Foundational Collective Actions for Achieving Agile High-Quality Primary Care in the United States.

In 2021, the National Academy of Science, Engineering, and Medicine Committee on Implementing High-Quality Primary Care published its recommendations to expand the provision of high-quality primary care in the USA. These include paying for primary care teams to care for people, ensuring that high-quality primary care is available, training primary care teams where people live and work, and designing information technology that serves the patient, family, and care team. Many of these recommendations echo those of prior calls for action, including the Institute of Medicine's 1996 report. However, the 2021 report recognizes the importance of implementation in its final recommendation of ensuring that high-quality primary care is implemented in the USA. We consider the NASEM recommendations in terms of the complexity of the task of supporting interconnected implementation activities that occur in local contexts. With this vantage point, we identify foundational collective actions, including the creation of an accountable leadership entity, payment reform, and community networks. We then discuss the creation of a monitoring mechanism to assess and support sustained action.

Variation in Family Physicians' Experiences Across Different Electronic Health Record Platforms: a Descriptive Study.

BACKGROUND: Electronic health records (EHRs) have been connected to excessive workload and physician burnout. Little is known about variation in physician experience with different EHRs, however. OBJECTIVE: To analyze variation in reported usability and satisfaction across EHRs. DESIGN: Internet-based survey available between December 2021 and October 2022 integrated into American Board of Family Medicine (ABFM) certification process. PARTICIPANTS: ABFM-certified family physicians who use an EHR with at least 50 total responding physicians. MEASUREMENTS: Self-reported experience of EHR usability and satisfaction. KEY RESULTS: We analyzed the responses of 3358 physicians who used one of nine EHRs. Epic, athenahealth, and Practice Fusion were rated significantly higher across six measures of usability. Overall, between 10 and 30% reported being very satisfied with their EHR, and another 32 to 40% report being somewhat satisfied. Physicians who use athenahealth or Epic were most likely to be very satisfied, while physicians using Allscripts, Cerner, or Greenway were the least likely to be very satisfied. EHR-specific factors were the greatest overall influence on variation in satisfaction: they explained 48% of variation in the probability of being very satisfied with Epic, 46% with eClinical Works, 14% with athenahealth, and 49% with Cerner. CONCLUSIONS: Meaningful differences exist in physician-reported usability and overall satisfaction with EHRs, largely explained by EHR-specific factors. User-centric design and implementation, and robust ongoing evaluation are needed to reduce physician burden and ensure excellent experience with EHRs.

Measuring Trust in Primary Care.

Policy Points Trust in primary care clinicians is essential for effective patient care and is associated with better health outcomes, but it is rarely assessed, and existing measures have not been thoroughly evaluated. This scoping review reveals that research assessing patients' trust in primary care clinicians largely stopped more than a decade ago but offers candidate measures for future testing, implementation, and policy applications. CONTEXT: Trust is a fundamental aspect of any human relationship, and medical care is no exception. An ongoing, trusting relationship between clinicians and patients has shown demonstrable value to primary care. However, there is currently no measure of trust in general use, and none endorsed for use by most value-based payment programs. This review searched the literature for any existing measures of patient trust in primary care clinicians and assessed their potential to be implemented as a patient-reported outcome measure. METHODS: A keyword search on PubMed along with scanning references was conducted to find any trust measures in health care. Measures that did not address primary care clinicians were eliminated and the remaining measures were then assessed for their utility to primary care. RESULTS: This purposeful, scoping review found four tested measures for assessing patients' trust in primary care clinicians that are candidates for general use. Of these four, the revised Trust in Physicians Scale and Wake Forest Physician Trust Scale are the most tested and viable options. CONCLUSION: Renewed national interest in trust in health care should focus on the capacity to measure it. This review informs the effort to test trust measures for use in research, practice improvement, and value-based payment. Measuring trust, how it relates to outcomes, and learning how it is produced or lost are key to assisting practices and health systems toward earning it.

