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Unless implementation of systematic depression screening is associated with timely treatment, quality measures based on screening are unlikely to improve outcomes. To assess the impact of integrating systematic depression screening with clinical decision support on depression identification and treatment. Retrospective pre-post study. 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. Initiation of systematic screening using the Patient Health Questionnaire (PHQ) which began in mid-2016. 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. 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

BACKGROUND: Physicians play a key role in mitigating and managing costs in healthcare which are rising. OBJECTIVE: Conduct a cross-sectional survey in 2017, comparing results to a 2012 survey to understand US physicians’ evolving attitudes and strategies concerning healthcare costs. PARTICIPANTS: Random sample of 1200 US physicians from the AMA Masterfile. MEASURES: Physician views on responsibility for costs of care, enthusiasm for cost-saving strategies, cost-consciousness scale, and practice strategies on addressing cost. KEY RESULTS: Among 1200 physicians surveyed in 2017, 489 responded (41%). In 2017, slightly more physicians reported that physicians have a major responsibility for addressing healthcare costs (32% vs. 27%, p = 0.03). In 2017, more physicians attributed “major responsibility” for addressing healthcare costs to pharmaceutical companies (68% vs. 56%, p 70%). After adjusting for specialty, political affiliation, practice setting, age, and gender, only democratic/independent affiliation remained a significant predictor of cost-consciousness. CONCLUSIONS AND RELEVANCE: US physicians increasingly attribute responsibility for rising healthcare costs to organizations and express less enthusiasm for strategies that increase patient out-of-pocket cost. Interventions that focus on physician knowledge and communication strategies regarding cost of care may be helpful. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05807-0) contains supplementary material, which is available to authorized users.

Hematopoietic stem cell transplantation (HSCT) has become the standard treatment for many diseases, but it is an intense and distinctive experience for patients. HSCT-related mortality is present throughout the whole process of transplantation, from pretransplantation to recovery. Long-term rehabilitation and the uncertain risk of death evoke feelings of vulnerability, helplessness, and intense fear. Zimmermann et al. proposed that spiritual well-being is an important dimension of quality of life and that patients at the end stage of life require spiritual support in addition to physical care, psychological care, and social support. Therefore, the purpose of this review is to examine the role of spirituality in the process of HSCT. A systematic mixed studies review (SMSR) was based on Pluye and Hong’s framework to understand the role of spirituality in patients’ experiences while undergoing HSCT. We use the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement to report the results of integration. Fifteen original qualitative studies, 19 quantitative studies, and one mixed method study were included in the systematic mixed studies review. The evidence from the review revealed the following three themes: the spiritual experiences of HSCT patients, the spiritual coping styles of HSCT patients, and the spiritual need changes brought about by HSCT. Few medical institutions currently offer spiritual healing, although HSCT patients with different cultural backgrounds may have different spiritual experiences and spiritual coping styles. Psychotherapists or nurses should be considered to provide spiritual care for patients undergoing HSCT, to help patients cope with disease pressures, promote HSCT patients’ comfort, and improve their quality of life.

BACKGROUND: Studies suggest that black patients have better interactions, on average, with physicians of their own race. Whether this reflects greater “cultural competence” in race-concordant relationships, or other effects of race unrelated to physician behavior, is unclear. It is also unclear if physician race influences patient decision-making. OBJECTIVE: To determine whether physician race affects patients’ ratings of physicians and decision-making, independent of physician behavior. DESIGN: Randomized study using standardized video vignettes. PARTICIPANTS: Primary care patients with coronary risk factors or disease. INTERVENTIONS: Each participant viewed one of 16 vignettes depicting a physician reviewing cardiac catheterization results and recommending coronary artery bypass graft (CABG) surgery. Vignettes varied only in terms of physicians’ race, gender, age, and communication style (high vs. low patient-centeredness). MAIN MEASURES: Participants rated the video physician’s communication, interpersonal style, competence, trustworthiness, likability, and overall performance (0–4 Likert scales). They also rated the necessity of CABG (0–5 scale) and whether they would undergo CABG or obtain a second opinion if they were the video patient (0–3 scales). KEY RESULTS: Participants included 107 black and 131 white patients (72% participation rate). Black participants viewing a black (vs. white) video physician gave higher ratings on all physician attributes (e.g., overall rating 3.22 vs. 2.34, p

Uncontrolled hypertension contributes to disparities in cardiovascular outcomes. Patient intervention strategies informed by behavioral economics and social psychology could improve blood pressure (BP) control in disadvantaged minority populations. To assess the impact on BP control of an intervention combining short-term financial incentives with promotion of intrinsic motivation among highly disadvantaged patients. Randomized controlled trial. Two hundred seven adults (98% African American or Latino) aged 18 or older with uncontrolled hypertension attending Federally Qualified Health Centers. Six-month intervention, combining financial incentives for measuring home BP, recording medication use, BP improvement, and achieving target BP values with counseling linking hypertension control efforts to participants’ personal reasons to stay healthy. Primary outcomes: percentage achieving systolic BP (SBP)

Poor medication adherence contributes to inadequate control of hypertension. However, the value of adherence monitoring is unknown. To evaluate the impact of monitoring adherence with electronic pill bottles or bidirectional text messaging on improving hypertension control. Three-arm pragmatic randomized controlled trial. One hundred forty-nine primary care patients aged 18–75 with hypertension and text messaging capabilities who were seen at least twice in the prior 12 months with at least two out-of-range blood pressure (BP) measurements, including the most recent visit. Patients were randomized in a 1:2:2 ratio to receive (1) usual care, (2) electronic pill bottles for medication adherence monitoring (pill bottle), and (3) bidirectional text messaging for medication adherence monitoring (bidirectional text). Change in systolic BP during the final 4-month visit compared with baseline. At the 4-month follow-up visit, mean (SD) change values in systolic blood pressure were − 4.7 (23.4) mmHg in usual care, − 4.3 (21.5) mmHg in the pill bottle arm, and − 4.6 (19.8) mmHg in the text arm. There was no significant change in systolic blood pressure between control and the pill bottle arm (p = 0.94) or the text messaging arm (p = 1.00), and the two intervention arms did not differ from each other (p = 0.93). Despite good measured adherence, neither feedback with electronic pill bottles nor bidirectional text messaging about medication adherence improved blood pressure control. Adherence to prescribed medications was not improved enough to affect BP control or it was not the primary driver of poor control. clinicaltrials.gov (NCT02778542)

Women with Down syndrome have a lower breast cancer risk and significantly lower life expectancies than women without Down syndrome. Therefore, it is not clear whether mammography screening strategies used for women without Down syndrome would benefit women with Down syndrome in the same way. To determine the benefits and harms of various mammography screening strategies for women with Down syndrome using collaborative simulation modeling. Two established Cancer Intervention and Surveillance Modeling Network (CISNET) simulation models estimated the benefits and harms of various screening strategies for women with Down syndrome over a lifetime horizon. We modeled a hypothetical cohort of US women with Down syndrome who were born in 1970. Annual, biennial, triennial, and one-time digital mammography screenings during the ages 40–74. The models estimated numbers of mammograms, false-positives, benign biopsies, breast cancer deaths prevented, and life-years gained per 1000 screened women when compared with no screening. In average-risk women 50–74, biennial screening incurred 122 mammograms, 10 false-positive mammograms, and 1.4 benign biopsies per one life-year gained compared with no screening. In women with Down syndrome, the same screening strategy incurred 2752 mammograms, 242 false-positive mammograms, and 34 benign biopsies per one life-year gained compared with no screening. The harm/benefit ratio varied for other screening strategies, and was most favorable for one-time screening at age 50, which incurred 1629 mammograms, 144 false-positive mammograms, and 20 benign biopsies per one life-year gained compared with no screening. The harm/benefit ratios for various mammography screening strategies in women with Down syndrome are not as favorable as those for average-risk women. The benefit of screening mammography for women with Down syndrome is less pronounced due to lower breast cancer risk and shorter life expectancy.

Discontinuous Medicaid insurance erodes access to care, increases administrative costs, and exposes enrollees to substantial out-of-pocket spending. To assess the impact of Medicaid expansion under the Affordable Care Act on continuity of Medicaid coverage among those enrolled prior to expansion. Using a difference-in-differences framework, we compared Colorado, a state that expanded Medicaid, to Utah, a nonexpansion state, before and after Medicaid expansion implementation. Adults ages 18–62 who were enrolled in Medicaid coverage in Colorado and Utah prior to expansion, from the Utah and Colorado All Payer Claims Databases, 2013–2015. The primary outcomes were the duration of Medicaid enrollment and rates of disrupted coverage. Following Medicaid expansion, enrollees in Colorado gained an additional 2 months of coverage over two years of follow-up and were 16 percentage points less likely to experience a coverage disruption in a given year relative to enrollees in Utah. Increasing Medicaid eligibility levels under the Affordable Care Act appears to be an effective strategy to reduce churning in the Medicaid program, with important implications for other states that are considering Medicaid expansion.

