Preoperative Communication Between Anesthesia, Surgery, and Primary Care Providers for Older Surgical Patients.

BACKGROUND: Suboptimal communication between clinicians remains a frequent driver of preventable adverse health care-related events, increased costs, and patient and physician dissatisfaction. METHODS: Cross-sectional surveys on preoperative interspecialty communication, tailored by stakeholder type, were administered to (1) primary care providers in northern New England, (2) anesthesia providers working in the perioperative clinic of a tertiary rural academic medical center, (3) surgeons from the same center, and (4) older surgical patients who underwent preoperative assessment at the same center. RESULTS: In total, 107/249 (43.0%) providers and 103/265 (39.9%) patients completed the survey. Preoperative communication was perceived as logistically challenging (59.8%), particularly across health systems. More than 77% of anesthesia and surgery providers indicated that they communicate frequently or sometimes, but 92.5% of primary care providers indicated that they rarely or never communicate with anesthesia providers. Some of the most common reasons for preoperative communication were discussion of complex patients, perioperative medication management, and optimization of comorbidities. Although 96.1% of older surgical patients reported that preoperative communication between providers is important, only 40.4% felt that their providers communicate very or extremely well. Many patients emphasized the importance of preoperative communication between providers to ensure transfer of critical clinical information. CONCLUSION: Surgeons and anesthesiologists infrequently communicate with primary care providers in one rural tertiary center, in contrast to patient expectations and values. These study results will help identify priorities and potentially resolvable barriers to bridging the gap between the inpatient perioperative and outpatient primary care teams. Future studies should focus on strategies to improve communication between hospital and community providers to prevent complications and readmission.

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial.

Importance: Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results. Objective: To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results. Design, Setting, and Participants: Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021. Intervention: Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment. Main Outcomes and Measures: The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk. Results: Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result. Conclusions and Relevance: A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer. Trial Registration: ClinicalTrials.gov Identifier: NCT03979495.

Primary Care Practitioner Perceptions on the Follow-up of Abnormal Cancer Screening Test Results.

Importance: Health care systems focus on delivering routine cancer screening to eligible individuals, yet little is known about the perceptions of primary care practitioners (PCPs) about barriers to timely follow-up of abnormal results. Objective: To describe PCP perceptions about factors associated with the follow-up of abnormal breast, cervical, colorectal, and lung cancer screening test results. Design, Setting, and Participants: Survey study of PCPs from 3 primary care practice networks in New England between February and October 2020, prior to participating in a randomized clinical trial to improve follow-up of abnormal cancer screening test results. Participants were physicians and advanced practice clinicians from participating practices. Main Outcomes and Measures: Self-reported process, attitudes, knowledge, and satisfaction about the follow-up of abnormal cancer screening test results. Results: Overall, 275 (56.7%) PCPs completed the survey (range by site, 34.9%-71.9%) with more female PCPs (61.8% [170 of 275]) and general internists (73.1% [201 of 275]); overall, 28,7% (79 of 275) were aged 40 to 49 years. Most PCPs felt responsible for managing abnormal cancer screening test results with the specific cancer type being the best factor (range, 63.6% [175 of 275] for breast to 81.1% [223 of 275] for lung; P < .001). The PCPs reported limited support for following up on overdue abnormal cancer screening test results. Standard processes such as automated reports, reminder letters, or outreach workers were infrequently reported. Major barriers to follow-up of abnormal cancer screening test results across all cancer types included limited electronic health record tools (range, 28.5% [75 of 263]-36.5%[96 of 263]), whereas 50% of PCPs felt that there were major social barriers to receiving care for abnormal cancer screening test results for colorectal cancer. Fewer than half reported being very satisfied with the process of managing abnormal cancer screening test results, with satisfaction being greatest for breast cancer (46.9% [127 of 271]) and lowest for cervical (21.8% [59 of 271]) and lung cancer (22.4% [60 of 268]). Conclusions and Relevance: In this survey study of PCPs, important deficiencies in systems for managing abnormal cancer screening test results were reported. These findings suggest a need for comprehensive organ-agnostic systems to promote timely follow-up of abnormal cancer screening results using a primary care-focused approach across the range of cancer screening tests.