Treatment of breakthrough and prevention of refractory chemotherapy-induced nausea and vomiting in pediatric cancer patients: Clinical practice guideline update.

This clinical practice guideline update provides recommendations for treating breakthrough chemotherapy-induced nausea and vomiting (CINV) and preventing refractory CINV in pediatric patients. Two systematic reviews of randomized controlled trials in adult and pediatric patients informed the recommendations. In patients with breakthrough CINV, escalation of antiemetic agents to those recommended for chemotherapy of the next higher level of emetogenic risk is strongly recommended. A similar recommendation to escalate therapy is made to prevent refractory CINV in patients who did not experience complete breakthrough CINV control and are receiving minimally or low emetogenic chemotherapy. A strong recommendation to use antiemetic agents that controlled breakthrough CINV for the prevention of refractory CINV is also made.

How the Gender Wage Gap for Primary Care Physicians Differs by Compensation Approach : A Microsimulation Study.

BACKGROUND: The physician gender wage gap may be due, in part, to productivity-based compensation models that undervalue female practice patterns. OBJECTIVE: To determine how primary care physician (PCP) compensation by gender differs when applying existing productivity-based and alternative compensation models. DESIGN: Microsimulation. SETTING: 2016 to 2019 national clinical registry of 1222 primary care practices. PARTICIPANTS: Male and female PCPs matched on specialty, years since medical school graduation, practice site, and sessions worked. MEASUREMENTS: Net annual, full-time-equivalent compensation for male versus female PCPs, under productivity-based fee-for-service, panel size-based capitation without or with risk adjustment, and hybrid payment models. Microsimulation inputs included patient and visit characteristics and overhead expenses. RESULTS: Among 1435 matched male (n = 881) and female (n = 554) PCPs, female PCP panels included patients who were, on average, younger, had lower diagnosis-based risk scores, were more often female, and were more often uninsured or insured by Medicaid rather than by Medicare. Under productivity-based payment, female PCPs earned a median of $58 829 (interquartile range [IQR], $39 553 to $120 353; 21%) less than male PCPs. This gap was similar under capitation ($58 723 [IQR, $42 141 to $140 192]). It was larger under capitation risk-adjusted for age alone ($74 695 [IQR, $42 884 to $152 423]), for diagnosis-based scores alone ($114 792 [IQR, $49 080 to $215 326] and $89 974 [IQR, $26 175 to $173 760]), and for age-, sex-, and diagnosis-based scores ($83 438 [IQR, $28 927 to $129 414] and $66 195 [IQR, $11 899 to $96 566]). The gap was smaller and nonsignificant under capitation risk-adjusted for age and sex ($36 631 [IQR, $12 743 to $73 898]). LIMITATION: Panel attribution based on office visits. CONCLUSION: The gender wage gap varied by compensation model, with capitation risk-adjusted for patient age and sex resulting in a smaller gap. Future models might better align with primary care effort and outcomes. PRIMARY FUNDING SOURCE: None.

Predicting relapse or recurrence of depression: systematic review of prognostic models.

BACKGROUND: Relapse and recurrence of depression are common, contributing to the overall burden of depression globally. Accurate prediction of relapse or recurrence while patients are well would allow the identification of high-risk individuals and may effectively guide the allocation of interventions to prevent relapse and recurrence. AIMS: To review prognostic models developed to predict the risk of relapse, recurrence, sustained remission, or recovery in adults with remitted major depressive disorder. METHOD: We searched the Cochrane Library (current issue); Ovid MEDLINE (1946 onwards); Ovid Embase (1980 onwards); Ovid PsycINFO (1806 onwards); and Web of Science (1900 onwards) up to May 2021. We included development and external validation studies of multivariable prognostic models. We assessed risk of bias of included studies using the Prediction model risk of bias assessment tool (PROBAST). RESULTS: We identified 12 eligible prognostic model studies (11 unique prognostic models): 8 model development-only studies, 3 model development and external validation studies and 1 external validation-only study. Multiple estimates of performance measures were not available and meta-analysis was therefore not necessary. Eleven out of the 12 included studies were assessed as being at high overall risk of bias and none examined clinical utility. CONCLUSIONS: Due to high risk of bias of the included studies, poor predictive performance and limited external validation of the models identified, presently available clinical prediction models for relapse and recurrence of depression are not yet sufficiently developed for deploying in clinical settings. There is a need for improved prognosis research in this clinical area and future studies should conform to best practice methodological and reporting guidelines.