Inpatient attending physicians may change during a patient’s hospital stay. This study measured the association of attending physician continuity and discharge probability. All patients admitted to general medicine service at a tertiary care teaching hospital in 2015 were included. Attending inpatient physician continuity was measured as the consecutive number of days each patient was treated by the same staff-person. Generalized estimating equation methods were used to model the adjusted association of attending inpatient physician continuity with daily discharge probability. 6301 admissions involving 41 internists, 5134 patients, and 38,242 patient-days were studied. The final model had moderate discrimination (c-statistic = 0.70) but excellent calibration (Hosmer-Lemeshow statistic 11.5, 18 df, p value 0.89). Daily discharge probability decreased significantly with greater severity of illness, higher patient death risk, and longer length of stay, on admission day, for elective admissions, and on the weekend. Discharge likelihood increased significantly with attending inpatient physician continuity; daily discharge probability increased for the average patient from 15.3 to 20.9% when the consecutive number of days the patient was treated by the same attending inpatient physician increased from 1 to 7 days. Inpatient attending physician continuity is significantly associated with the likelihood of patient discharge. This finding could be considered if resource utilization is a factor when scheduling attending inpatient physician coverage.

Previous studies have suggested that a healthy lifestyle (HL) may prolong the years of life spent in good health. However, the impact of HL on disability-free survival (DFS) among the elderly is still uncertain. To investigate the relationship between HL and DFS in the general elderly population. Prospective cohort study with a 10-year follow-up (2006–2016). 9910 community-dwelling elderly people (≥ 65 years). A HL index derived by summing the number of HL behaviors. Data on incident disability were retrieved from the public Long-term Care Insurance database. Multivariate-adjusted 50th percentile differences (PDs) in age at disability or death (months) and their 95% CIs were estimated with the Laplace regression model. During the 10 years, 4562 disability or death events occurred. Participants who adhered to all three HL behaviors lived 17.1 (95% CI 12.7, 21.5) months longer without disability than those who adhered to zero or one. Each 1-point increase of the index score conferred 8.8 months additional life without disability. The tendency for the 50th PDs to increase with a higher HL index score did not differ according to age (

BACKGROUND: The patient-centered medical home (PCMH) is an enhanced primary care model that aims to improve quality of care. Over the past several years, the PCMH model has been adopted by Medicare and private payers, which offer financial resources and technical assistance to participating practices. However, few studies have examined provider experiences and perspectives on the adoption of payer-based PCMH models in different practice settings. OBJECTIVE: The goal of this qualitative study was to analyze how providers experienced specific elements of a payer-based PCMH model and identify cross-cutting themes that can be applied to other payer-based PCMH initiatives. DESIGN: Observational qualitative study. PARTICIPANTS: A total of 65 individuals (which includes 57 primary care physicians) participated in focus group sessions. Telephone interviews were conducted with an additional 14 physicians and 2 practice administrators. APPROACH: Interviews and focus groups were recorded after obtaining the informed consent of participants. Written transcripts from the recordings were then imported into NVivo 11 for subsequent coding and qualitative analysis of themes. KEY RESULTS: We found that nurse care coordinators (NCCs) were the single most valuable and visible program element. Individual care plans served as effective tools of communication between the NCC and physician on patient care management goals and issues. The online data portal was viewed as the least valuable element. With regard to cross-cutting themes, some providers expressed a strained relationship with CareFirst due to communication challenges, a lack of trust, and differing priorities in selecting patients for care plans. CONCLUSION: Nurse care coordinators and the targeted use of individualized care plans are essential components in a payer-based PCMH program. Improving communication and trust in data reports are critical for effective implementation. Future research should examine provider experiences in other payer-based PCMH programs to see how interactions with payers affect program implementation. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05005-7) contains supplementary material, which is available to authorized users.

A clinically practical, brief, user-friendly, multi-domain self-report and caregiver-report tool is needed for tracking actionable symptoms in primary care for elderly patients with multiple chronic conditions (MCCs). Develop and assess usability, administration time, and internal reliability of SymTrak. Phase I: legacy instruments, content validity, analyses of existing data, focus groups (physicians, nurses, patients, informal caregivers), and Think Aloud interviews (patients, caregivers) were used to develop SymTrak. Phase II (pilot feasibility study): 81 (27 patient-caregiver dyads, 27 patients without an identified caregiver) participants were self-administered SymTrak in clinic. SymTrak and demographic questions. Consistent themes emerged from phase I focus groups. Ambiguous wording was corrected with Think Aloud feedback. In phase II, patients and caregivers preferred circling words instead of numbers for item response options. SymTrak self-administration completion time in clinic was brief; mean was 2.4, 3.0, and 3.3 min for the finalized circlingwords version, respectively, for caregivers, dyadic patients, and patients without a caregiver; and the maximum was 6.2 min for any participant. Usability questionnaire ratings were high. Cronbach’s alpha for the SymTrak 23-item total score was 0.86, 0.79, and 0.81 for caregivers, dyadic patients, and patients without a caregiver, respectively. SymTrak demonstrates content validity, positive qualitative findings, high perceived usability, brief self-administered completion time, and good internal reliability.

BackgroundPatient activation is associated with better outcomes in chronic conditions.ObjectiveWe evaluated the psychometric properties of the 12-item Altarum Consumer Engagement™ Measure (ACE-12) in patients with prediabetes.ParticipantsACE-12 was administered to patients in the Prediabetes Informed Decisions and Education Study.Main measuresWe conducted an exploratory factor analysis followed by confirmatory factor analytic models. We evaluated item response categories using item characteristic curves. Construct validity was assessed by examining correlations of the ACE-12 scales with education, depressive symptoms, self-rated health, hemoglobin A1c, body mass index, and weight loss.Key resultsParticipants (n = 515) had a median age of 58; 56% were female; 17% Hispanic; 54% were non-White. The scree plot and Tucker and Lewis reliability coefficient (0.95) suggested three factors similar to the original scales. One item loaded on the navigation rather than the informed choice scale. Ordinal alpha coefficients for the original scales were commitment (0.75); informed choice (0.71); and navigation (0.54). ICCs indicated that one or more of the response categories for 5 of the 12 items were never most likely to be selected. Patients with lower education were less activated on the commitment (r = - 0.124, p = 0.004), choice (r = - 0.085, p = 0.009), and overall score (r = - 0.042, p = 0.011). Patients with depressive symptoms had lower commitment (r = - 0.313, p ≤ 0.001) and overall scores (r = - 0.172, p = 0.012). Patients with poorer health scored lower on the Commitment (r = - 0.308, p ≤ 0.001), Navigation (r = - 0.137, p ≤ 0.001), and overall score (r = - 0.279, p ≤ 0.001).ConclusionThe analyses provide some support for the psychometric properties of the ACE-12 in prediabetic patients. Future research evaluating this tool among patients with other chronic conditions are needed to determine whether Q1 (I spend a lot of time learning about health) should remain in the informed choice or be included in the navigation scale. Additional items may be needed to yield acceptable reliability for the navigation scale.

BACKGROUND: Epidemiological, imaging, and anatomical studies suggest an association between proximal arterial atherosclerosis and development of low back pain (LBP). OBJECTIVES: We aimed to define (1) the frequency and (2) factors associated with exercise-induced proximal ischemia (EIPI) in individuals with LBP and (3) develop a clinical screening scale. DESIGN: Monocentric cross-sectional study. PARTICIPANTS: All patients with history of ongoing LBP referred to our exercise investigation laboratory for exercise transcutaneous oximetry (ex-tcPO(2)) between January 2011 and December 2017 (n = 542; mean age, 65.4 ± 10.9; 83.9% men). MAIN MEASURES: EIPI was defined as a decrease from rest of oxygen pressure (DROP) below − 15 mmHg on the lumbar and/or buttock probes. Ex-tcPO(2) is a reliable validated tool for diagnosing EIPI in comparison with arteriography and computed tomography angiography. Ex-tcPO(2) was performed on a treadmill until symptom manifestation or exhaustion. Clinical data were collected using interview questionnaires, medical file review, and clinical examination. KEY RESULTS: EIPI was diagnosed in 282 patients (52%). Age ≤ 70 years (OR, 2.22; 95% CI, 1.35–3.57; p = 0.002), a history of proximal revascularization (OR, 2.64; 95% CI, 1.50–4.65; p = 0.001), use of antiplatelet medication (OR, 1.71; 95% CI, 0.96–3.06; p = 0.069), a relationship between exercise and LBP (OR, 2.61; 95% CI, 1.49–4.57; p = 0.001), and an abnormal ankle to brachial index (OR, 2.87; 95% CI, 1.77–4.66; p

As of 2019, 37 US states have breast density notification laws. No qualitative study to date has examined women's perspectives about breast density in general or by states with and without notification laws.Explore women's knowledge and perceptions of breast density and experiences of breast cancer screening across three states with and without notification laws.Qualitative research design using four focus groups conducted in 2017.Forty-seven women who had a recent normal mammogram and dense breasts in registry data obtained through the Breast Cancer Surveillance Consortium.Focus groups were 90 min, audio recorded, and transcribed for analysis. Data were analyzed using mixed deductive and inductive coding.Women reported variable knowledge levels of personal breast density and breast density in general, even among women living in states with a notification law. A number of women were aware of the difficulty of detecting cancer with dense breasts, but only one knew that density increased breast cancer risk. Across all states, very few women reported receiving information about breast density during healthcare visits beyond being encouraged to get supplemental imaging or to pay for new mammography technology (i.e., breast tomosynthesis). Women offered more imaging or different technology held strong convictions that these were "better," even though knowledge of differences, effectiveness, or harms across technologies seemed limited. Women from all states expressed a strong desire for more information about breast density.More research needs to be done to understand how the medical community can best assist women in making informed decisions related to breast density, mammography, and supplemental screening. Options to explore include improved breast density notifications and education materials about breast density, continued development of personalized risk information tools, strategies for providers to discuss evidence and options based on risk stratification, and shared decision-making.