Transitional Care Management Quality Improvement Methods That Reduced Readmissions in a Rural, Primary Care System.

BACKGROUND: Transitional Care Management (TCM) is a reimbursable service designed to minimize hospital readmissions. We describe a multifaceted approach to increase TCM services among 107 primary care providers in a rural catchment area of 4250 square miles. OBJECTIVE: The primary objective was to increase use of TCM phone calls, office visits, and billing codes; the secondary objective was to decrease hospital readmissions. METHODS: We utilized a learning health system model, an improvement support team (IST), and a learning collaborative that included webinars and in-person support. The process emphasized user-centered system redesign, coaching, electronic health record (EHR) improvements, and real-time feedback. Analyses included statistical process control charts, box plots, analysis of variance, and t-tests. RESULTS: The IST engaged stakeholders to design and test TCM workflows and EHR prototypes. This resulted in rapid, iterative improvements and system-wide spread of new processes. In the month following implementation, TCM calls and visits quadrupled and increased during 18 subsequent months. Pragmatically, most discharged patients (95% in a subsample) did not receive both the TCM call and visit, serving as a comparison group. The Readmission rate for patients receiving complete TCM services was 5.0% (n = 101) versus 11.9% for comparators (n = 2103, P = .03). Billing codes increased initially, then returned to baseline. CONCLUSIONS: Our approach led to rapid, sustained scaling of TCM calls and visits in a rural primary care group. Patients who received TCM calls and visits had significantly fewer readmissions. Training of new staff, including PCPs, is required for sustainability. Future research is warranted to increase adoption and evaluate additional outcomes including mortality rates, patient satisfaction, and health care economics.

Multilevel Follow-up of Cancer Screening (mFOCUS): Protocol for a multilevel intervention to improve the follow-up of abnormal cancer screening test results.

INTRODUCTION: While substantial attention is focused on the delivery of routine preventive cancer screening, less attention has been paid to systematically ensuring that there is timely follow-up of abnormal screening test results. Barriers to completion of timely follow-up occur at the patient, provider, care team and system levels. METHODS: In this pragmatic cluster randomized controlled trial, primary care sites in three networks are randomized to one of four arms: (1) standard care, (2) "visit-based" reminders that appear in a patient's electronic health record (EHR) when it is accessed by either patient or providers (3) visit based reminders with population health outreach, and (4) visit based reminders, population health outreach, and patient navigation with systematic screening and referral to address social barriers to care. Eligible patients in participating practices are those overdue for follow-up of an abnormal results on breast, cervical, colorectal and lung cancer screening tests. RESULTS: The primary outcome is whether an individual receives follow-up, specific to the organ type and screening abnormality, within 120 days of becoming eligible for the trial. Secondary outcomes assess the effect of intervention components on the patient and provider experience of obtaining follow-up care and the delivery of the intervention components. CONCLUSIONS: This trial will provide evidence for the role of a multilevel intervention on improving the follow-up of abnormal cancer screening test results. We will also specifically assess the relative impact of the components of the intervention, compared to standard care. TRIAL REGISTRATION: ClinicalTrials.gov NCT03979495.

Designing health information technology tools for behavioral health clinicians integrated within a primary care team.

BACKGROUND: Electronic health records (EHRs) are a key tool for primary care practice. However, EHR functionality is not keeping pace with the evolving informational and decision-support needs of behavioral health clinicians (BHCs) working on integrated teams. OBJECTIVE: Describe workflows and tasks of BHCs working with integrated teams, identify their health information technology needs, and develop EHR tools to address them. METHOD: A mixed-methods, comparative-case study of six community health centers (CHCs) in Oregon, each with at least one BHC integrated in their primary care team. We observed clinical work and conducted interviews to understand workflows and clinical tasks, aiming to identify how effectively current EHRs supported integrated care delivery, including transitions, documentation, information sharing, and decision making. We analyzed these data and employed a user-centered design process to develop EHR tools addressing the identified needs. RESULTS: BHCs used the primary care EHR for documentation and communication with other team members, but the EHR lacked the functionality to fully support integrated care. Needs include the ability to: (1) automate and track paper-based screening; (2) document behavioral health history; (3) access patient social and medical history relevant to behavioral health issues, and (4) rapidly document and track progress on goals. To meet these needs, we engaged users and developed a set of EHR tools called the BH e-Suite. CONCLUSION: Integrated primary care teams, and particularly BHCs, have unique information needs, workflows and tasks. These needs can be met and supported by the EHR with a moderate level of modification.

