Outcomes of A Virtual Practice-Tailored Medicare Annual Wellness Visit Intervention.

INTRODUCTION: Interventions are needed to promote utilization of the Medicare Annual Wellness Visit (AWV), an underused opportunity to perform screenings and plan individualized preventive health services. METHOD: Using remote practice redesign and electronic health record (EHR) support, we implemented the Practice-Tailored AWV intervention in 2021 (during the COVID-19 pandemic) in 3 small community-based practices. The intervention combines EHR-based tools with practice redesign approaches and resources. Outcomes included completion of AWV and fulfillment of recommended preventive services. RESULTS: At baseline the 3 practices had 1,513 Medicare patients with at least 1 visit in the past 12 months. AWV utilization went from 7% at baseline to 54% 8 months postintervention implementation; advance care planning increased 10.7% (from 7.9% to 18.6%); depression screening increased 16.3% (from 51.7% to 68.0%); and alcohol misuse screening increased 17.3% (from 42.6% to 59.9%). Every individual preventive health service was received more often by patients with an AWV than those without. At the patient level, fulfillment of all eligible preventive services (of a maximum of 12 evaluated) went from 47.5% to 53.8% (P < .001). Subgroup analyses showed that patients with AWVs completed a greater percentage of their total recommended preventive health services than those without an AWV. CONCLUSION: Virtual implementation of an intervention that combined EHR-based tools with practice redesign approaches increased AWV and preventive services utilization in Medicare patients. Given the success of this intervention during the COVID-19 pandemic (when practices had many competing demands), greater consideration should be given to delivering future interventions virtually.

Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial.

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

The 3 Wishes Program Improves Families' Experience of Emotional and Spiritual Support at the End of Life.

BACKGROUND: The end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL. AIM: To assess whether the 3WP is associated with improved ratings of EOL care. PROGRAM DESCRIPTION: In the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families. SETTING: 2-hospital academic healthcare system. PARTICIPANTS: Dying patients in the ICU and their families. PROGRAM EVALUATION: A modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS-derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care). RESULTS: Of 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups. DISCUSSION: The 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience.

Use of Acute Mental Health Care in U.S. Children's Hospitals Before and After Statewide COVID-19 School Closure Orders.

Objective: This study aimed to examine changes in child emergency department (ED) discharges and hospitalizations for primary general medical (GM) and primary psychiatric disorders; prevalence of psychiatric disorders among acute care encounters; and change in acute mental health (MH) care encounters by disorder type and, within these categories, by child sociodemographic characteristics before and after statewide COVID-19­related school closure orders. Methods: This retrospective, cross-sectional cohort study used the Pediatric Health Information System database to assess percent changes in ED discharges and hospitalizations (N=2,658,474 total encounters) among children ages 3­17 years in 44 U.S. children's hospitals in 2020 compared with 2019, by using matched data for 36- and 12-calendar-week intervals. Results: Decline in MH ED discharges accounted for about half of the decline in ED discharges and hospitalizations for primary GM disorders (−24.8% vs. −49.1%), and MH hospitalizations declined 3.4 times less (−8.0% vs. −26.8%) in 2020. Suicide attempt or self-injury and depressive disorders accounted for >50% of acute MH care encounters before and after the statewide school closures. The increase in both ED discharges and hospitalizations for suicide attempt or self-injury was 5.1 percentage points (p<0.001). By fall 2020, MH hospitalizations for suicide attempt or self-injury rose by 41.7%, with a 43.8% and 49.2% rise among adolescents and girls, respectively. Conclusions: Suicide or self-injury and depressive disorders drove acute MH care encounters in 44 U.S. children's hospitals after COVID-19­related school closures. Research is needed to identify continuing risk indicators (e.g., sociodemographic characteristics, psychiatric disorder types, and social determinants of health) of acute child MH care.

Survival After Severe COVID-19: Long-Term Outcomes of Patients Admitted to an Intensive Care Unit.

BACKGROUND: Understanding the long-term sequelae of severe COVID-19 remains limited, particularly in the United States. OBJECTIVE: To examine long-term outcomes of patients who required intensive care unit (ICU) admission for severe COVID-19. DESIGN, PATIENTS, AND MAIN MEASURES: This is a prospective cohort study of patients who had severe COVID-19 requiring an ICU admission in a two-hospital academic health system in Southern California. Patients discharged alive between 3/21/2020 and 12/31/2020 were surveyed approximately 6 months after discharge to assess health-related quality of life using Patient-Reported Outcomes Measurement Information System (PROMIS®)-29 v2.1, post-traumatic stress disorder (PTSD) and loneliness scales. A preference-based health utility score (PROPr) was estimated using 7 PROMIS domain scores. Patients were also asked their attitude about receiving aggressive ICU care. KEY RESULTS: Of 275 patients admitted to the ICU for severe COVID-19, 205 (74.5%) were discharged alive and 132 (64%, median age 59, 46% female) completed surveys a median of 182 days post-discharge. Anxiety, depression, fatigue, sleep disturbance, ability to participate in social activities, pain interference, and cognitive function were not significantly different from the U.S. general population, but physical function (44.2, SD 11.0) was worse. PROPr mean score of 0.46 (SD 0.30, range -0.02 to 0.96 [<0 is worse than dead and 1 represents perfect health]) was slightly lower than the U.S. general population, with an even distribution across the continuum. Poor PROPr was associated with chronic medical conditions and receipt of life-sustaining treatments, but not demographics or social vulnerability. PTSD was suspected in 20% and loneliness in 29% of patients. Ninety-eight percent of patients were glad they received life-saving treatment. CONCLUSION: Most patients who survive severe COVID-19 achieve positive outcomes, with health scores similar to the general population at 6 months post-discharge. However, there is marked heterogeneity in outcomes with a substantial minority reporting severely compromised health.