Physicians' Choice of Board Certification Activity Is Unaffected by Baseline Quality of Care: The TRADEMaRQ Study.

PURPOSE: Physicians' use of self-assessment to guide quality improvement or board certification activities often does not correlate with more objective measures, and they may spend valuable time on activities that support their strengths instead of addressing gaps. Our objective was to study whether viewing quality measures, with peer comparisons, would affect the selection of certification activities. METHODS: We conducted a cluster-randomized controlled trial-the Trial of Data Exchange for Maintenance of certification and Raising Quality (TRADEMaRQ)-with 4 partner organizations during 2015-2017. Physicians were presented their quality data within their online certification portfolios before (intervention) vs after (control) they chose board certification activities. The primary outcome was whether the selected activity addressed a quality gap (a quality area in which the physician scored below the mean for the study population). RESULTS: Of 2,570 invited physicians, 254 physicians completed the study: 130 in the intervention group and 124 in the control group. Nearly one-fifth of participating physicians did not complete any certification activities during the study. A sizable minority of those in the intervention group, 18.4%, never reviewed their quality dashboard. Overall, just 27.2% of completed certification activities addressed a quality gap, and there was no significant difference in this outcome in the intervention group vs the control group in either bivariate or adjusted analyses (odds ratio = 1.28; 95% CI, 0.90-1.82). CONCLUSIONS: Physicians did not use quality performance data in choosing certification activities. Certification boards are being pressed to make their programs relevant to practice, less burdensome, and supportive of quality improvement in alignment with value-based payment models. Using practice data to drive certification choices would meet these goals.

Interventions for the prevention of acute phase chemotherapy-induced nausea and vomiting in adult and pediatric patients: a systematic review and meta-analysis.

PURPOSE: To identify effective and safe interventions to prevent acute phase chemotherapy-induced nausea and vomiting (CINV) in adult and pediatric patients. METHODS: We conducted a systematic review of randomized trials evaluating interventions to prevent acute CINV. Outcomes assessed were complete chemotherapy-induced vomiting (CIV) control, complete chemotherapy-induced nausea (CIN) control, complete CINV control, and discontinuation of antiemetics due to adverse effects. RESULTS: The search identified 65,172 citations; 744 were evaluated at full-text, and 295 (25 pediatric) met eligibility criteria. In patients receiving highly emetogenic chemotherapy (HEC), complete CIV (risk ratio (RR) 1.23, 95% confidence interval (CI) 1.05-1.44) and CIN (RR 1.34, 95% CI 1.10-1.62) control improved when olanzapine was added. The addition of a neurokinin-1 receptor antagonist (NK1RA) to a corticosteroid plus a serotonin-3 receptor antagonist (5HT3RA) also improved complete CIV (RR 1.11, 95% CI 1.08-1.14) and CIN (RR 1.05, 95% CI 1.01-1.08) control. Compared to granisetron/ondansetron, palonosetron provided improved complete CIV control when the 5HT3RA was given alone or when combined with dexamethasone. In patients receiving moderately emetogenic chemotherapy (MEC), dexamethasone plus a 5HT3RA improved complete CIV control compared to a 5HT3RA alone (RR 1.29, 95% CI 1.21-1.39). Only a single meta-analysis evaluating the safety outcome was possible. CONCLUSIONS: For patients receiving HEC, various antiemetic regimens improved CIV and CIN control. For patients receiving MEC, administration of a 5HT3RA plus dexamethasone improved CIV control. Analysis of antiemetic safety was constrained by lack of data.

