The association between primary care appointment lengths and opioid prescribing for common pain conditions.

BACKGROUND: While brief duration primary care appointments may improve access, they also limit the time clinicians spend evaluating painful conditions. This study aimed to evaluate whether 15-minute primary care appointments resulted in higher rates of opioid prescribing when compared to ≥ 30-minute appointments. METHODS: We performed a retrospective cohort study using electronic health record (EHR), pharmacy, and administrative scheduling data from five primary care practices in Minnesota. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 scheduled for 15-minute appointments were propensity score matched to those scheduled for ≥ 30-minutes. Sub-groups were analyzed to include patients with acute and chronic pain conditions and prior opioid exposure. Multivariate logistic regression was performed to examine the effects of appointment length on the likelihood of an opioid being prescribed, adjusting for covariates including ethnicity, race, sex, marital status, and prior ED visits and hospitalizations for all conditions. RESULTS: We identified 45,471 eligible acute primary care visits during the study period with 2.7% (N = 1233) of the visits scheduled for 15 min and 98.2% (N = 44,238) scheduled for 30 min or longer. Rates of opioid prescribing were significantly lower for opioid naive patients with acute pain scheduled in 15-minute appointments when compared to appointments of 30 min of longer (OR 0.55, 95% CI 0.35-0.84). There were no significant differences in opioid prescribing among other sub-groups. CONCLUSIONS: For selected indications and for selected patients, shorter duration appointments may not result in greater rates of opioid prescribing for common painful conditions.

Improving colorectal cancer screening disparities among Somali-speaking patients in an Internal Medicine Residency Clinic.

Colorectal cancer (CRC) is the third-most lethal cancer in the USA, and early detection through screening is crucial for improving outcomes. However, significant disparities in access and utilisation of CRC screening exist among patients with limited English proficiency. Our Quality Improvement (QI) team developed and implemented a video, featuring a Somali-speaking physician, created with input from internal medicine (IM) residents, patient education experts and community leaders to increase the rate of CRC screening uptake within a Somali-speaking population receiving primary care within an IM Residency Clinic. The baseline proportion of average-risk Somali-speaking patients who had successfully been screened for CRC was 46.3% (63/134). The proportion of patients agreeable to undergo CRC screening was assessed monthly from the beginning of video implementation (June 2022 to December 2022). We found that this intervention corresponded with a significant increase in willingness to undergo CRC screening from 36.4% to 100% during the early stages of intervention. At the end of our measurement timeframe, the proportion of the original population fully screened for CRC was 50.7% (68/134). Implementation of the video intervention was also assessed and determined to be minimally disruptive to the clinic flow.

Relief in Sight? Chatbots, In-baskets, and the Overwhelmed Primary Care Clinician.

The recent emergence of publically facing artificial intelligence (AI) chatbots has generated vigorous discussion in the lay public around the possibilities, liabilities, and uncertainties of the integration of such technology into everyday life. As primary care clinicians continue to struggle against ever-increasing loads of asynchronous, electronic work, the potential for AI to improve the quality and efficiency of this work looms large. In this essay, we discuss the basic premise of open-access AI chatbots such as CHATGPT, review prior applications of AI in healthcare, and preview some possible AI chatbot-assisted in-basket assistance including scenarios of communicating test results with patients, providing patient education, and clinical decision support in history taking, review of prior diagnostic test characteristics, and common management scenarios. We discuss important concerns related to the future adoption of this technology including the transparency of the training data used in developing these models, the level of oversight and trustworthiness of the information generated, and possible impacts on equity, bias, and patient privacy. A stepwise and balanced approach to simultaneously understand the capabilities and address the concerns associated with these tools will be needed before these tools can improve patient care.

Evaluation of pharmacist consults within a collaborative enhanced primary care team model to improve diabetes care.