BACKGROUND: People with chronic kidney disease (CKD) are at risk for adverse events and/or CKD progression with use of renally eliminated or nephrotoxic medications. OBJECTIVE: To examine the prevalence of potentially inappropriate medication (PIM) use by U.S. adults by CKD stage and self-reported CKD awareness. DESIGN: Cross-sectional analysis of National Health and Nutrition Examination Surveys, 2011–2016 PARTICIPANTS: Non-pregnant adults with stages 3a (eGFR 45–59 mL/min/1.73 m(2)), 3b (eGFR 30–44), or 4–5 (eGFR < 30) CKD, stratified as CKD-aware/unaware. MAIN MEASURES: PIMs were identified on the basis of KDIGO guidelines, label information, and literature review. We calculated proportions using any and individual PIMs, assessing for differences over CKD awareness within each CKD stage. Analyses were adjusted for age, sex, race/ethnicity, education, comorbidities, and insurance type. KEY RESULTS: Adjusted proportions of U.S. adults taking any PIM(s) exceeded 50% for all CKD stages and awareness categories, and were highest among CKD-unaware patients with stages 4–5 CKD: 66.6% (95% CI, 55.5–77.8). Proton pump inhibitors, opioids, metformin, sulfonylureas, and non-steroidal anti-inflammatory drugs (NSAIDs) were all used frequently across CKD stages. NSAIDs were used less frequently when CKD-aware by patients with stage 3a CKD (2.2% [95% CI, − 0.3 to 4.7] vs. 10.7% [95% CI, 7.6 to 13.8]) and stages 4–5 CKD (0.8% [95% CI, − 0.9 to 2.5] vs. 16.5% [95% CI, 4.0 to 29.0]). Metformin was used less frequently when CKD-aware by patients with stage 3b CKD (8.1% [95% CI, 0.3–15.9] vs. 26.5% [95% CI, 17.4–35.7]) and stages 4–5 CKD (none vs. 20.8% [95% CI, 1.8–39.8]). The impact of CKD awareness was statistically significant after correction for multiple comparisons only for NSAIDs in stage 3a CKD. CONCLUSIONS: PIMs are frequently used by people with CKD, with some impact of CKD awareness on NSAID and metformin use. This may lead to adverse outcomes or hasten CKD progression, reinforcing the need for improved medication management among people with CKD. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05557-8) contains supplementary material, which is available to authorized users.

BACKGROUND: Half of women undergoing mammography have dense breasts. Mandatory dense breast notification and educational materials have been shown to confuse women, rather than empower them. OBJECTIVE: This study used a mixed method, multi-stakeholder approach to assess acceptability of an interactive, computer-animated agent that provided breast density information to women and changes in knowledge, satisfaction, and informational needs. DESIGN: A pre-post survey and qualitative focus groups assessed the acceptability of the computer-animated agent among women. An anonymous, online survey measuring acceptability was delivered to a multi-stakeholder group. PARTICIPANTS: English-speaking, mammography-eligible women ages 40–74 were invited and 44 women participated in one of nine focus groups. In addition, 14 stakeholders representing primary care, radiology, patient advocates, public health practitioners, and researchers completed the online survey. INTERVENTIONS: A prototype of a computer-animated agent was delivered to women in a group setting; stakeholders viewed the prototype independently. MAIN MEASURES: Data collected included open-ended qualitative questions that guided discussion about the content and form of the computer-animated agent. Structured surveys included domains related to knowledge, acceptability, and satisfaction. Stakeholder acceptability was measured with a series of statements about aspects of the intervention and delivery approach and are reported as the proportion of respondents who endorsed each statement. KEY RESULTS: Six of 12 knowledge items demonstrated improvement post-intervention, satisfaction with the agent was high (81%), but the number of unanswered questions did not improve (67% vs. 54%, p = 0.37). Understanding of the distinction between connective and fatty tissue in the breast did not increase (30% vs. 26%, p = 0.48). Results of the multi-stakeholder survey suggest broad acceptability of the approach and agent. CONCLUSIONS: Findings highlight the benefits of a brief interactive educational exposure as well as misperceptions that persisted. Results demonstrate the need for an evidence-based, accessible intervention that is easy to understand for patients.

Little is known about the frequency, patterns, and determinants of readmissions among patients initially hospitalized for an ambulatory care-sensitive condition (ACSC). The degree to which hospitalizations in close temporal proximity cluster has also not been studied. Readmission patterns involving clustering likely reflect different underlying determinants than the same number of readmissions more evenly spaced.To characterize readmission rates, patterns, and predictors among patients initially hospitalized with an ACSC.Retrospective analysis of the 2010-2014 Nationwide Readmissions Database.Non-pregnant patients aged 18-64 years old during initial ACSC hospitalization and who were discharged alive (N = 5,007,820).Frequency and pattern of 30-day all-cause readmissions, grouped as 0, 1, 2+ non-clustered, and 2+ clustered readmissions.Approximately 14% of patients had 1 readmission, 2.4% had 2+ non-clustered readmissions, and 3.3% patients had 2+ clustered readmissions during the 270-day follow-up. A higher Elixhauser Comorbidity Index was associated with increased risk for all readmission groups, namely with adjusted odds ratios (AORs) ranging from 1.12 to 3.34. Compared to patients aged 80 years and older, those in younger age groups had increased risk of 2+ non-clustered and 2+ clustered readmissions (AOR range 1.27-2.49). Patients with chronic versus acute ACSCs had an increased odds ratio of all readmission groups compared to those with 0 readmissions (AOR range 1.37-2.69).Among patients with 2+ 30-day readmissions, factors were differentially distributed between clustered and non-clustered readmissions. Identifying factors that could predict future readmission patterns can inform primary care in the prevention of readmissions following ACSC-related hospitalizations.

Although hip fractures in older adults are associated with a high degree of mortality and disability, the use of advance care planning (ACP) in this population is unknown.To determine the prevalence of ACP and need for surrogate decision-making prior to death in older adults with hip fracture and to identify factors associated with ACP.Retrospective cohort study using Health and Retirement Study (HRS) interviews linked to Medicare fee-for-service claims data.Six hundred six decedent participants aged 65 or older who sustained a hip fracture during HRS enrollment and had a proxy participate in the exit HRS survey.Survey responses by proxies were used to determine ACP, defined by either advance directive completion or surrogate designation, and to assess decision-making at the end of life. Multivariate logistic regression was used to analyze correlates of ACP.Prior to death, 54.9% of all participants had an advance directive and 68.9% had designated a surrogate decision-maker; however, 24.5% had no ACP. Of the total cohort, 32.5% required decisions to be made about treatment at the end of life and lacked capacity to make these decisions themselves. In this subset, 19.9% had no ACP. In all participants, ACP was less likely in non-white individuals (adjusted odds ratio (aOR) 0.14, 95% CI 0.06-0.31), those with less than a high school education (aOR 0.58, 95% CI 0.35-0.97), and those with a net worth below the median of the cohort (aOR 0.49, 95% CI 0.26-0.72). No clinical factors were found to be associated with ACP completion prior to death.A considerable number of older adults with hip fracture required surrogate decision-making at the end of life, of whom one fifth had no ACP prior to death. Clinicians providing care for these patients are uniquely poised to address ACP.

BACKGROUND: Understanding ethical concerns that arise in the care of patients with advanced kidney disease may help identify opportunities to support medical decision-making. OBJECTIVE: To describe the clinical contexts and types of ethical concerns that arise in the care of patients with advanced kidney disease. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 28,568 Veterans with advanced kidney disease between 2000 and 2009 followed through death or 2011. EXPOSURE: Clinical scenarios that prompted clinicians to consider an ethics consultation as documented in the medical record. MAIN MEASURES: Dialysis initiation, dialysis discontinuation, receipt of an intensive procedure during the final month of life, and hospice enrollment. KEY RESULTS: Patients had a mean age of 67.1 years, and the majority were male (98.5%) and white (59.0%). Clinicians considered an ethics consultation for 794 patients (2.5%) over a median follow-up period of 2.7 years. Ethical concerns involved code status (37.8%), dialysis (54.5%), other invasive treatments (40.6%), and noninvasive treatments (61.1%) and were related to conflicts between patients, their surrogates, and/or clinicians about treatment preferences (79.3%), who had authority to make healthcare decisions (65.9%), and meeting the care needs of patients versus obligations to others (10.6%). Among the 20,583 patients who died during follow-up, those for whom clinicians had considered an ethics consultation were less likely to have been treated with dialysis (47.6% versus 62.0%, adjusted odds ratio [aOR] 0.63, 95% CI 0.53–0.74), more likely to have discontinued dialysis (32.5% versus 20.9%, aOR 2.07, CI 1.61–2.66), and less likely to have received an intensive procedure in the last month of life (8.9% versus 18.9%, aOR 0.41, CI 0.32–0.54) compared with patients without documentation of clinicians having considered consultation. CONCLUSIONS: Clinicians considered an ethics consultation for patients with advanced kidney disease in situations of conflicting preferences regarding dialysis and other intensive treatments, especially when these treatments were not pursued. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05466-w) contains supplementary material, which is available to authorized users.

