Health Disparities Among Hispanics With Rheumatoid Arthritis: Delay in Presentation to Rheumatologists Contributes to Later Diagnosis and Treatment.

OBJECTIVE: The aim of this study was to evaluate referral and treatment delays by ethnicity/race in patients with rheumatoid arthritis (RA) treated at an academic rheumatology center. METHODS: We reviewed the medical records of all RA patients evaluated at an outpatient clinic between 2011 and 2016 to identify newly diagnosed and naive-to-treatment patients. We determined the durations between symptom onset and first rheumatology visit and time to initiate treatment. Data extraction included referral source, demographics, treatment, and laboratory tests. Routine use of a multidimensional health assessment questionnaire allowed us to calculate baseline RAPID3 (routine assessment of patient index data 3) scores. Comparisons between self-reported ethnicity/race groups were performed. We used logistic regression models to analyze associations between baseline variables and early referral. RESULTS: Data from 152 disease-modifying antirheumatic drug-naive RA patients were included in the study; 35% were white, 37% black, 20% Hispanic, and 8% other. The range in median time to first rheumatology visit was 6 to 8 months for all patient groups, except Hispanic. This group had a median time of 22.7 months (p = 0.01). The referral pattern was considerably variable between-groups; 40% of Hispanic patients were self-referred (p = 0.01). There were no statistically significant between-group differences for time to treatment initiation according to ethnicity/race. RAPID3 scores (p = 0.04) and erythrocyte sedimentation rates (p = 0.01) were significantly higher in the black and Hispanic groups. A high C-reactive protein value at baseline was associated with earlier referral. CONCLUSIONS: There is significant delay in initial presentation to a rheumatologist that was associated with a higher disease severity at presentation, especially for Hispanic patients.

Perceptions of Ambulatory Workflow Changes in an Academic Primary Care Setting.

As health care moves to a value-based system, the need for team-based models of care becomes increasingly important to adequately address the growing number of clinical quality metrics required of health care providers. Finding ways to better engage certified medical assistants (CMAs) in the process allows providers to focus on more complex tasks while improving the efficiency of each office visit. Although the roles and responsibilities for CMAs across the specialties can vary widely, standardizing the work can be a helpful step in scaling best practices across an institution. This article presents the results of a survey that evaluated various components of a CMA workflow in adult primary care practices within an academic medical center. Although the survey identified improved engagement and satisfaction with standardized changes overall, it also showed time constraints and provider discretion forcing unplanned modifications. Reviewing and reconciling medications seemed to be the most challenging for CMA staff, leading us to reconsider their involvement in this aspect of each visit. It will be important to continue innovating and testing team-based care models to keep up with the demands of a quality-based health care system.

Interventions of an Academic Medical Center to Improve Likelihood to Recommend.

Improved patient satisfaction is correlated with improved adherence and health outcomes for patients and financial performance for health care organizations. Increasingly, efforts are being made to measure and optimize patient satisfaction by both providers and insurers. Researchers investigated whether specific changes in staff interaction with patients would improve patients' likelihood to recommend a practice. There were 4 separate initiatives implemented by the medical staff and providers at 14 unique practice sites. At these sites, patients' satisfaction was measured 9 weeks prior to the initiative and then for 9 weeks after to assess impact on patients' likelihood to recommend the practice. Each of the 4 initiatives demonstrated improved patient satisfaction, whereas 2 reached statistical significance. These interventions demonstrated a rise in likelihood to recommend the practice score from 78.6% (33rd percentile) to 83.1% (68th percentile) in all of the combined practices.

Results of an initiative to charge for previously uncompensated care in an academic primary care practice.

Increasing clinical workload with dwindling compensation has challenged primary care medical practices over the past decade. This has led to more physicians leaving and fewer medical trainees entering primary care. In an effort to make primary care practices viable, many groups routinely charge for providing care that was uncompensated in the past. We initiated a program in our practice that charged for certain after-hour and electronic communications, completion of forms outside of office visits, and failure to show for appointments. We assessed the effect on workload, patient adherence to appointments, and financial outcomes. This initiative decreased our physicians' workload, increased physicians' satisfaction, and produced a modest increase in revenues.

Can electronic health records help improve patients' understanding of medications?