Clinical Quality Measure Exchange is Not Easy.

PURPOSE: The Trial of Aggregate Data Exchange for Maintenance of Certification and Raising Quality was a randomized controlled trial which first had to test whether quality reporting could be a by-product of clinical care. We report on the initial descriptive study of the capacity for and quality of exchange of whole-panel, standardized quality measures from health systems. METHODS: Family physicians were recruited from 4 health systems with mature quality measurement programs and agreed to submit standardized, physician-level quality measures for consenting physicians. Identified measure or transfer errors were captured and evaluated for root-cause problems. RESULTS: The health systems varied considerably by patient demographics and payer mix. From the 4 systems, 256 family physicians elected to participate. Of 19 measures negotiated for use, 5 were used by all systems. There were more than 15 types of identified errors including breaks in data delivery, changes in measures, and nonsensical measure results. Only 1 system had no identified errors. CONCLUSIONS: The secure transfer of standardized, physician-level quality measures from 4 health systems with mature measure processes proved difficult. There were many errors that required human intervention and manual repair, precluding full automation. This study reconfirms an important problem, namely, that despite widespread health information technology adoption and federal meaningful use policies, we remain far from goals to make clinical quality reporting a reliable by-product of care.

Well-Being in the Nation: A Living Library of Measures to Drive Multi-Sector Population Health Improvement and Address Social Determinants.

Policy Points Well-being In the Nation (WIN) offers the first parsimonious set of vetted common measures to improve population health and social determinants across sectors at local, state, and national levels and is driven by what communities need to improve health, well-being, and equity. The WIN measures were codesigned with more than 100 communities, federal agencies, and national organizations across sectors, in alignment with the National Committee on Vital and Health Statistics, the Foundations for Evidence-Based Policymaking Act, and Healthy People 2030. WIN offers a process for a collaborative learning measurement system to drive a learning health and well-being system across sectors at the community, state, and national levels. The WIN development process identified critical gaps and opportunities in equitable community-level data infrastructure, interoperability, and protections that could be used to inform the Federal Data Strategy.

Primary Care Research Priorities in Low-and Middle-Income Countries.

PURPOSE: To identify and prioritize the needs for new research evidence for primary health care (PHC) in low-and middle-income countries (LMICs) about organization, models of care, and financing of PHC. METHODS: Three-round expert panel consultation of LMIC PHC practitioners and academics sampled from global networks, via web-based surveys. Iterative literature review conducted in parallel. Round 1 (pre-Delphi survey) elicited possible research questions to address knowledge gaps about organization and models of care and about financing. Round 2 invited panelists to rate the importance of each question, and in round 3 panelists provided priority ranking. RESULTS: One hundred forty-one practitioners and academics from 50 LMICs from all global regions participated and identified 744 knowledge gaps critical to improving PHC organization and 479 for financing. Four priority areas emerged: effective transition of primary and secondary services, horizontal integration within a multidisciplinary team and intersectoral referral, integration of private and public sectors, and ways to support successfully functioning PHC professionals. Financial evidence priorities were mechanisms to drive investment into PHC, redress inequities, increase service quality, and determine the minimum necessary budget for good PHC. CONCLUSIONS: This novel approach toward PHC needs in LMICs, informed by local academics and professionals, created an expansive and prioritized list of critical knowledge gaps in PHC organization and financing. It resulted in research questions, offering valuable guidance to global supporters of primary care evaluation and implementation. Its source and context specificity, informed by LMIC practitioners and academics, should increase the likelihood of local relevance and eventual success in implementing research findings.

Higher Primary Care Physician Continuity is Associated With Lower Costs and Hospitalizations.