Background Clinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine (LS-MRI) is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded LS-MRIs do not improve patient outcomes, lead to unnecessary surgeries and procedures, and cost the US healthcare system about $300 million dollars per year. However, why primary care providers (PCPs) order unneeded LS-MRI for acute, uncomplicated low-back pain is poorly understood. Objective To characterize and explain the factors contributing to PCPs ordering unneeded LS-MRI for acute, uncomplicated low-back pain. Design Qualitative study using semi-structured interviews. Participants Veterans Affairs PCPs identified from administrative data as having high or low rates of guideline-concordant LS-MRI ordering in 2016. Approach Providers were interviewed about their use of LS-MRI for acute, uncomplicated low-back pain and factors contributing to their decision-making. Directed content analysis of transcripts was conducted to identify and compare environmental-, patient-, and provider-level factors contributing to unneeded LS-MRI. Key Results Fifty-five PCPs participated (8.6% response rate). Both low (n = 33) and high (n = 22) guideline-concordant providers reported that LS-MRIs were required for specialty care referrals, but they differed in how other environmental factors (stringency of radiology utilization review, management of patient travel burden, and time constraints) contributed to LS-MRI ordering patterns. Low- and high-guideline-concordant providers reported similar patient factors (beliefs in value of imaging and pressure on providers). However, provider groups differed in how provider-level factors (guideline familiarity and agreement, the extent to which they acquiesced to patients, and belief in the value of LS-MRI) contributed to LS-MRI ordering patterns. Conclusions Results describe how diverse environmental, patient, and provider factors contribute to unneeded LS-MRI for acute, uncomplicated low-back pain. Prior research using a single intervention to reduce unneeded LS-MRI has been ineffective. Results suggest that multifaceted de-implementation strategies may be required to reduce unneeded LS-MRI. Electronic supplementary material The online version of this article (10.1007/s11606-019-05410-y) contains supplementary material, which is available to authorized users.

Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably. We sought to identify factors associated with the decision to admit patents with TIA. We conducted a secondary analysis of a prior study’s data including semi-structured interviews, administrative data, and chart review. We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011. For the qualitative data, we focused on interviewees’ responses to the prompt: “Tell me what influences you in the decision to or not to admit TIA patients.” We used administrative data to identify admission rates and chart review data to identify ABCD2 scores (a tool to classify stroke risk after TIA). Providers’ decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD2 score, and concerns about facilities’ ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD2 scores and related guidelines in admission decision-making. Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians’ uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies.

Decades of persuasive messages have reinforced the importance of traditional screening mammography at regular intervals. A potential new paradigm, risk-based screening, adjusts mammography frequency based on a woman’s estimated breast cancer risk in order to maximize mortality reduction while minimizing false positives and overdiagnosis. Women’s views of risk-based screening are unknown. To explore women’s views and personal acceptability of a potential risk-based mammography screening paradigm. Four semi-structured focus group discussions about screening mammography and surveys before provision of information about risk-based screening. We analyzed coded focus group transcripts using a mixed deductive (content analysis) and inductive (grounded theory) approach. Convenience sample of 29 women (40–74 years old) with no personal history of breast cancer recruited by print and online media in New Hampshire and Vermont. Twenty-seven out of 29 women reported having undergone mammography screening. All participants were white and most were highly educated. Some women accepted the idea that early cancer detection with traditional screening was beneficial—although many also reported hearing inconsistent recommendations from clinicians and mixed messages from media reports about mammography. Some women were familiar with a risk-based screening paradigm (primarily related to cervical cancer, n = 8) and thought matching screening mammography frequency to personal risk made sense (n = 8). Personal acceptability of risk-based screening was mixed. Some believed risk-based screening could reduce the harms of false positives and overdiagnosis (n = 7). Others thought screening less often might result in missing a dangerous diagnosis (n = 14). Many (n = 18) expressed concerns about the feasibility of risk-based screening and questioned whether breast cancer risk estimates could be accurate. Some suspected that risk-based mammography was motivated by a desire to save money (n = 6). Some women thought risk-based screening made sense. Willingness to abandon traditional screening for the new paradigm was mixed. Broad acceptability of risk-based screening will require clearer communication about its rationale and feasibility and consistent messages from the health care team.

Sleep impairment is highly prevalent among resident physicians and is associated with both adverse patient outcomes and poor resident mental and physical health. Risk factors for sleep problems during residency are less clear, and no screening model exists to identify residents at risk for sleep impairment. The objective of this study was to assess change in resident sleep during training and to evaluate utility of baseline sleep screening in predicting future sleep impairment. This is a prospective observational repeated-measures survey study. The participants comprised PGY-1 residents across multiple specialties at Partners HealthCare hospitals. Main measures used for this study were demographic queries and two validated scales: the Pittsburgh Sleep Quality Index (PSQI), measuring sleep quality, and the Epworth Sleepiness Scale (ESS), measuring excessive daytime sleepiness. Two hundred eighty-one PGY-1 residents completed surveys at residency orientation, and 153 (54%) completed matched surveys 9 months later. Mean nightly sleep time decreased from 7.6 to 6.5 hours (p

Depression is prevalent and costly, but despite effective treatments, is often untreated. Recent efforts to improve depression care have focused on primary care settings. Disparities in treatment initiation for depression have been reported, with fewer minority and older individuals starting treatment. To describe patient characteristics associated with depression treatment initiation and treatment choice (antidepressant medications or psychotherapy) among patients newly diagnosed with depression in primary care settings. A retrospective observational design was used to analyze electronic health record data. A total of 241,251 adults newly diagnosed with depression in primary care settings among five health care systems from 2010 to 2013. ICD-9 codes for depression, following a 365-day period with no depression diagnosis or treatment, were used to identify new depression episodes. Treatment initiation was defined as a completed psychotherapy visit or a filled prescription for antidepressant medication within 90 days of diagnosis. Depression severity was measured with Patient Health Questionnaire (PHQ-9) scores on the day of diagnosis. Overall, 35.7% of patients with newly diagnosed depression initiated treatment. The odds of treatment initiation among Asians, non-Hispanic blacks, and Hispanics were at least 30% lower than among non-Hispanic whites, controlling for all other variables. The odds of patients aged ≥ 60 years starting treatment were half those of patients age 44 years and under. Treatment initiation increased with depression severity, but was only 53% among patients with a PHQ-9 score of ≥ 10. Among minority patients, psychotherapy was initiated significantly more often than medication. Screening for depression in primary care is a positive step towards improving detection, treatment, and outcomes for depression. However, study results indicate that treatment initiation remains suboptimal, and disparities persist. A better understanding of patient factors, and particularly system-level factors, that influence treatment initiation is needed to inform efforts by heath care systems to improve depression treatment engagement and to reduce disparities.

BACKGROUND: Early detection of melanoma represents an opportunity to reduce the burden of disease among people at increased risk for melanoma. OBJECTIVE: To develop and demonstrate the efficacy of online training. DESIGN: Randomized educational trial. PARTICIPANTS: Primary care providers (PCPs). INTERVENTION: Mastery learning course with visual and dermoscopic assessment, diagnosis and management, and deliberate practice with feedback to reach a minimum passing standard. MAIN MEASURES: Pre-test/post-test diagnostic accuracy. Referral of concerning lesions for 3 months before and after the educational intervention. KEY RESULTS: Among the 89 PCPs, 89.8% were internal medicine physicians, and the remainder were physician assistants embedded in internists’ practices. There were no differences between control and intervention groups regarding gender, age, race, or percentage of full-time PCPs. The control group had more PCPs who reported less than 5 years of practice (n = 18) than the intervention group (n = 6) (χ(2) [6, n = 89] = 14.34, p = 0.03). PCPs in the intervention group answered more melanoma detection questions correctly on the post-test (M = 10.05, SE = 1.24) compared to control group PCPs (M = 7.11, SE = 0.24), and had fewer false-positive and no false-negative melanoma diagnoses (intervention, M = 1.09, SE = 0. 20; control, M = 3.1, SE = 0.23; ANCOVA, F[1,378] =27.86, p