OBJECTIVES: To present pilot data from an ongoing electronic health record (EHR) quality improvement study to improve medication management using patient previsit review of the EHR medication list and a plain-language new medication information sheet to provide with every new EHR prescription. STUDY DESIGN: Postvisit survey of 191 patients at an academic general internal medicine clinic. METHODS: Patients were asked about discrepancies and problems, concerns, and questions (PCQs) in their EHR summary for up to 10 current medications and about knowledge of new prescriptions. Findings describe the extent of medication discrepancies, perceived PCQs about current medications, and patient knowledge about new medications. RESULTS: Overall, 78.0% of patients had at least 1 discrepancy, more than half had a drug listed that they were not taking or dose or frequency discrepancies, and 8.9% reported an omission; 41.9% indicated at least 1 PCQ about their current medications. Among patients who received a new prescription, most knew what the new medication was for and how to take it. However, 66.0% indicated uncertainty about potential adverse effects that they should telephone the physician about. CONCLUSIONS: Discrepancies can be efficiently categorized by previsit review of EHR medication lists. Prereview offers physicians the opportunity to better address important medication PCQs. Testing the value of EHR-generated plain-language medication information sheets requires follow-up interviews after medications are filled. Patients may not understand the actual benefits of new medications.

Improving medication reconciliation in the 21st century.

Approximately 7000 deaths occur yearly in the United States as a result of medication errors, and 1.5 million people are harmed by adverse drug events at a cost of $3.5 billion per year. Computerized order entry has been shown to decrease the number of medication errors by 55% to 80 % in the hospital. This has led many to advocate the use of electronic medical records in both the inpatient and outpatient setting. However, there is little evidence at present that electronic medical records reduce adverse drug events in the outpatient setting. This may be largely due to the quality of medication lists in the medical record: Among complicated patients, complete agreement between the medication list and what the patient is actually taking occurs in only 5% of patients. Unless there is improved medication reconciliation, it will be difficult to realize the potential safety benefits of information technology. An accurate medication list requires a healthcare team dedicated to obtaining and maintaining this information.

Patient-directed intervention versus clinician reminders alone to improve aspirin use in diabetes: a cluster randomized trial.

BACKGROUND: Physician-directed approaches have not eliminated the underuse of effective preventive therapies. METHODS: In a cluster-randomized design, 19 physicians caring for 334 eligible patients at least 40 years of age were randomized. All clinicians received computerized reminders at office visits. Intervention physicians received e-mails asking whether aspirin was indicated for each patient. If so, patients received a mailing and nurse telephone call addressing aspirin. The primary outcome was self-reported regular aspirin use. RESULTS: Outcome assessment telephone interviews were completed for 242 (72.5%) patients. At follow-up, aspirin use was reported by 60 (46%) of the 130 intervention patients and 44 (39%) of the 112 reminder-only patients, a nonsignificant 7.2% difference (95% confidence interval: -3.9 to 18 percentage points, p = .20). In the subgroup reporting no aspirin use at baseline and no contraindications, 33 (43%) of the 76 intervention and 22 (30%) of the 74 reminder-only patients used aspirin, a 10% difference accounting for clustering (95% CI: 2.2 to 18 percentage points, p = .013). DISCUSSION: A patient-directed intervention modestly increased aspirin use among diabetes patients beyond that achieved using computerized clinician reminders for ideal candidates. Obstacles included difficulty contacting patients, real or perceived contraindications, and failure to follow the nurse's advice.

Use of an electronic medical record to detect patients at high risk of metformin-induced lactic acidosis.

The Notes section welcomes the following types of contributions: (1) practical innovations or solutions to everyday practice problems, (2) substantial updates or elaborations on work previously published by the same authors, (3) important confirmations of research findings previously published by others, and (4) short research reports, including practice surveys, of modest scope or interest. Notes should be submitted with AJHP's manuscript checklist. The text should be concise, and the number of references, tables, and figures should be limited.

Dietary differences among women of Polish descent by country of birth and duration of residency in the United States.

OBJECTIVES: Changes in breast and gastric cancers and coronary artery disease among people of Polish descent after migration to the United States suggest there may be potentially modifiable factors affecting incidence of these diseases. We examined relationships of dietary factors associated with these diseases with stage of migration among Polish women in Chicago. DESIGN: Women of Polish descent (N = 396) were selected from Polish women's social organizations. Women completed a modified Health Habits and History Questionnaire. SETTING: The questionnaire was completed either at the participant's home or at a Polish social organization. PARTICIPANTS: Participants ranged in age from 17-81 years, and included women born in Poland or the United States, who had at least one parent of Polish. INTERVENTIONS: Participants were stratified by country of birth and migration period (1935-1979, 1980-1989, 1990-1997). MAIN OUTCOME MEASURES: The average daily intake of food groups and nutrients was assessed using multiple linear regression. RESULTS: We found statistically significant differences by birth country for 19 of 34 nutrients, 4 of 7 food groups, and for 21 nutrients, and 5 food groups among the different migration tertiles. CONCLUSIONS: Women from Poland and more recent migrants had generally more nutritious intakes, compared to US-born women, or earlier migrants. APPLICATIONS/CONCLUSIONS: There are significant dietary differences among women of Polish descent that vary by duration of US residency and birth country. Women with dietary intakes which place them at higher risk for cancers and cardiovascular disease could be targeted for interventions to lower their disease risk.