folic acid testing for patients with anemia or dementia/altered mental status in the era of folic acid fortification.Design: Retrospective analysis of consecutive folic acid tests performed on adults over a 4-month period; chart review of patients without anemia.Measurements and Main Results: Serum folic acid level, mean corpuscular volume (MCV), and hematocrit. We reviewed 1,007 folic acid tests performed on 980 patients. The average age was 63.8 years, and 62% of the tests were from outpatient facilities. Only 4 (0.4%) patients had folic acid levels <3 ng/mL, while 10 (1%) patients had levels of 3-4 ng/mL (borderline). Thirty-five percent of the folic acid tests were performed on patients who were not anemic; most of these were ordered to evaluate dementia or altered mental status and folic acid level was normal in all these patients. Only 7% of the patients tested had a macrocytic anemia; these patients were more likely than those without macrocytic anemia to have low folic acid levels (2.8% vs 0.4%, p < .03).Conclusion: Low serum folic acid levels were rarely detected in a series of patients being evaluated for anemia, dementia, or altered mental status. The test should be reserved for patients with macrocytic anemia and those at high risk for folic acid deficiency. [ABSTRACT FROM AUTHOR]

It's true we had a larger proportion of Internal versus Family Medicine physicians and a moderately different case mix of patients, but our finding of no association between empathy and diabetes outcomes was consistent in all multivariable and sensitivity analyses. Whether using their empathy cut points, analyzing scores continuously to maximize statistical power, or looking at subsets of patients with poorly controlled diabetes, we found no relationship between JSE and outcomes. Finally, the authors cite our "error in judgment" for acknowledging that the two studies that found correlations between empathy and diabetes outcomes were conducted by the same group. [Extracted from the article]

The article discusses the Patient-Reported Outcomes Measurement System (PROMIS) developed by the U.S. National Institutes of Health (NIH) for measuring self-reported health. Topics include the use of patient-reported outcomes (PRO) in the clinical setting, the measurement of symptoms like sleep problems, pain and anxiety using PROMIS, and the importance of routine measurement to improve outcomes for patients with chronic disease.

The author reflects on the negative impact of diet to ones health in the U.S. He states that the most cited causes of heart failure exacerbation and hospital admission is dietary indiscretion. In addition, normal sodium diet combined with appropriate reninangiotensin-aldosterone system blockade can restore intravascular volume and renal blood flow.

Background: Professional societies have recommended against use of self-monitoring blood glucose (SMBG) in non-insulin-treated type 2 diabetes (NITT2D) to control blood sugar levels, but patients are still monitoring.Objective: To understand patients' motivation to monitor their blood sugar, and whether they would stop if their physician suggested it.Design: Cross-sectional in-person and electronic survey conducted between 2018 and 2020.Participants: Adults with type 2 diabetes not using insulin who self-monitor their blood sugar.Main Measures: The survey included questions about frequency and reason for using SMBG, and the impact of SMBG on quality of life and worry. It also asked, "If your doctor said you could stop checking your blood sugar, would you?" We categorized patients based on whether they would stop. To identify the characteristics independently associated with desire to stop SMBG, we performed a logistic regression using backward stepwise selection.Key Results: We received 458 responses. The common reasons for using SMBG included the doctor wanted the patient to check (67%), desire to see the number (65%), and desire to see if their medications were working (61%). Forty-eight percent of respondents stated that using SMBG reduced their worry about their diabetes and 61% said it increased their quality of life. Fifty percent would stop using SMBG if given permission. In the regression model, respondents who said that they check their blood sugar levels because "I was told to" were more likely to want to stop (AOR: 1.69, 95%CI: 1.11, 2.58). Those that used SMBG due to habit and to understand their diabetes better had lower odds of wanting to stop (AOR: 0.33, 95%CI: 0.18-0.62; AOR: 0.60, 95%CI: 0.39-0.93, respectively).Conclusions: Primary care physicians should discuss patients' reasons for using SMBG and offer them the option of discontinuing. [ABSTRACT FROM AUTHOR]