Mental Health-Related Emergency Department Visits Among Children During The Early COVID-19 Pandemic.

Objective: To measure univariate and covariate-adjusted trends in children's mental health-related emergency department (MH-ED) use across geographically diverse areas of the U.S. during the first wave of the Coronavirus-2019 (COVID-19) pandemic. Method: This is a retrospective, cross-sectional cohort study using electronic health records from four academic health systems, comparing percent volume change and adjusted risk of child MH-ED visits among children aged 3-17 years, matched on 36-week (3/18/19-11/25/19 vs. 3/16/20-11/22/20) and 12-week seasonal time intervals. Adjusted incidence rate ratios (IRR) were calculated using multivariate Poisson regression. Results: Visits declined during spring-fall 2020 (n = 3892 vs. n = 5228, -25.5%) and during spring (n = 1051 vs. n = 1839, -42.8%), summer (n = 1430 vs. n = 1469, -2.6%), and fall (n = 1411 vs. n = 1920, -26.5%), compared with 2019. There were greater declines among males (28.2% vs. females -22.9%), children 6-12-year (-28.6% vs. -25.9% for 3-5 years and -22.9% for 13-17 years), and Black children (-34.8% vs. -17.7% to -24.9%). Visits also declined for developmental disorders (-17.0%) and childhood-onset disorders (e.g., attention deficit and hyperactivity disorders; -18.0%). During summer-fall 2020, suicide-related visits rose (summer +29.8%, fall +20.4%), but were not significantly elevated from 2019 when controlling for demographic shifts. In contrast, MH-ED use during spring-fall 2020 was significantly reduced for intellectual disabilities (IRR 0.62 [95% CI 0.47-0.86]), developmental disorders (IRR 0.71 [0.54-0.92]), and childhood-onset disorders (IRR 0.74 [0.56-0.97]). Conclusions: The early pandemic brought overall declines in child MH-ED use alongside co-occurring demographic and diagnostic shifts. Children vulnerable to missed detection during instructional disruptions experienced disproportionate declines, suggesting need for future longitudinal research in this population.

Patient experience with electronic health record-integrated postoperative telemedicine visits in an academic endocrine surgery program.

BACKGROUND: In response to the coronavirus 2019 pandemic, telemedicine use has increased throughout the United States. We aimed to measure patient experience with electronic health record-integrated postoperative telemedicine encounters following thyroid and parathyroid surgery. METHODS: In this preliminary study, adult patients receiving postoperative electronic health record-integrated telemedicine video encounters or standard in-person visits after thyroid or parathyroid surgery at a single institution were prospectively enrolled from November 2019 through May 2020. Patients with home zip codes 10 to 75 miles from the medical center were included. Patient experience was assessed using the Consumer Assessment of Health Care Providers and Systems Clinician & Group Visit Survey 2.0 and the Communication Assessment Tool. Top box analysis was performed, defined as the percentage of respondents who chose the most positive response score. RESULTS: The cohort consisted of 45 telemedicine and 32 in-person encounters. Both groups reported similar and excellent patient experience and satisfaction (9.7 of 10 for telemedicine vs 9.8 of 10 for in-person encounters, mean difference 0.02, 95% confidence interval, [-0.25 to 0.29]). Similar surgeon communication performance was observed (mean Communication Assessment Tool top box score 83% telemedicine vs 86% in-person, mean difference 3%, 95% confidence interval [-10% to 17%]). Nonlinear increases in monthly telemedicine encounter volume were observed within the section of endocrine surgery (3-fold increase) and the health system (125-fold increase) from November 2019 to May 2020. CONCLUSION: Patients who underwent cervical endocrine surgery reported similarly high rates of satisfaction and excellent surgeon communication following either telemedicine or in-person postoperative encounters. Electronic health record-integrated telemedicine for a subset of low-risk procedures can act as a suitable replacement for in-person encounters. A surge in telemedicine use, stimulated by the coronavirus 2019 pandemic, was experienced at our institution.