Implementation of a Routine Health Literacy Assessment at an Academic Medical Center.

Limited health literacy is a common but often unrecognized problem associated with poor health outcomes. Well-validated screening tools are available to identify and provide the opportunity to intervene for at-risk patients in a resource-efficient manner. This is a multimethod study describing the implementation of a hospital-wide routine health literacy assessment at an academic medical center initiated by nurses in April 2014 and applied to all adult inpatients. Results were documented in the electronic health record, which then generated care plans and alerts for patients who screened positive. A nursing survey showed good ease of use and adequate patient acceptance of the screening process. Six months after hospital-wide implementation, retrospective chart abstraction of 1,455 patients showed that 84% were screened. We conclude that a routine health literacy assessment can be feasibly and successfully implemented into the nursing workflow and electronic health record of a major academic medical center.

A Patient-Centered Emergency Department Management Strategy for Sickle-Cell Disease Super-Utilizers.

INTRODUCTION: A subpopulation of sickle-cell disease patients, termed super-utilizers, presents frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the healthcare needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that alter utilization through coordinated care. Our goals were to assess feasibility primarily, and to assess resource use secondarily. METHODS: We evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (seven months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). Our approach included patient-specific best practice advisories (BPA); an ED management protocol; and formation of a "medical home" for these patients. RESULTS: For 10 subjects targeted initially we developed and implemented coordinated care plans; after deployment, we observed a tendency toward reduction in ED and inpatient utilization across all measured indices. Between the annualized pre- and post-implementation periods we found the following: ED visits decreased by 16.5 visits/pt-yr (95% confidence interval [CI] [-1.32-34.2]); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI [-82.9-313.5]); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI [-1.73-10.1]); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI [-74.9-146.7]); and visits where the patient left before treatment were reduced by an annualized total of 13.7 visits. We observed no patient mortality in our 10 subjects, and no patient required admission to the intensive care unit 72 hours following discharge. CONCLUSION: This effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.

The Use of Evidence-Based, Problem-Oriented Templates as a Clinical Decision Support in an Inpatient Electronic Health Record System.

BACKGROUND: The integration of clinical decision support (CDS) in documentation practices remains limited due to obstacles in provider workflows and design restrictions in electronic health records (EHRs). The use of electronic problem-oriented templates (POTs) as a CDS has been previously discussed but not widely studied. OBJECTIVE: We evaluated the voluntary use of evidence-based POTs as a CDS on documentation practices. METHODS: This was a randomized cohort (before and after) study of Hospitalist Attendings in an Academic Medical Center using EPIC EHRs. Primary Outcome measurement was note quality, assessed by the 9-item Physician Documentation Quality Instrument (PDQI-9). Secondary Outcome measurement was physician efficiency, assessed by the total charting time per note. RESULTS: Use of POTs increased the quality of note documentation [score 37.5 vs. 39.0, P = 0.0020]. The benefits of POTs scaled with use; the greatest improvement in note quality was found in notes using three or more POTs [score 40.2, P = 0.0262]. There was no significant difference in total charting time [30 minutes vs. 27 minutes, P = 0.42]. CONCLUSION: Use of evidence-based and problem-oriented templates is associated with improved note quality without significant change in total charting time. It can be used as an effective CDS during note documentation.

Redesign of an internal medicine ward rotation: operational challenges and outcomes.

INTRODUCTION: In anticipation of the 2011 ACGME duty hour requirements, we redesigned our internal medicine resident ward experience. Our previous ward structure included a maximum 30-hour duty period for postgraduate year-1 (PGY-1) residents. In the redesigned ward structure, PGY-1 residents had a maximum 18-hour duty period. METHODS: We evaluated resident conference attendance and duty hour violations before and after implementation of our new ward redesign. We administered a satisfaction survey to residents and faculty 6 months after implementation of the new ward redesign. RESULTS: Before implementation of the ward redesign, 30-hour continuous and 80-h/wk duty violations were each 2/year, and violations of the 10-hour rest between duty periods were 10/year for 74 residents. After implementation of the ward redesign, there were no 30-hour continuous or 80-h/wk duty violations, but violations of the 10-hour rest between duty periods more than doubled (26/year for 75 residents). Duty hours were reported by different mechanisms for the 2 periods. Conference attendance improved. Resident versus faculty satisfaction scores were similar. Both groups judged overall professional satisfaction as slightly worse after implementation. CONCLUSION: Our ward rotation redesign eliminated 30-hour continuous and 80-h/wk duty violations as well as improved conference attendance. These benefits occurred at the cost of more faculty hires, decreased resident elective time, and slightly worse postimplementation satisfaction scores.

Chronic non-cancer pain: a siren for primary care--a report from the PRImary Care MultiEthnic Network (PRIME Net).