BACKGROUND: An enhanced primary care team model was implemented to provide proactive, longitudinal care to patients with diabetes, grounded in close partnership between primary care providers (PCPs), nurses, and Medication Management Services (MMS) pharmacists. The purpose of this study is to evaluate the impact of the MMS pharmacist involvement in the enhanced primary care model for patients with diabetes. METHODS: This retrospective cohort study compared the quality of diabetes care between patients referred to a pharmacist and propensity score matched controls who were not. Eligible patients were adults (age 18 to 75 years) enrolled in the enhanced primary care team process who did not meet at least one of four diabetes quality indicators at 13 Mayo Clinic Rochester primary care practice locations. The intervention examined was asynchronous e-consults by pharmacists affiliated with the primary care practice. MAIN MEASURES: The primary outcome was change in the proportion of patients meeting the composite of four diabetes treatment goals (D4), including hemoglobin A1c (HbA1c) control, blood pressure control, aspirin use, and statin use at six months from enrollment among patients who received pharmacist intervention compared to matched patients who did not. Secondary outcomes were each of the D4 goal individually. RESULTS: The proportion of patients meeting the D4 increased with pharmacist e-consults (N = 85) compared to matched controls with no review (N = 170) (27% vs 7.0%, p<0.001). The change in patients meeting treatment goals of HbA1c (12.9% vs 4.1%, p = 0.020), blood pressure (9.4% vs 2.4%, p = 0.023), aspirin use (10.6% vs 2.9%, p = 0.018), and statin use (17.6% vs -1.2%, p<0.001) all increased with pharmacist e-consults. CONCLUSIONS: Pharmacist engagement in the enhanced primary care team improved diabetes management. This supports the inclusion and utilization of pharmacists in multidisciplinary efforts to improve diabetes care.

Supporting the Pursuit of Quality Improvement Publication: What Your Organization Can Do Now.

Many health care organizations encourage frontline staff to pursue quality improvement (QI), local spread of those improvements, and publication of their work. Although much has been written about building and sustaining a culture of continuous QI, less is known about how to support success in QI rigor, credibility, spread, and publication. In this perspective article, we offer QI leaders practical suggestions to identify challenges in publishing QI and strategies to overcome these challenges. Health care organizations can assist QI teams with publication by intentionally formalizing scholarship early in their QI project work, providing accountability, and connecting the QI team to necessary resources. A carefully designed program supporting QI publication can both improve the rigor of QI work and enhance the professional development of QI professionals.

Moving Away from Chaos: Intentional and Adaptive Management of the Non-visit Care River.

In modern primary care practice, clinicians face increasing volumes of asynchronous, electronic, non-visit care (NVC). Systems for completing this work, however, remain under-developed and often lack definition around patient and practice expectations for work completion and team member contributions. The resulting reactive, unstructured, and unscheduled NVC workflows cause and exacerbate physicians' cognitive overload, distraction, and dissatisfaction. Herein, we propose that primary care practices take an intentional, holistic approach to managing systems of NVC and offer a conceptual model for managing NVC work, analogizing the flow of these tasks to the flow of water through a river system: (1) by carefully controlling the inputs into the NVC system (the tributaries entering the river system); (2) by carefully defining the workflows, roles and responsibilities for completion of common tasks (the direction of river flow); (3) by improving the interface of the electronic health record (obstacles encountered in the river); and (4) by optimizing effectiveness of primary care teams (the contours of the river determining rate of flow). This framework for managing NVC, viewed from a broader system perspective, has the potential to improve productivity, quality of care, and clinician work experience.

Evaluation of an Enhanced Primary Care Team Model to Improve Diabetes Care.

PURPOSE: Primary care practices manage most patients with diabetes and face considerable operational, regulatory, and reimbursement pressures to improve the quality of this care. The Enhanced Primary Care Diabetes (EPCD) model was developed to leverage the expertise of care team nurses and pharmacists to improve diabetes care. METHODS: Using a retrospective, interrupted-time series design, we evaluated the EPCD model's impact on D5, a publicly reported composite quality measure of diabetes care: glycemic control, blood pressure control, low-density lipoprotein control, tobacco abstinence, and aspirin use. We examined 32 primary care practices in an integrated health care system that cares for adults with diabetes; practices were categorized as staff clinician practices (having physicians and advanced practice providers) with access to EPCD (5,761 patients); resident physician practices with access to EPCD (1,887 patients); or staff clinician practices without access to EPCD (10,079 patients). The primary outcome was the percentage of patients meeting the D5 measure, compared between a 7-month preimplementation period and a 10-month postimplementation period. RESULTS: After EPCD implementation, staff clinician practices had a significant improvement in the percentage of patients meeting the D5 composite quality indicator (change in incident rate ratio from 0.995 to 1.005; P = .01). Trends in D5 attainment did not change significantly among the resident physician practices with access to EPCD (P = .14) and worsened among the staff clinician practices without access to EPCD (change in incident rate ratio from 1.001 to 0.994; P = .05). CONCLUSIONS: Implementation of the EPCD team model was associated with an improvement in diabetes care quality in the staff clinician group having access to this model. Further study of proactive, multidisciplinary chronic disease management led by care team nurses and integrating clinical pharmacists is warranted.

Differentiation of hydrochlorothiazide-induced dermatitis from stasis dermatitis.