PURPOSE: Continuity of care is a defining characteristic of primary care associated with lower costs and improved health equity and care quality. However, we lack provider-level measures of primary care continuity amenable to value-based payment, including the Medicare Quality Payment Program (QPP). We created 4 physician-level, claims-based continuity measures and tested their associations with health care expenditures and hospitalizations. METHODS: We used Medicare claims data for 1,448,952 beneficiaries obtaining care from a nationally representative sample of 6,551 primary care physicians to calculate continuity scores by 4 established methods. Patient-level continuity scores attributed to a single physician were averaged to create physician-level scores. We used beneficiary multilevel models, including beneficiary controls, physician characteristics, and practice rurality to estimate associations with total Medicare Part A & B expenditures (allowed charges, logged), and any hospitalization. RESULTS: Our continuity measures were highly correlated (correlation coefficients ranged from 0.86 to 0.99), with greater continuity associated with similar outcomes for each. Adjusted expenditures for beneficiaries cared for by physicians in the highest Bice-Boxerman continuity score quintile were 14.1% lower than for those in the lowest quintile ($8,092 vs $6,958; ß = -0.151; 95% CI, -0.186 to -0.116), and the odds of hospitalization were 16.1% lower between the highest and lowest continuity quintiles (OR = 0.839; 95% CI, 0.787 to 0.893). CONCLUSIONS: All 4 continuity scores tested were significantly associated with lower total expenditures and hospitalization rates. Such indices are potentially useful as QPP measures, and may also serve as proxy resource-use measures, given the strength of association with lower costs and utilization.

Outcome Measure Scores Predict Discharge Destination in Patients With Acute and Subacute Stroke: A Systematic Review and Series of Meta-analyses.

BACKGROUND AND PURPOSE: To identify the association between outcome measure score and discharge destination in adults following acute or subacute stroke in the United States. METHODS: A systematic literature search was performed in 3 databases using the PRISMA guidelines. Cohort studies were selected that included patients with acute or subacute stroke, which explored the relationship between scores on outcome measures and discharge destination. Four meta-analyses were performed. RESULTS: Nine articles met the inclusion criteria for systematic review and 5 for the series of meta-analyses. For every 1-point increase on the Functional Independence Measure (FIM), a patient is approximately 1.08 times more likely to be discharged home than to institutionalized care (odds ratio [OR] = 1.079; 95% confidence interval [CI], 1.056- 1.102). Patients with stroke who performed above-average (FIM ≥80; NIH Stroke Scale [NIHSS] score ≤5; etc) are 12 times (OR = 12.08; 95% CI, 3.550-41.07) more likely to discharge home. Patients who perform poorly (FIM ≤39; NIHSS score ≥14), experience discharge to institutionalized care 3.4 times (OR = 3.385; 95% CI, 2.591-4.422) more likely than home, with skilled nursing facility admission more likely than inpatient rehabilitation facility. Patients who perform average (FIM = 40-79; NIHSS score = 6-13) are 1.9 times (OR = 1.879; 95% CI, 1.227-2.877) more likely to be discharged to institutionalized care. DISCUSSION AND CONCLUSION: Outcome measure scores are strong predictors of discharge destination among patients with stroke and provide an objective means of early discharge planning. Discharge decisions should be made with consideration for patient-specific biopsychosocial factors that may supersede isolated results of the outcome measures, and further research needs to assess the success of the location that a patient is referred at discharge.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A194).

Guideline for the prevention of acute chemotherapy-induced nausea and vomiting in pediatric cancer patients: A focused update.

This update of the 2013 clinical practice guideline provides clinicians with guidance regarding the use of aprepitant and palonosetron for the prevention of acute chemotherapy-induced nausea and vomiting (CINV) in children. The recommendations were based on three systematic reviews. Substantive changes were made to the guideline recommendations including the inclusion of palonosetron to the 5-HT3 antagonists recommended for children receiving highly emetogenic chemotherapy (HEC) and the recommendation of aprepitant for children 6 months of age or older receiving HEC. To optimize CINV control in children, future work must focus on closing critical research gaps.

Critical review of current clinical practice guidelines for antifungal therapy in paediatric haematology and oncology.