The decision to initiate insulin in patients with type 2 diabetes is a challenging escalation of care that requires an individualized approach. However, the sociodemographic and clinical factors affecting insulin initiation are not well understood. We sought to identify patient factors that were independent predictors of insulin initiation among participants in the Look AHEAD (Action for Health in Diabetes) clinical trial. Retrospective analysis of a randomized clinical trial. Beginning in 2001, Look AHEAD enrolled ambulatory U.S. adults with type 2 diabetes who were overweight or obese and had a primary healthcare provider. Participants were randomized (1:1) to an intensive lifestyle intervention, or diabetes support and education. This study examined 3913 participants across the two trial arms who were not using insulin at baseline. We used Cox proportional hazards models to estimate the association between participant characteristics and time to insulin initiation. We performed time-varying adjustment for HbA1c measured eight times over the 10-year study period, as well as for multiple clinical and socioeconomic factors. A total of 1087 participants (27.8%) initiated insulin during a median follow-up of 8.0 years. Age was inversely associated with insulin initiation (adjusted hazard ratio [aHR] 0.88 per 10 years, P = 0.025). The risk of insulin initiation was greater with a higher number of diabetes complications (P

Patients with chronic pain often lack the skills and resources necessary to manage this disease. To develop a chronic pain self-management program reflecting community stakeholders’ priorities and to compare functional outcomes from training in two settings. A parallel-group randomized trial. Eligible subjects were 35–70 years of age, with chronic non-cancer pain treated with opioids for >2 months at two primary care and one HIV clinic serving low-income Hispanics. In one study arm, the 6-month program was delivered in monthly one-on-one clinic meetings by a community health worker (CHW) trained as a chronic pain health educator, and in the second arm, content experts gave eight group lectures in a nearby library. Five times Sit-to-Stand test (5XSTS) assessed at baseline and 3 and 6 months. Other reported physical and cognitive measures include the 6-Min Walk (6 MW), Borg Perceived Effort Test (Borg Effort), 50-ft Speed Walk (50FtSW), SF-12 Physical Component Summary (SF-12 PCS), Patient-Specific Functional Scale (PSFS), and Symbol–Digit Modalities Test (SDMT). Intention-to-treat (ITT) analyses in mixed-effects models adjust for demographics, body mass index, maximum pain, study arm, and measurement time. Multiple imputation was used for sensitivity analyses. Among 111 subjects, 53 were in the clinic arm and 58 in the community arm. In ITT analyses at 6 months, subjects in both arms performed the 5XSTS test faster (−4.9 s, P = 0.001) and improved scores on Borg Effort (−1, P = 0.02), PSFS (1.6, P

In 2012, nearly one-third of adults 65 years or older with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between the hospital and HHC is frequently inadequate and may contribute to medication errors and readmissions. Insights from HHC nurses could inform improvements to care coordination. To describe HHC nurse perspectives about challenges and solutions to coordinating care for recently discharged patients. We conducted a descriptive qualitative study with six focus groups of HHC nurses and staff (n = 56) recruited from six agencies in Colorado. Focus groups were recorded, transcribed, and analyzed using a mixed deductive/inductive approach to theme analysis with a team-based iterative method. HHC nurses described challenges and solutions within domains of Accountability, Communication, Assessing Needs & Goals, and Medication Management. One additional domain of Safety, for both patients and HHC nurses, emerged from the analysis. Within each domain, solutions for improving care coordination included the following: 1) Accountability—hospital physicians willing to manage HHC orders until primary care follow-up, potential legislation allowing physician assistants and nurse practitioners to write HHC orders; 2) Communication—enhanced access to hospital records and direct telephone lines for HHC; 3) Assessing Needs & Goals—liaisons from HHC agencies meeting with patients in hospital; 4) Medication Management—HHC coordinating directly with clinician or pharmacist to resolve discrepancies; and 5) Safety—HHC nurses contributing non-reimbursable services for patients, and ensuring that cognitive and behavioral health information is shared with HHC. In an era of shared accountability for patient outcomes across settings, solutions for improving care coordination with HHC are needed. Efforts to improve care coordination with HHC should focus on clearly defining accountability for orders, enhanced communication, improved alignment of expectations for HHC between clinicians and patients, a focus on reducing medication discrepancies, and prioritizing safety for both patients and HHC nurses.

Medical management of acute pain among hospital inpatients may be enhanced by mind-body interventions.We hypothesized that a single, scripted session of mindfulness training focused on acceptance of pain or hypnotic suggestion focused on changing pain sensations through imagery would significantly reduce acute pain intensity and unpleasantness compared to a psychoeducation pain coping control. We also hypothesized that mindfulness and suggestion would produce significant improvements in secondary outcomes including relaxation, pleasant body sensations, anxiety, and desire for opioids, compared to the control condition.This three-arm, parallel-group randomized controlled trial conducted at a university-based hospital examined the acute effects of 15-min psychosocial interventions (mindfulness, hypnotic suggestion, psychoeducation) on adult inpatients reporting "intolerable pain" or "inadequate pain control." Participants (N = 244) were assigned to one of three intervention conditions: mindfulness (n = 86), suggestion (n = 73), or psychoeducation (n = 85).Participants in the mind-body interventions reported significantly lower baseline-adjusted pain intensity post-intervention than those assigned to psychoeducation (p 0.001, percentage pain reduction: mindfulness = 23%, suggestion = 29%, education = 9%), and lower baseline-adjusted pain unpleasantness (p 0.001). Intervention conditions differed significantly with regard to relaxation (p 0.001), pleasurable body sensations (p = 0.001), and desire for opioids (p = 0.015), but all three interventions were associated with a significant reduction in anxiety (p 0.001).Brief, single-session mind-body interventions delivered by hospital social workers led to clinically significant improvements in pain and related outcomes, suggesting that such interventions may be useful adjuncts to medical pain management.Trial Registry: ClinicalTrials.gov ; registration ID number: NCT02590029 URL: https://clinicaltrials.gov/ct2/show/NCT02590029.

Benzodiazepines and benzodiazepine-receptor agonists (BDZRAs, often known as "Z-drugs") are commonly used in older adults despite well-documented harms.To evaluate patterns of benzodiazepine and BDZRA use in Israel, focusing on potential leverage points where quality improvement initiatives might effectively curtail new use or the transition from intermittent to chronic use.We used national electronic medical data to assess a 10% random sample of adults receiving care in Clalit Health Services, which serves half of Israel's population. The sample included 267,221 adults, of whom 56,808 (21%) were age 65 and older.Medication use from 2013 to 2015 was ascertained using pharmacy dispensing data.In 2014, 7% of adults age 21-64 and 32% of adults age 65 and older received at least one benzodiazepine/BDZRA, including 49% of adults age 85 and older (P 0.001). The majority of older users (59%) were long-term users of the drugs, and 21% of older adults who were short-term users in 2014 transitioned to medium- or long-term use in 2015. Older Arab Israelis were much less likely to receive benzodiazepine/BDZRAs than older Jewish Israelis (adjusted OR 0.28, 95% 0.25-0.31), but within each community there was no major variation in prescribing rates across clinics. Depression diagnosis was associated with particularly high rates of benzodiazepine/BDZRA use: 17% of older adults with depression received a benzodiazepine/BDZRA but no antidepressant, and 42% received both. Recent hospitalization increased the risk of new benzodiazepine/BDZRA use (adjusted OR 1.41, 95% CI 1.01-1.96), but the absolute risk increase was only 3%.Benzodiazepines/BDZRAs are used at exceptionally high rates by older Israeli adults, especially the oldest old. Important leverage points for quality improvement efforts include curtailing the transition from short-term to long-term use, reducing use in older adults with depression, and identifying reasons that explain large differences in benzodiazepine/BDZRA prescribing between different ethnic groups.

Having more than one chronic condition is common and is associated with greater health care utilization, higher medication burden and complexity of treatment. However, clinical practice guidelines (CPGs) do not routinely address the balance between harms and benefits of treatments for people with multiple chronic conditions (MCCs).To partner with the Kaiser Permanente Integrated Cardiovascular Health (ICVH) program to engage multiple stakeholders in a mixed-methods approach in order to: 1) identify two high-priority clinical questions related to MCCs, and 2) understand patients' and family caregivers' perceptions of meaningful outcomes to inform benefit/harm assessments for these two high-priority questions. These clinical questions and outcomes will be used to inform CPG recommendations for people with MCCs. DESIGN AND PARTICIPANTS: The ICVH program provided 130 topics rank-ordered by the potential for finding evidence that would change clinical recommendations regarding the topic. We used a modified Delphi method to identify and reword topics into questions relevant to people with MCCs. We used two sets of focus groups (n = 27) to elicit patient and caregiver perspectives on two important research questions and relevant patient-important outcomes on benefit/harm balance for people with MCCs.Co-investigators, patients and caregivers identified "optimal blood pressure goals" and "diabetes medication management" as important clinical topics for CPGs related to people with MCCs. Stakeholders identified a list of relevant outcomes to be addressed in future CPG development including 1) physical function and energy, 2) emotional health and well-being, 3) avoidance of treatment burden, side effects and risks, 4) interaction with providers and health care system, and 5) prevention of adverse long-term health outcomes.Through the application of a mixed-methods process, we identified the questions regarding optimal blood pressure goals and diabetes medication management, along with related patient-centered outcomes, to inform novel evidence syntheses for those with MCCs. This study provides the lessons learned and a generalizable process for CPG developers to engage patient and caregivers in priority-setting for the translation of evidence into future CPGs. Ultimately, engaging patient and stakeholders around MCCs could improve the relevance of CPGs for the care of people with MCCs.

