Pre-Anesthetic Medical Evaluations: Criteria Considerations for Telemedicine Alternatives to Face to Face Visits.

BACKGROUND: The number of pre-anesthetic medical evaluations (PAMEs) being conducted in primary care is increasing. Due to the COVID-19 pandemic, the use of telemedicine has surged, providing a feasible way to conduct some of these visits. This study aimed to identify patient-related factors where a face to face (FTF) evaluation is indicated, measured by the need for pre-operative testing. METHODS: A retrospective chart review was conducted on patients age ≥ 18 years who had a PAME between January 2019-June 2020 at a rural primary care clinic in Southeast Minnesota. Data collected included age, gender, Charlson Comorbidity Index Score, medications, revised cardiac risk index (RCRI), smoking status, exercise capacity, body mass index, and pre-operative testing. Logistical regression modeling for odds ratios of outcomes was performed. RESULTS: 254 patients were included, with an average age of 64.1 years; 43.7% were female. Most were obese (mean BMI 31.6), non-smoking (93.7%) with excellent functional capacity (87.8% ≥ 5 METs). 76.8% of the planned surgeries were intermediate or high risk. 35.0% (n = 89) of visits resulted in medication adjustments and 76.7% (n = 195) in pre-operative testing. Age ≥ 65 years, ≥7 current medications, and diabetes all significantly increased the odds of requiring pre-operative testing (P < .05). CONCLUSIONS: This study was able to identify patient-related factors that increased the likelihood of requiring pre-operative testing. Patients who are age ≥ 65 years, ≥7 current medications, and those with diabetes could be scheduled for a FTF evaluation. Others could be scheduled for a telemedicine visit to minimize health-care exposures.

Getting SET for Student Success: Foundations for a Student Education Team.

BACKGROUND: Family medicine clinical education poses logistic issues that we sought to address with the Student Education Team model. METHODS: The model combined team-based, patient-centered care with student experiences in a sustainable precepting model. Four learners successfully underwent precepting simultaneously. Schedulers booked patients in the team schedule, and the patients knew they would see a student and a faculty team member. RESULTS: The Student Education Team model increased the learner to preceptor ratio compared to traditional precepting models. Use of the team increased the number of learners completing rotations. The team schedule nearly eliminated patients refusing student involvement and enhanced throughput because patients saw the most readily available staff. DISCUSSION: The team offered clinicians and learners a model for incorporating learning into clinicians' schedules.

Gynecomastia in a Patient Taking Meloxicam-A Case Report.

Gynecomastia is benign enlargement of glandular tissue in the male breast. It occurs due to an imbalance of estrogen and testosterone. It may be unilateral or bilateral. Physiologic gynecomastia commonly occurs in infants and during puberty and is self-limited. Gynecomastia may affect up to 50% of adult men over age 50 years old and can be related to underlying medical illness or caused by certain medications. Known causative agents include anti-androgenic and estrogenic drugs. Probable agents include alcohol and anti-ulcer, psychoactive, and antiretroviral medications. Non-steroidal anti-inflammatory drugs (NSAIDs) are not commonly associated with the development of gynecomastia. This case presents an instance in which the NSAID, meloxicam, was the only identified variable in a patient who developed unilateral gynecomastia. His breast tenderness and abnormal exam resolved spontaneously within 4 weeks of cessation of meloxicam therapy.

Provider Approachability: An All-Staff Survey Approach to Creating a Culture of Safety.

OBJECTIVES: A culture-of-safety survey of our hospital staff revealed fear-based reluctance to question those in authority. We aimed to examine provider approachability (words and actions that promote trust and reduce or eliminate fear of interaction). METHODS: Providers and staff completed an anonymous facility-wide survey (survey 1) regarding perceptions of provider approachability. Results were safely communicated to providers, and improvement resources were offered. A follow-up survey (survey 2 [S2]) was performed. RESULTS: The survey participation rate was 59% (389/658). Eighty-four percent of providers had improved scores in S2. Mean top-box scores improved from 0.63 to 0.76 (P < .001). Providers deemed less approachable by nonprovider staff were also deemed less approachable by their peers (r = 0.82; survey 1). Forty-four percent reported improvement in the safety culture in S2. Twenty-eight percent of providers reported making efforts to improve how they were perceived by others. CONCLUSIONS: Provider approachability surveys are a safe, effective method of assessing and encouraging positive interactions that promote trust and influence positive communication. The process created an opportunity to identify and assist providers who were less approachable.