INTRODUCTION: Patients with chronic non-cancer pain (CNCP) are common and have a high degree of morbidity. Previous studies document clinician frustration and variability in CNCP management. We conducted this study to gather in-depth clinicians' views about factors that affect management of CNCP. METHODS: We conducted a survey in the Primary Care MultiEthnic Network, a consortium of PBRNs of primary care clinicians practicing in low-income, medically underserved communities, and in a network of private primary care offices. RESULTS: Of 792 clinicians surveyed, 497 (63%) participated. Responses and accompanying narrative comments clustered around 5 themes: (1) barriers to and uncertainties in optimal management; (2) the complex biopsychosocial nature of CNCP; (3) seriousness of prescription opioid abuse; (4) effort and burden required to properly manage CNCP; and (5) clinician commitment to provide care for CNCP patients and benefits of expanded care model for CNCP. One-third reported a severe outcome (death or life-threatening event) in a CNCP patient for whom they had prescribed opioids. Roughly one-third do not initiate prescribing of opioids. CONCLUSIONS: Guidelines and increased continuing medical education alone are unlikely to be the solutions to the challenges of CNCP management. Increased evidence for recommendations and resources for more comprehensive care management are needed.

Context of clinical care: the case of hepatitis C in underserved communities--a report from the Primary Care Multiethnic Network (PRIME Net) Consortium.

BACKGROUND: The importance of Hepatitis C (HCV) as a public and individual health concern is well established. However, national groups differ in their recommendations to primary care clinicians about screening people at high risk for HCV. The purpose of this study was to explore the context of care within which primary care clinicians decide to detect and initially manage HCV. METHODS: The Primary Care Multiethnic Network conducted a web- and paper-based survey of primary care clinicians who largely practice in low-income, medically underserved communities in 3 regions across the country. RESULTS: A total of 494 clinicians participated, for a response rate of 61%. Most (68%) clinicians view HCV as an important problem; more than half (59%) consider screening for HCV to be important when compared with other conditions they screen for in practice. With regard to reported screening habits for risk factors, 54% of clinicians routinely ask new patients whether they have used intravenous drugs and 28% inquire about blood transfusions before 1992. Sixty-one percent order an alanine aminotransferase test when patients present with other risk factors for HCV. The majority of clinicians (54%) refer 75% or fewer of their patients with HCV for treatment; nearly one-fifth (18%) provide antiviral treatment themselves. Key factors influencing clinician HCV decision making are patient comorbidities (74% reported this as a factor), access to treatment (55% reported this as a factor), and tolerance (44% reported this as a factor) of treatment. CONCLUSIONS: In the face of conflicting national guideline recommendations about screening people at high risk for HCV, clinicians have varied views and practice habits influenced by multiple patient, access, and treatment issues.

Obesity counseling and guidelines in primary care: a qualitative study.

BACKGROUND: The problem of obesity is now epidemic in the United States. Despite the existence of clinical guidelines for prevention and treatment of obesity and documented clinician concern about this problem, counseling for obesity reduction in primary care is infrequent. The principal aim of this study was to examine the views of clinicians on obesity counseling and to compare these views to the recommendations of leading obesity guidelines. METHODS: Twenty individual, in-depth interviews and two focus groups of clinicians serving predominantly low-income minority populations were conducted in a practice-based research network. Data were analyzed using immersion/crystallization and template approaches. RESULTS: Clinicians believe obesity is an important problem and report using mostly brief, targeted, low-intensity counseling in the face of limited patient motivation and lack of resources to support weight loss. They view family, cultural, social, and community factors as central to the problem of obesity, and their own efforts as generally ineffective. These clinicians similarly were unconvinced of the long-term effectiveness of any weight-loss strategies. CONCLUSIONS: Low levels of obesity counseling in primary care may reflect clinicians' self-assessment of their ineffectiveness in this area rather than lack of interest or knowledge. These clinicians perceive that obesity control efforts aimed at local community factors and environmental modifications are key strategies in augmenting and linking their efforts to successful outcomes.

Does office-based counseling of adolescents and young adults improve self-reported safety habits? A randomized controlled effectiveness trial.

PURPOSE: The purpose of this study was to evaluate brief physician advice regarding seatbelt and bicycle helmet use in adolescents and young adults. METHODS: We recruited 200 patients ages 11-24 years presenting for all visits to a primary care clinic in the Southwestern United States from January 2000 to March 2001. Patients were randomized to control or a single 2- to 3-minute scripted motivational counseling intervention delivered by physicians with an educational brochure and discount helmet coupon. We conducted telephone follow-up evaluation at 3 months. Main outcome measures were self-reported seatbelt and bicycle helmet use assessed on a 4-point Likert scale and attitudes toward these behaviors assessed on a 5-point Likert scale and analyzed by the Wilcoxon signed-rank test. RESULTS: For the intervention group, mean Likert scores precounseling and postcounseling for self-reported seatbelt use were 1.3 and 1.4, respectively, with a mean difference of .04 (95% confidence interval [CI], -.1 to .2). For self-reported bicycle helmet use, scores were 3.1 and 3.0, respectively, with a mean difference of .1 (95% CI, -.3 to .2). Combined mean Likert scores measuring subject's attitudes about seat belt use were 13.8 and 14.0, respectively, with a mean difference of .2 (95% CI, -.3 to .6). For bicycle helmet use, scores were 20.0 and 20.9, respectively, with a mean difference of .9 (95% CI, -1.4 to 3.3). CONCLUSION: We were unable to detect a significant improvement in safety behaviors or attitudes by adolescents and young adults after a brief intervention by physicians during routine office visits.