Diabetes disproportionately affects African Americans and is associated with poorer outcomes. Self-management is important for glycemic control; however, evidence in African Americans is limited.To assess the efficacy of a combined telephone-delivered education and behavioral skills intervention (TBSI) in reducing hemoglobin A1c (HbA1c) levels in African Americans with type 2 diabetes, using a factorial design.This is a four-year randomized clinical trial, using a 2 x 2 factorial design.: Participants: African American adults ≥18 years) with poorly controlled type 2 diabetes (HbA1c ≥9%) were randomly assigned to one of four groups: 1) knowledge only, 2) skills only, 3) combined knowledge and skills (TBSI), or 4) control group.All participants received 12 telephone-delivered 30-min intervention sessions specific to their assigned group. Participants were assessed at baseline and 3, 6, and 12 months.The primary outcome was HbA1c at 12 months post-randomization in the intent-to-treat (ITT) population.Two hundred fifty-five participants were randomly assigned to the four groups. Based on the ITT population after multiple imputation, the analysis of covariance with baseline HbA1c as the covariate showed that HbA1c at 12 months for the intervention groups did not differ significantly from that of the control group (knowledge: 0.49, p = 0.123; skills: 0.23, p = 0.456; combined: 0.48, p = 0.105). Absolute change from baseline at 12 months for all treatment arms was 0.6. Longitudinal mixed effects analysis showed that, on average, there was a significant decline in HbA1c over time for all treatment groups (-0.07, p 0.001). However, the rates of decline for the intervention groups were not significantly different from that of the control group (knowledge: 0.06, p = 0.052; skills: 0.02, p = 0.448; combined: 0.05, p = 0.062). Results from per-protocol populations were similar.For African Americans with poorly controlled type 2 diabetes, combined education and skills training did not achieve greater reductions in glycemic control (i.e., HbA1c levels) at 12 months compared to the control group, education alone, or skills training alone. This trial is registered with ClinicalTrials.gov, identifier no. NCT00929838.

A practical instrument is needed to reliably measure the clinical learning environment and professionalism for residents. To develop and present evidence of validity of an instrument to assess the culture of residency programs and the clinical learning environment. During 2014–2015, we surveyed residents using the C - Change Resident Survey to assess residents’ perceptions of the culture in their programs. Residents in all years of training in 34 programs in internal medicine, pediatrics, and general surgery in 14 geographically diverse public and private academic health systems. The C - Change Resident Survey assessed residents’ perceptions of 13 dimensions of the culture: Vitality, Self-Efficacy, Institutional Support, Relationships/Inclusion, Values Alignment, Ethical/Moral Distress, Respect, Mentoring, Work–Life Integration, Gender Equity, Racial/Ethnic Minority Equity, and self-assessed Competencies. We measured the internal reliability of each of the 13 dimensions and evaluated response process, content validity, and construct-related evidence validity by assessing relationships predicted by our conceptual model and prior research. We also assessed whether the measurements were sensitive to differences in specialty and across institutions. A total of 1708 residents completed the survey [internal medicine: n = 956, pediatrics: n = 411, general surgery: n = 311 (51% women; 16% underrepresented in medicine minority)], with a response rate of 70% (range across programs, 51–87%). Internal consistency of each dimension was high (Cronbach α: 0.73–0.90). The instrument was able to detect significant differences in the learning environment across programs and sites. Evidence of validity was supported by a good response process and the demonstration of several relationships predicted by our conceptual model. The C - Change Resident Survey assesses the clinical learning environment for residents, and we encourage further study of validity in different contexts. Results could be used to facilitate and monitor improvements in the clinical learning environment and resident well-being.

Despite the benefits of influenza vaccination, each year more than half of adults in the United States do not receive it.To evaluate the association between an active choice intervention in the electronic health record (EHR) and changes in influenza vaccination rates.Observational study.Adults eligible for influenza vaccination with a clinic visit at one of three internal medicine practices at the University of Pennsylvania Health System between September 2010 and March 2013.The EHR confirmed patient eligibility during the clinic visit and, upon accessing the patient chart, prompted the physician and their medical assistant to actively choose to "accept" or "cancel" an order for the influenza vaccine.Change in influenza vaccination order rates at the intervention practice compared to two control practices for the 2012-2013 flu season, comparing trends during the prior two flu seasons adjusting for time trends and patient and clinic visit characteristics.The sample (n = 45,926 patients) was 62.9% female, 35.9% white, and 54.4% black, with a mean age of 50.2 years. Trends were similar between practices during the 2 years in the pre-intervention period. Vaccination rates increased in both groups in the post-intervention year, but the intervention practice using active choice had a significantly greater increase than the control (adjusted difference-in-difference: 6.6 percentage points; 95% CI, 5.1-8.1; P 0.001), representing a 37.3% relative increase compared to the pre-intervention period. More than 99.9% (9938/9941) of orders placed during the study period resulted in vaccination.Active choice through the EHR was associated with a significant increase in influenza vaccination rates.

Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians.To study the associations of burnout among primary care providers (PCPs), nurse care managers, clinical associates (MAs, LPNs), and administrative clerks with the staffing and workload on their teams.We conducted an individual-level cross-sectional analysis of survey and administrative data in 2014.Primary care personnel at VA clinics responding to a national survey.Burnout was measured with a validated single-item survey measure dichotomized to indicate the presence of burnout. The independent variables were survey measures of team staffing (having a fully staffed team, serving on multiple teams, and turnover on the team), and workload both from survey items (working extended hours), and administrative data (patient panel overcapacity and average panel comorbidity).There were 4610 respondents (estimated response rate of 20.9%). The overall prevalence of burnout was 41%. In adjusted analyses, the strongest associations with burnout were having a fully staffed team (odds ratio [OR] = 0.55, 95% CI 0.47-0.65), having turnover on the team (OR = 1.67, 95% CI 1.43-1.94), and having patient panel overcapacity (OR = 1.19, 95% CI 1.01-1.40). The observed burnout prevalence was 30.1% lower (28.5% vs. 58.6%) for respondents working on fully staffed teams with no turnover and caring for a panel within capacity, relative to respondents in the inverse condition.Complete team staffing, turnover among team members, and panel overcapacity had strong, cumulative associations with burnout. Further research is needed to understand whether improvements in these factors would lower burnout.

BackgroundThe growing movement toward more accountable care delivery and the increasing number of people with chronic illnesses underscores the need for primary care practices to engage patients in their own care.ObjectiveFor adult primary care practices seeing patients with diabetes and/or cardiovascular disease, we examined the relationship between selected practice characteristics, patient engagement, and patient-reported outcomes of care.DesignCross-sectional multilevel observational study of 16 randomly selected practices in two large accountable care organizations (ACOs).ParticipantsPatients with diabetes and/or cardiovascular disease (CVD) who met study eligibility criteria (n = 4368) and received care in 2014 were randomly selected to complete a patient activation and PRO survey (51% response rate; n = 2176). Primary care team members of the 16 practices completed surveys that assessed practice culture, relational coordination, and teamwork (86% response rate; n = 411).Main measuresPatient-reported outcomes included depression (PHQ-4), physical functioning (PROMIS SF12a), and social functioning (PROMIS SF8a), the Patient Assessment of Chronic Illness Care instrument (PACIC-11), and the Patient Activation Measure instrument (PAM-13). Patient-level covariates included patient age, gender, education, insurance coverage, limited English language proficiency, blood pressure, HbA1c, LDL-cholesterol, and disease comorbidity burden. For each of the 16 practices, patient-centered culture and the degree of relational coordination among team members were measured using a clinician and staff survey. The implementation of shared decision-making activities in each practice was assessed using an operational leader survey.Key resultsHaving a patient-centered culture was positively associated with fewer depression symptoms (odds ratio [OR] = 1.51; confidence interval [CI] 1.04, 2.19) and better physical function scores (OR = 1.85; CI 1.25, 2.73). Patient activation was positively associated with fewer depression symptoms (OR = 2.26; CI 1.79, 2.86), better physical health (OR = 2.56; CI 2.00, 3.27), and better social health functioning (OR = 4.12; CI 3.21, 5.29). Patient activation (PAM-13) mediated the positive association between patients' experience of chronic illness care and each of the three patient-reported outcome measures-fewer depression symptoms, better physical health, and better social health. Relational coordination and shared decision-making activities reported by practices were not significantly associated with higher patient-reported outcome scores.ConclusionsDiabetic and CVD patients who received care from ACO-affiliated practices with more developed patient-centered cultures reported lower PHQ-4 depression symptom scores and better physical functioning. Diabetic and CVD patients who were more highly activated to participate in their care reported lower PHQ-4 scores and better physical and social outcomes of care.