A woman in her 60s with a history of hypertension and stasis dermatitis presented to a primary care clinic with a bilateral, erythematous rash on the legs, stomach, and chest. Photosensitive rash and dermatitis may be caused by many conditions. Hydrochlorothiazide-induced dermatitis is a rare side effect of thiazide diuretics. Early identification of sulfa-sensitivity and photoallergic or phototoxic reaction is essential to accurate diagnosis and treatment of photosensitive dermatitis. Soliciting a targeted history is essential to delineating drug-induced dermatitis from stasis dermatitis. A thorough skin examination can elucidate the focal or extensive nature of the rash and is essential to making an accurate diagnosis. Immediate cessation of hydrochlorothiazide and switching drugs classes for hypertension management typically leads to resolution of symptoms.

Association between primary care appointment lengths and subsequent ambulatory reassessment, emergency department care, and hospitalization: a cohort study.

BACKGROUND: To meet increasing demand, healthcare systems may leverage shorter appointment lengths to compensate for a limited supply of primary care providers (PCPs). Limiting the time spent with patients when evaluating acute health needs may adversely affect quality of care and increase subsequent healthcare utilization; however, the impact of brief duration appointments on healthcare utilization in the United States has not been examined. This study aimed to assess for potential inferiority of shorter (15-min) primary care appointments compare to longer (≥ 30-min appointments) with respect to downstream healthcare utilization within 7 days of the initial appointment. METHODS: We performed a retrospective cohort study using electronic health record (EHR), billing, and administrative scheduling data from five primary care practices in Midwest United States. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 were included. Patients scheduled for 15-min appointments were propensity score matched to those scheduled for ≥ 30-min. Multivariate regression models examined the effects of appointment length on repeat primary care visits, emergency department (ED) visits, hospitalizations, and diagnostic services within 7 days following the visit. Models were adjusted for baseline patient, visit, and provider characteristics. A non-inferiority approach was employed. RESULTS: We identified 173,758 total index visits (6.5% 15-min, 93.5% ≥ 30-min). 11,222 15-min appointments were matched to a comparable ≥ 30-min visit. Longer appointments were more frequent among trainee physicians, patients with limited English proficiency, and patients with more comorbidities. There was no significant effect of scheduled appointment length on the incidence of repeat primary care visits (OR = 0.983, CI: 0.873, 1.106) or ED visits (OR = 0.856, CI: 0.700, 1.047). Shorter appointments were associated with lower rates of subsequent hospitalizations (OR = 0.689, CI: 0.504, 0.941), laboratory services (OR = 0.682, CI: 0.643, 0.724), and diagnostic imaging services (OR = 0.499, CI: 0.466, 0.534). None of the non-inferiority thresholds were exceeded. CONCLUSIONS: For select indications and select low risk patients, shorter duration appointments may be a non-inferior option for scheduling of patient care that will not result in greater downstream healthcare utilization. These findings can help inform healthcare delivery models and triage processes as health systems and payers re-examine how to best deliver care to growing patient populations.

Patient-Centered Appointment Scheduling: a Call for Autonomy, Continuity, and Creativity.

When making an appointment, patients are generally unaware of how much clinician time is available to address their concerns. Similarly, the primary care clinician is often unaware of what the patient expects to accomplish during the visit, leading to uncertainty about how much time they can allot to each sequentially appearing concern, and whether they can reasonably expect to address necessary preventive services and chronic disease management. Neither patient nor clinician expectations can be adequately managed through standardized scheduling templates, which assign a fixed appointment length based on a single stated reason for the visit. As such, standardized appointment scheduling may contribute to inefficient use of valuable face-to-face time, patient and clinician dissatisfaction, and low-value care. Herein, we suggest several potential mechanisms for improving the scheduling process, including (1) entrusting scheduling to the primary care team; (2) advance visit planning; (3) pro-active engagement of ancillary team members including behavioral health, nursing, social work, and pharmacy; and (4) application of innovative, technologically advanced solutions such as telehealth and artificial intelligence to the scheduling process. These changes have the potential to improve efficiency, patient and clinician satisfaction, and health outcomes, while decreasing low-value testing and return visits for unaddressed concerns.

Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies.