PURPOSE: The incidence of invasive fungal disease (IFD) is rising, but its treatment in paediatric haematology and oncology patients is not yet standardised. This review aimed to critically appraise and analyse the clinical practice guidelines (CPGs) that are available for paediatric IFD. METHODS: Electronic searches of MEDLINE, MEDLINE in-Process & Other non-Indexed Citations, the Guidelines International Network (GIN), guideline.gov and Google were performed and combined fungal disease (Fung* OR antifung*OR Candida* OR Aspergill*) with prophylaxis or treatment (prophyl* OR therap* OR treatment). All guidelines were assessed using the AGREE II tool and recommendations relating to prophylaxis, empirical treatment and specific therapy were extracted. RESULTS: Nineteen guidelines met the inclusion criteria. The AGREE II scores for the rigour of development domain ranged from 11 to 92 % with a median of 53 % (interquartile range 32-69 %). Fluconazole was recommended as antifungal prophylaxis in all nine of the included guidelines which recommended a specific drug. Liposomal amphotericin B was recommended in all five guidelines giving empirical therapy recommendations. Specific therapy recommendations were given for oral or genital candidiasis, invasive candida infection, invasive aspergillosis and other mould infections. CONCLUSIONS: In many areas, recommendations were clear about appropriate practice but further clarity was required, particularly relating to the decision to discontinue empirical antifungal treatment, the relative benefits of empiric and pre-emptive strategies and risk stratification. Future CPGs could consider working to published guideline production methodologies and sharing summaries of evidence appraisal to reduce duplication of effort, improving the quality and efficiency of CPGs in this area.

Guideline for the Treatment of Breakthrough and the Prevention of Refractory Chemotherapy-Induced Nausea and Vomiting in Children With Cancer.

This clinical practice guideline provides an approach to the treatment of breakthrough chemotherapy-induced nausea and vomiting (CINV) and the prevention of refractory CINV in children. It was developed by an international, interprofessional panel and is based on systematic literature reviews. Evidence-based interventions for the treatment of breakthrough and prophylaxis of refractory CINV are recommended. Gaps in the evidence used to support the recommendations made in this clinical practice guideline were identified. The contribution of these recommendations to breakthrough and refractory CINV control in children requires prospective evaluation.

Systematic review of reduced therapy regimens for children with low risk febrile neutropenia.

PURPOSE: Reduced intensity therapy for children with low-risk febrile neutropenia may provide benefits to both patients and the health service. We have explored the safety of these regimens and the effect of timing of discharge. METHODS: Multiple electronic databases, conference abstracts and reference lists were searched. Randomised controlled trials (RCT) and prospective observational cohorts examining the location of therapy and/or the route of administration of antibiotics in people younger than 18 years who developed low-risk febrile neutropenia following treatment for cancer were included. Meta-analysis using a random effects model was conducted. I (2) assessed statistical heterogeneity not due to chance. REGISTRATION: PROSPERO (CRD42014005817). RESULTS: Thirty-seven studies involving 3205 episodes of febrile neutropenia were included; 13 RCTs and 24 prospective observational cohorts. Four safety events (two deaths, two intensive care admissions) occurred. In the RCTs, the odds ratio for treatment failure (persistence, worsening or recurrence of fever/infecting organisms, antibiotic modification, new infections, re-admission, admission to critical care or death) with outpatient treatment was 0.98 (95% confidence interval (95%CI) 0.44-2.19, I (2) = 0 %) and with oral treatment was 1.05 (95%CI 0.74-1.48, I (2) = 0 %). The estimated risk of failure using outpatient therapy from all prospective data pooled was 11.2 % (95%CI 9.7-12.8 %, I (2) = 77.2 %) and using oral antibiotics was 10.5 % (95%CI 8.9-12.3 %, I (2) = 78.3 %). The risk of failure was higher when reduced intensity therapies were used immediately after assessment, with lower rates when these were introduced after 48 hours. CONCLUSIONS: Reduced intensity therapy for specified groups is safe with low rates of treatment failure. Services should consider how these can be acceptably implemented.