Limited English proficiency (LEP) is associated with poor health status and worse outcomes.To examine disparities in hypertension between National Health and Nutrition Examination Survey (NHANES) respondents with LEP versus adequate English proficiency.Retrospective analysis of multi-year survey data.Adults 18 years of age and older who participated in the NHANES survey during the period 2003-2012.We defined participants with LEP as anyone who completed the NHANES survey in a language other than English or with the support of an interpreter. Using logistic regression, we estimated the odds ratio for undiagnosed or uncontrolled hypertension (systolic blood pressure (SBP) 140 mmHg or diastolic blood pressure (DBP) 90 mmHg) among LEP participants relative to those with adequate English proficiency. We adjusted for sociodemographic, acculturation-related, and hypertension-related variables.Fourteen percent (n = 3,269) of the participants had limited English proficiency: 12.4% (n = 2906) used a Spanish questionnaire and 1.6% (n = 363) used an interpreter to complete the survey in another language. Those with LEP had higher odds of elevated blood pressure on physical examination (adjusted odds ratio [AOR] = 1.47 [1.07-2.03]). This finding persisted among participants using an interpreter (AOR = 1.88 [1.15-3.06]) but not among those using the Spanish questionnaire (AOR = 1.32 [0.98-1.80]). In a subgroup analysis, we found that the majority of uncontrolled hypertension was concentrated among individuals with a known diagnosis of hypertension (AOR = 1.80 [1.16-2.81]) rather than those with undiagnosed hypertension (AOR = 1.14 [0.74-1.75]). Interpreter use was associated with increased odds of uncontrolled hypertension, especially among patients who were not being medically managed for hypertension (AOR = 6.56 [1.30-33.12]).In a nationally representative sample, participants with LEP were more likely to have poorly controlled hypertension than those with adequate English proficiency. LEP is an important driver of disparities in hypertension management and outcomes.

Little is known about what determines strategy implementation around quality improvement (QI) in small- and medium-sized practices. Key questions are whether QI strategies are associated with practice readiness and practice characteristics.Grounded in organizational readiness theory, we examined how readiness and practice characteristics affect QI strategy implementation. The study was a component of a larger practice-level intervention, Heart of Virginia Healthcare, which sought to transform primary care while improving cardiovascular care.This observational study analyzed practice correlates of QI strategy implementation in primary care at 3 and 12 months. Data were derived from surveys completed by clinicians and staff and from assessments by practice coaches.A total of 175 small- and medium-sized primary care practices were included.Outcome was QI strategy implementation in three domains: (1) aspirin, blood pressure, cholesterol, and smoking cessation (ABCS); (2) care coordination; and (3) organizational-level improvement. Coaches assessed implementation at 3 and 12 months. Readiness was measured by baseline member surveys, 1831 responses from 175 practices, a response rate of 73%. Practice survey assessed practice characteristics, a response rate of 93%. We used multivariate regression.QI strategy implementation increased from 3 to 12 months: the mean for ABCS from 1.20 to 1.59, care coordination from 2.15 to 2.75, organizational improvement from 1.37 to 1.78 (95% CI). There was no statistically significant association between readiness and QI strategy implementation across domains. Independent practice implementation was statistically significantly higher than hospital-owned practices at 3 months for ABCS (95% CI, P = 0.01) and care coordination (95% CI, P = 0.03), and at 12 months for care coordination (95% CI, P = 0.04).QI strategy implementation varies by practice ownership. Independent practices focus on patient care-related activities. FQHCs may need additional time to adopt and implement QI activities. Practice readiness may require more structural and organizational changes before starting a QI effort.

Veterans involved in the legal system are at high risk for overdose but have lower receipt of medications for opioid use disorder than other veterans. The study aimed to understand barriers to medication access from the perspective of legally involved veterans with opioid use disorder and people who work with these veterans in the Veterans Health Administration (VHA) and the legal system. This national qualitative study interviewed veterans and stakeholders from 14 geographically diverse VHA facilities to explore perceptions of barriers to medications for opioid use disorder. Participants included veterans with a history of opioid use disorder and legal involvement (n = 18), VHA Veterans Justice Programs Specialists (n = 15), VHA and community substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12). We conducted interviews based on the Consolidated Framework for Implementation Research. Interview transcripts were analyzed using a team-based approach. Four key barriers, noted by group, were identified: (1) a preference for counseling along with or instead of medications (veterans, Specialists, treatment providers, criminal justice staff); (2) concerns about veterans using medications without a prescription, selling them, or providing them to others (veterans, Specialists, treatment providers, criminal justice staff); (3) concerns about perceived stigma towards medication use (veterans, Specialists, treatment providers, criminal justice staff); and (4) concerns about medication discontinuation after recurrent opioid use (veterans, criminal justice staff). A fifth theme, education, was noted by all stakeholders except providers as important to facilitating use of medications for opioid use disorder. All five themes mapped to the framework construct of knowledge and beliefs about the intervention. Based on identified barriers, interventions focused on enhancing medication knowledge, reducing stigma towards use of medications, and increasing knowledge that opioid use may recur during treatment may help increase access to medication for veterans with legal involvement.

BACKGROUND: Hyponatremia is the most common electrolyte disturbance amongst hospitalized patients. An overly rapid rate of correction of chronic hyponatremia is believed to increase the risk of poor clinical outcomes including osmotic demyelination syndrome (ODS). There is disagreement in the literature regarding the definition of hyponatremic overcorrection. METHODS: We performed a systematic review of all English language studies to identify those that calculated sodium correction rate and classified patients’ overcorrection status. We then identified all patients who presented to our hospital’s emergency department between 2003 and 2015 with a corrected serum sodium ≤ 116 mmol/L. All methods from the systematic review for sodium correction rate calculation and overcorrection status were applied to this cohort. RESULTS: We identified 24 studies citing 9 distinct sodium correction rate methods and 14 criteria for overcorrection. Six hundred twenty-four patients presenting with severe hyponatremia (median initial value 113 mMol) were identified. Depending on the method used, the median sodium correction rates in our cohort ranged from 0.271 to 1.13 mmol/L per hour. The proportion of patients classified with overcorrection with the different criteria varied almost 11-fold, ranging from 8.5 to 89.9%. CONCLUSION: Published methods disagree regarding the calculation of sodium correction rates and the definition of hyponatremic overcorrection. This leads to wide variations in sodium correction rates and the prevalence of overcorrection in patient cohorts. Definitions based on ODS risk are needed. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05286-y) contains supplementary material, which is available to authorized users.

BACKGROUND: The American Diabetes Association (ADA) recommends that treatment with metformin be considered for prevention of type 2 diabetes in persons with prediabetes. However, metformin use outside the setting of diagnosed diabetes in US adults is not well characterized. OBJECTIVE: To examine trends in self-reported prediabetes and treatment with metformin. We also compared characteristics of adults self-reported prediabetes who were vs. were not taking metformin. DESIGN: Cross-sectional analysis. PARTICIPANTS: Adults ≥ 20 years of age who participated in the 2005–2014 National Health and Nutrition and Examination Survey (NHANES), n = 28,461. APPROACH: We characterized trends in self-reported prediabetes and metformin use in this population. We used multiple logistic regression models to identify predictors of metformin use among adults with self-reported prediabetes. All analyses accounted for the weighted complex survey design to generate nationally representative estimates. KEY RESULTS: The prevalence of self-reported prediabetes increased from 5.1% in 2005–2006 to 7.4% in 2013–2014 (P-for-trend < 0.001). In persons with self-reported prediabetes, metformin use increased, from 2.4 to 8.3% (P-for-trend = 0.013). Adults who were taking metformin were more likely to be obese and to report trying to lose weight in the past year. CONCLUSIONS: Self-reported prediabetes has increased in the past decade. Metformin use in the setting of prediabetes has also increased but remains relatively uncommon at 8% in adults who self-report prediabetes, despite current clinical recommendations. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05398-5) contains supplementary material, which is available to authorized users.

BACKGROUND: Functional limitations may be more common in middle-aged adults than previously recognized. However, there are few published data on the prevalence of activity limitations, and their association with multimorbidity, among adults 50 to 64 years old. OBJECTIVE: To describe the prevalence of activity limitations and the association with multimorbidity in middle-aged adults. DESIGN: Cross-sectional analysis of US population-based National Health and Nutrition Examination Survey (NHANES) 2011–2016. PARTICIPANTS: The total number of community-dwelling NHANES participants aged 50–64 years old is 4217. MAIN MEASURES: Chronic conditions included hypertension, high cholesterol, diabetes mellitus, obesity, chronic kidney disease, cancer, stroke, coronary heart disease, heart failure, chronic obstructive pulmonary disease/asthma, arthritis, and depression. Activity limitations were defined as any difficulty within each of four International Classification of Functioning (ICF) domains: functional limitations (kneeling, carrying, standing, sitting, reaching, grasping, pulling), mobility (walking ¼ mile, climbing 10 steps), basic activities of daily living (BADLs; walking, transferring, eating, dressing), and instrumental activities of daily living (IADLs; finances, chores, cooking). We calculated prevalence ratios for activity limitations using generalized estimating equations. KEY RESULTS: The prevalence of functional limitations, mobility limitations, BADL difficulty, and IADL difficulty was 34%, 11%, 15%, and 17%, respectively. Seventy-two percent of participants had two or more chronic conditions; 23% had two, 18% had three, 15% had four, and 16% had five or more. Multivariable adjusted prevalence ratios (95% CI) for functional limitations among those with 2, 3, 4, and 5 or more chronic conditions, compared with 0–1 conditions, were 1.94 (1.43–2.63), 2.50 (1.93–3.23), 3.26 (2.48–4.27), and 4.54 (3.48–5.93), respectively (p trend