INTRODUCTION: Chronic kidney disease (CKD) is widely prevalent, associated with morbidity and mortality, but may be lessened with timely implementation of evidence-based strategies including blood pressure (BP) control. Nonetheless, an evidence-practice gap persists. We synthesize the evidence for clinician-facing interventions to improve hypertension management in CKD patients in primary care. METHODS: Electronic databases and related publications were queried for relevant studies. We used a conceptual model to address heterogeneity of interventions. We conducted a quantitative synthesis of interventions on blood pressure (BP) outcomes and a narrative synthesis of other CKD relevant clinical outcomes. Planned subgroup analyses were performed by (1) study design (randomized controlled trials (RCTs) or nonrandomized studies (NRS)); (2) intervention type (guideline-concordant decision support, shared care, pharmacist-facing); and (3) use of behavioral/implementation theory. RESULTS: Of 2704 manuscripts screened, 73 underwent full-text review; 22 met inclusion criteria. BP target achievement was reported in 15 and systolic BP reduction in 6 studies. Among RCTs, all interventions had a significant effect on BP control, (pooled OR 1.21; 95% CI 1.07 to 1.38). Subgroup analysis by intervention type showed significant effects for guideline-concordant decision support (pooled OR 1.19; 95% CI 1.12 to 1.27) but not shared care (pooled OR 1.71; 95% CI 0.96 to 3.03) or pharmacist-facing interventions (pooled OR 1.04; 95% CI 0.82 to 1.34). Subgroup analysis finding was replicated with pooling of RCTs and NRS. The five contributing studies showed large and significant reduction in systolic BP (pooled WMD - 3.86; 95% CI - 7.2 to - 0.55). Use of a behavioral/implementation theory had no impact, while RCTs showed smaller effect sizes than NRS. DISCUSSION: Process-oriented implementation strategies used with guideline-concordant decision support was a promising implementation approach. Better reporting guidelines on implementation would enable more useful synthesis of the efficacy of CKD clinical interventions integrated into primary care. PROSPERO REGISTRATION NUMBER: CRD42018102441.

Is a switch to a different electronic health record associated with a change in patient satisfaction?

OBJECTIVE: Financial impacts associated with a switch to a different electronic health record (EHR) have been documented. Less attention has been focused on the patient response to an EHR switch. The Mayo Clinic was involved in an EHR switch that occurred at 6 different locations and with 4 different "go-live" dates. We sought to understand the relationship between patient satisfaction and the transition to a new EHR. MATERIALS AND METHODS: We used patient satisfaction data collected by Press Ganey from July 2016 through December 2019. Our patient satisfaction measure was the percent of patients responding "very good" (top box) to survey questions. Twenty-four survey questions were summarized by Press Ganey into 6 patient satisfaction domains. Piecewise linear regression was used to model patient satisfaction before and after the EHR switch dates. RESULTS: Significant drops in patient satisfaction were associated with the EHR switch. Patient satisfaction with access (ease of getting clinic on phone, ease of scheduling appointments, etc.) was most affected (range of 6 sites absolute decline: -3.4% to -8.8%; all significant at 99% confidence interval). Satisfaction with providers was least affected (range of 6 sites absolute decline: -0.5% to -2.8%; 4 of 6 sites significant at 99% confidence interval). After 9-15 months, patient satisfaction with access climbed back to pre-EHR switch levels. CONCLUSIONS: Patient satisfaction in several patient experience domains dropped significantly and stayed lower than pre-"go-live" for several months after a switch in EHR. Satisfaction with providers declined less than satisfaction with access.

A survey of outpatient Internal Medicine clinician perceptions of diagnostic error.

Background Little is known about how practicing Internal Medicine (IM) clinicians perceive diagnostic error, and whether perceptions are in agreement with the published literature. Methods A 16-question survey was administered across two IM practices: one a referral practice providing care for patients traveling for a second opinion and the other a traditional community-based primary care practice. Our aim was to identify individual- and system-level factors contributing to diagnostic error (primary outcome) and conditions at greatest risk of diagnostic error (secondary outcome). Results Sixty-five of 125 clinicians surveyed (51%) responded. The most commonly perceived individual factors contributing to diagnostic error included atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). The most commonly cited system-level factors included cognitive burden created by the volume of data in the electronic health record (EHR) (68%), lack of time to think (64%) and systems that do not support collaboration (40%). Conditions felt to be at greatest risk of diagnostic error included cancer (46%), pulmonary embolism (43%) and infection (37%). Conclusions Inadequate clinician time and sub-optimal patient and test follow-up are perceived by IM clinicians to be persistent contributors to diagnostic error. Clinician perceptions of conditions at greatest risk of diagnostic error may differ from the published literature.

What Can Apologies in the Electronic Health Record Tell Us About Health Care Quality, Processes, and Safety?