A Model for Improving Adherence to Prescribing Guidelines for Chronic Opioid Therapy in Rural Primary Care.

OBJECTIVE: To describe the steps taken and results obtained by a rural primary care practice to effectively implement opioid prescribing guidelines. PATIENTS AND METHODS: Between December 1, 2014, and May 30, 2017, a quality improvement project was undertaken. Elements included prescribing registries, a nurse coordinator, and an Opioid Use Review Panel. Clinic workflow was redesigned to more consistently incorporate these and other guideline recommendations into practice. The effect on opioid prescribing was measured as well as patient outcomes. RESULTS: There were 462 patients meeting inclusion criteria before implementation. At the conclusion, 16 patients (3%) had died, 9 patients (2%) were no longer seeing clinicians participating in the project, and 2 patients (0.4%) had transitioned to hospice or long-term care facilities. Of the remaining 435 patients, 96 (22.1%; 95% CI, 18.4-26.2) had decreased prescribing below the threshold for inclusion or were no longer receiving opioid prescriptions. Originally, 64 patients (13.9%; 95% CI, 11.0-17.3) were using average daily doses equal to or greater than 90 morphine milligram equivalents. After implementation, 54 of 435 patients (12.4%; 95% CI, 9.6-15.8) were still using equal to or greater than 90 morphine milligram equivalents per day after accounting for death or loss to follow-up. CONCLUSION: A change in clinic process to implement guidelines for prescribing of chronic opioid therapy was completed. It was associated with a decrease in the number of patients using chronic opioid therapy, primarily at lower doses. This was accomplished in a rural practice with very limited resources in pain medicine, psychiatry, and addiction medicine.

Collaborative Care Management Associated With Improved Depression Outcomes in Patients With Personality Disorders, Compared to Usual Primary Care.

BACKGROUND: The use of a collaborative care management (CCM) model can dramatically improve short- and long-term treatment outcomes for patients with major depressive disorder (MDD). Patients with comorbid personality disorder (PD) may experience poorer treatment outcomes for MDD. Our study seeks to examine the differences in MDD treatment outcomes for patients with comorbid PD when using a CCM approach rather than usual care (UC). METHODS: In our retrospective cohort study, we reviewed the records of 9614 adult patients enrolled in our depression registry with the clinical diagnosis MDD and the diagnosis of PD (Yes/No). Clinical outcomes for depression were measured with Patient Health Questionnaire-9 (PHQ-9) scores at 6 months. RESULTS: In our study cohort, 59.4% of patients (7.1% of which had comorbid PD) were treated with CCM, as compared with 40.6% (6.8% with PD) treated with UC. We found that the presence of a PD adversely affected clinical outcomes of remission within both groups, however, at 6 months patients with PD had significantly lower MDD remission rates when treated with UC as compared with those treated with CCM (11.5% vs 25.2%, P = .002). Patients with PD in the UC group were also noted to have an increased rate of persistent depressive symptoms (PHQ-9 score ≥10) at 6 months as compared with those in the CCM group (67.7% vs 51.7%, P = .004). CONCLUSIONS: In patients with comorbid MDD and PD, clinical outcomes at 6 months were significantly improved when treated with CCM compared with UC. This finding is encouraging and supports the idea that CCM is an effective model for caring for patients with behavioral concerns, and it may be of even greater benefit for those patients being treated for comorbid behavioral health conditions.

A Systematic Approach to Clinical Peer Review in a Critical Access Hospital.

PURPOSE: Clinical provider peer review (CPPR) is a process for evaluating a patient's experience in encounters of care. It is part of ongoing professional practice evaluation and focused professional practice evaluation-important contributors to provider credentialing and privileging. Critical access hospitals are hindered in CPPR by having a limited number of providers, shortages of staff resources, and relationships among staff members that make unbiased review difficult. Small departments within larger institutions may face similar challenges. METHODS: A CPPR process created at Mayo Clinic Health System is described. It involved a case review questionnaire built on the Institute of Medicine "Six Aims for Changing the Health Care System," a standardized intervention algorithm and tracking tool. OUTCOMES: During 2007 through 2014, a total of 994 cases were reviewed; 31% led to provider dialog and education or intervention. Findings were applied to core measure processes with success rate going from 87% to 97%. Changes were adopted in end-of-life care, contributing to a 50% reduction in all-cause mortality rate. CONCLUSIONS: Providing peer review tools to a critical access hospital can keep peer review within a group with knowledge of the individual provider's practice and can make process improvement the everyday work of those involved.