The use of medications not relieving symptoms or maximizing quality of life should be minimized following hospice enrollment.To evaluate the frequency of and predictive factors for continuation of medications with limited benefit after hospice admission among those admitted for cancer- and non-cancer-related causes.Cohort study using the Surveillance, Epidemiology and End Results-Medicare linked database.Medicare Part D-enrolled beneficiaries 66 years and older who were admitted to and died under hospice care between January 1, 2008, and December 31, 2013 (N = 70,035).Patients were followed from hospice enrollment through death for Part D dispensing of limited benefit medications (LBMs) they had used in the 6 months prior to hospice admission, including anti-hyperlipidemics, anti-hypertensives, oral anti-diabetics, anti-platelets, anti-dementia medications, anti-osteoporotic medications, and proton pump inhibitors. The proportion of patients continuing an LBM after hospice admission was evaluated. Adjusted relative risks (RRs) were estimated for factors associated with LBM continuation.Overall, 29.8% and 30.5% of patients admitted to hospice for a cancer- and non-cancer-related cause, respectively, continued at least one LBM after hospice admission. Anti-dementia medications were continued most frequently (29.3%) while anti-osteoporotic medications were continued least often (14.1%). Compared to home hospice, LBM continuation was greater in hospice patients residing in skilled nursing (RR 1.25, 95% CI 1.20-1.29), non-skilled nursing (RR 1.29, 95% CI 1.25-1.32), and assisted living facilities (RR 1.28, 95% CI 1.24-1.32). Patients with hospice stays ≥ 180 days were more likely to continue at least one LBM compared to those with stays of 1 week or less (RR 13.11, 95% CI 12.25-14.02).A substantial proportion of Medicare hospice beneficiaries continued to receive LBMs following hospice enrollment. Providers should evaluate the necessity of continuing non-palliative medications at the end of life through a careful, patient-centric consideration of their potential risks and benefits.

BACKGROUND: Unhealthy alcohol use has adverse effects on HIV treatment. Screening, brief intervention, and referral to treatment (SBIRT) has some evidence of efficacy but may not be sufficient for those with low motivation or comorbid substance use. OBJECTIVE: To examine the effectiveness of motivational interviewing (MI) and emailed feedback (EF) among primary care HIV-positive patients, compared with treatment as usual care (UC) only, which included SBIRT. DESIGN: Randomized clinical trial. PARTICIPANTS: Six hundred fourteen adult HIV-positive patients in Kaiser Permanente Northern California who reported prior-year unhealthy alcohol use. INTERVENTION: Participants were randomized to either three sessions of MI (one in person and two by phone), information regarding alcohol risks via EF through a patient portal, or UC alone. MI and EF participants who reported unhealthy alcohol use at 6 months were offered additional MI and EF treatment, respectively. MAIN MEASURES: Participant-reported unhealthy alcohol use (defined as ≥ 4/≥ 5 drinks per day for women/men), alcohol problems at 12 months, based on blinded telephone interviews. Secondary outcomes included drug use and antiretroviral (ART) adherence. KEY RESULTS: At 12 months, there were no overall group differences, but in all three arms, there were declines in unhealthy alcohol use and alcohol-related problems (p

Patients with diabetic kidney disease (DKD) often struggle with blood pressure control. In team-based models of care, pharmacists and primary care providers (PCPs) play important roles in supporting patients’ blood pressure management. To describe whether PCPs’ acceptance of pharmacists’ recommendations impacts systolic blood pressure (SBP) at 36 months. An observational analysis of a subset of participants randomized to the intervention arm of the Simultaneous risk factor control using Telehealth to slOw Progression of Diabetic Kidney Disease (STOP-DKD) study. STOP-DKD participants for whom (1) the pharmacist made at least one recommendation to the PCP; (2) there were available data regarding the PCP’s corresponding action; and (3) there were SBP measurements at baseline and 36 months. Participants received monthly telephone calls with a pharmacist addressing health behaviors and medication management. Pharmacists made medication-related recommendations to PCPs. We fit an unadjusted generalized linear mixed model to assess the association between the number of pharmacists’ recommendations for DKD and blood pressure management and PCPs’ acceptance of such recommendations. We used a linear regression model to evaluate the association between PCP acceptance and SBP at 36 months, adjusted for baseline SBP. Pharmacists made 176 treatment recommendations (among 59 participants), of which 107 (61%) were accepted by PCPs. SBP significantly declined by an average of 10.5 mmHg (p < 0.01) among 47 of 59 participants who had valid measurements at baseline and 36 months. There was a significant association between the number of pharmacist recommendations and the odds of PCP acceptance (OR 1.19; 95%CI 1.00, 1.42; p < 0.05), but no association between the number of accepted recommendations and SBP. Pharmacists provided actionable medication-related recommendations. We identified a significant decline in SBP at 36 months, but this reduction was not associated with recommendation acceptance. NCT01829256

BACKGROUND: Pay-for-performance (P4P) has been used expansively to improve quality of care delivered by physicians. However, to what extent P4P works through the provision of information versus financial incentives is poorly understood. OBJECTIVE: To determine whether an increase in information feedback without changes to financial incentives resulted in improved physician performance within an existing P4P program. INTERVENTION/EXPOSURE: Implementation of a new registry enabling real-time feedback to physicians on quality measure performance. DESIGN: Observational, predictive piecewise model at the physician-measure level to examine whether registry introduction associated with performance changes. We used detailed physician quality measure data 3 years prior to registry implementation (2010–2012) and 2 years after implementation (2014–2015). We also linked physician-level data including age, gender, and board certification; group-level data including registry click rates; and patient panel data including chronic conditions. PARTICIPANTS: Four hundred thirty-four physicians continuously affiliated with Advocate from 2010 to 2015. MAIN MEASURES: Physician performance on ten quality metrics. KEY RESULTS: We found no consistent pattern of improvement associated with the availability of real-time information across ten measures. Relative to predicted performance without the registry, average performance increased for two measures (childhood immunization status—rotavirus (p

BACKGROUND: Programs addressing social determinants of health for high-utilizing patients are gaining interest among health systems as an avenue to promote health and decrease utilization. OBJECTIVE: To evaluate impacts of a social needs screening and navigation program for adult predicted high utilizers on total medical visit utilization. DESIGN: A prospective, quasi-experimental study using an intent-to-treat propensity-weighted difference-in-differences approach. Stratified analyses assessed intervention effects among three low–socioeconomic status sub-samples: patients in low-income areas, in low-education areas, and with Medicaid insurance. PARTICIPANTS: Predicted high utilizers—patients predicted to be in the highest 1% for total utilization in a large integrated health system. INTERVENTION: A telephonic social needs screening and navigation program. MAIN MEASURES: Primary difference-in-difference analyses compared total visit count utilization, including outpatient, emergency department (ED), and inpatient utilization, between the intervention and control groups at both in-network and out-of-network facilities. Prevalence of social needs among sample patients and their connection rates to social needs resources are also described. KEY RESULTS: The study included 34,225 patients (7107 intervention, 27,118 control). Most (53%) patients screened reported social needs, but only a minority (10%) of those with a need were able to connect with resources to address these needs. Primary analysis found total utilization visits decreased 2.2% (95% CI − 4.5%, 0.1%; p = 0.058) in the intervention group. Stratified analyses showed decreases in total utilization for all low–socioeconomic status subgroups receiving the intervention compared with controls: − 7.0% (95% CI − 11.9%, − 1.9%; p = 0.008) in the low-income area group, − 11.5% (− 17.6%, 5.0%; p

BACKGROUND: Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns. OBJECTIVES: To explore potential imprinting on clinical rotations by (a) describing high- and low-value behaviors among medical students and (b) examining relationships with regional healthcare intensity (HCI). DESIGN: Multisite cross-sectional survey PARTICIPANTS: Third- and fourth-year students at nine US medical schools MAIN MEASURES: Survey items measured high-value (n = 10) and low-value (n = 9) student behaviors. Regional HCI was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data (ratio of physician visits per decedent compared with the US average, hospital care intensity index, ratio of medical specialty to primary care physician visits per decedent). Associations between regional HCI and student behaviors were examined using unadjusted and adjusted (controlling for age, sex, and year in school) logistic regression analyses, using median item ratings to summarize reported engagement in high- and low-value behaviors. KEY RESULTS: Of 2623 students invited, 1304 (50%) responded. Many reported trying to determine healthcare costs (1085/1234, 88%), but only 45% (571/1257) reported including cost details in case presentations. Students acknowledged suggesting tests solely to anticipate what their supervisor would want (1143/1220, 94%), show off their ability to generate a broad differential diagnosis (1072/1218, 88%), satisfy curiosity (958/1217, 79%), protect the team from liability (938/1215, 77%), and build clinical experience (533/1217, 44%). Students in higher intensity regions reported significantly more low-value behaviors: each one-unit increase in the ratio of physician visits per decedent increased the odds of reporting low-value behaviors by 20% (OR 1.20, 95% CI 1.04–1.38; P = 0.01). CONCLUSIONS: Third- and fourth-year medical students report engaging in both high- and low-value behaviors, which are related to regional HCI. This underscores the importance of the clinical learning environment and suggests imprinting is already underway during medical school.