INTRODUCTION: Apologizing to patients is an encouraged practice, yet little is known about how and why providers apologize and what insights apologies could provide in improving quality and safety. OBJECTIVE: The aim of the study was to determine whether provider apologies in the electronic health record could identify patient safety concerns and opportunities for improvement. METHODS: After performing a free-text search, we randomly selected 100 clinical notes from 1685 available containing terminology related to apology. We categorized the reason for apology, presence and classification of medical error, level of patient harm, and practice improvement opportunities. We compared patient events discovered from apologies in the medical record to standard patient incident report logs. RESULTS: Of 100 randomly selected apologies, 37 were related to a delay in care, 14 to misunderstanding, 11 to access to care, and 8 to information technology. For apologies related to delay, the median delay was 6 days (mean = 8.9, range = 0-41). Twenty-four (65%) of the 37 delays were related to diagnostic testing.Medical errors were associated with 46 (46%) of the 100 apologies. Sixty-four (64%) of the 100 apologies were associated with actionable opportunities for improvement. These opportunities were classified into 37 discrete issues across 8 broad categories. When apology review was compared with standard incident report logs, 27 (73%) of the 37 discrete issues identified by patient apology review were not found in incident reporting; both methods identified similar rates of patient harm. CONCLUSIONS: Review of apologies in the electronic health record can identify patient safety concerns and improvement opportunities not apparent through standard incident reporting.

Implementation strategies for interventions to improve the management of chronic kidney disease (CKD) by primary care clinicians: protocol for a systematic review.

INTRODUCTION: There is a considerable implementation gap in managing early stage chronic kidney disease (CKD) in primary care despite the high prevalence and risk for increased morbidity and mortality associated with CKD. This systematic review aims to synthesise the evidence of efficacy of implementation interventions aimed at primary care practitioners (PCPs) to improve CKD identification and management. We further aim to describe the interventions' behavioural change components. METHODS AND ANALYSIS: We will conduct a systematic review of studies from 2000 to October 2017 that evaluate implementation interventions targeting PCPs and which include at least one clinically meaningful CKD outcome. We will search several electronic data bases and conduct reference mining of related systematic reviews and publications. An interdisciplinary team will independently and in duplicate, screen publications, extract data and assess the risk of bias. Clinical outcomes will include all clinically meaningful medical management outcomes relevant to CKD management in primary care such as blood pressure, chronic heart disease and diabetes target achievements. Quantitative evidence synthesis will be performed, where possible. Planned subgroup analyses include by (1) study design, (2) length of follow-up, (3) type of intervention, (4) type of implementation strategy, (5) whether a behavioural or implementation theory was used to guide study, (6) baseline CKD severity, (7) patient minority status, (8) study location and (9) academic setting or not. ETHICS AND DISSEMINATION: Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will inform a future trial of an intervention to promote uptake of CKD diagnosis and treatment guidelines in our primary care setting and the development of complementary tools to support its successful adoption and implementation. We will publish our findings in a peer-reviewed journal and develop accessible summaries of the results. PROSPERO REGISTRATION NUMBER: CRD42018102441.

Primary Care Provider Continuity Is Associated With Improved Preventive Service Ordering During Brief Visits for Acute Symptoms.

BACKGROUND: If a patient presents for an acute care visit and sees their assigned primary care provider (PCP), they may be more likely to receive preventive and other services than a patient not seeing their assigned PCP. METHODS: After exclusion of 2 visits with insufficient information, we reviewed 98 consecutive, outpatient internal medicine 15-minute acute care visits comparing patients seeing their assigned PCP with those seeing a non-PCP provider. The primary outcome, preventive service ordering, was measured in 2 ways: percentage of patient visits with any preventive service ordered and the total number of preventive services ordered as a proportion of all preventive service items due for each entire cohort. The secondary outcome of other work completed was assessed by comparing tests and consults ordered, and by counting the number of physical examination elements and discrete medical diagnoses documented. RESULTS: The PCPs were significantly more likely than non-PCPs to order any preventive service 45% versus 17% (P = .005; odds ratio [OR]: 4.16, 95% confidence interval [CI]: 1.45-12.0). The PCP cohort ordered a higher proportion of the total number of preventive services due compared with the non-PCP cohort (30% vs 11%; P = .002; OR: 3.4, CI: 1.5-7.7). The PCPs also addressed more medical diagnoses (2.3 vs 1.4; P = .008) and more frequently ordered tests outside the reason for that visit (40% vs 13%; P = .003; OR: 4.27, CI: 1.5-11.8). CONCLUSION: Patients seeing their assigned PCP in brief, acute visits have higher rates of preventive and other service ordering compared to those not seeing their assigned PCP.