Development and use of a clinical decision support tool for behavioral health screening in primary care clinics.

OBJECTIVE: Screening, brief intervention, and referral for treatment (SBIRT) for behavioral health (BH) is a key clinical process. SBIRT tools in electronic health records (EHR) are infrequent and rarely studied. Our goals were 1) to design and implement SBIRT using clinical decision support (CDS) in a commercial EHR; and 2) to conduct a pragmatic evaluation of the impact of the tools on clinical outcomes. METHODS: A multidisciplinary team designed SBIRT workflows and CDS tools. We analyzed the outcomes using a retrospective descriptive convenience cohort with age-matched comparison group. Data extracted from the EHR were evaluated using descriptive statistics. RESULTS: There were 2 outcomes studied: 1) development and use of new BH screening tools and workflows; and 2) the results of use of those tools by a convenience sample of 866 encounters. The EHR tools developed included a flowsheet for documenting screens for 3 domains (depression, alcohol use, and prescription misuse); and 5 alerts with clinical recommendations based on screening; and reminders for annual screening. Positive screen rate was 21% (≥1 domain) with 60% of those positive for depression. Screening was rarely positive in 2 domains (11%), and never positive in 3 domains. Positive and negative screens led to higher rates of documentation of brief intervention (BI) compared with a matched sample who did not receive screening, including changes in psychotropic medications, updated BH terms on the problem list, or referral for BH intervention. Clinical process outcomes changed even when screening was negative. CONCLUSIONS: Modified workflows for BH screening and CDS tools with clinical recommendations can be deployed in the EHR. Using SBIRT tools changed clinical process metrics even when screening was negative, perhaps due to conversations about BH not captured in the screening flowsheet. Although there are limitations to the study, results support ongoing investigation.

Effectiveness and cost of recruiting healthy volunteers for clinical research studies using an electronic patient portal: A randomized study.

INTRODUCTION: It is not clear how to effectively recruit healthy research volunteers. METHODS: We developed an electronic health record (EHR)-based algorithm to identify healthy subjects, who were randomly assigned to receive an invitation to join a research registry via the EHR's patient portal, letters, or phone calls. A follow-up survey assessed contact preferences. RESULTS: The EHR algorithm accurately identified 858 healthy subjects. Recruitment rates were low, but occurred more quickly via the EHR patient portal than letters or phone calls (2.7 vs. 19.3 or 10.4 d). Effort and costs per enrolled subject were lower for the EHR patient portal (3.0 vs. 17.3 or 13.6 h, $113 vs. $559 or $435). Most healthy subjects indicated a preference for contact via electronic methods. CONCLUSIONS: Healthy subjects can be accurately identified from EHR data, and it is faster and more cost-effective to recruit healthy research volunteers using an EHR patient portal.

"Community vital signs": incorporating geocoded social determinants into electronic records to promote patient and population health.

Social determinants of health significantly impact morbidity and mortality; however, physicians lack ready access to this information in patient care and population management. Just as traditional vital signs give providers a biometric assessment of any patient, "community vital signs" (Community VS) can provide an aggregated overview of the social and environmental factors impacting patient health. Knowing Community VS could inform clinical recommendations for individual patients, facilitate referrals to community services, and expand understanding of factors impacting treatment adherence and health outcomes. This information could also help care teams target disease prevention initiatives and other health improvement efforts for clinic panels and populations. Given the proliferation of big data, geospatial technologies, and democratization of data, the time has come to integrate Community VS into the electronic health record (EHR). Here, the authors describe (i) historical precedent for this concept, (ii) opportunities to expand upon these historical foundations, and (iii) a novel approach to EHR integration.

IMPACCT Kids' Care: a real-world example of stakeholder involvement in comparative effectiveness research.

The Patient-Centered Outcomes Research Institute has accelerated conversations about the importance of actively engaging stakeholders in all aspects of comparative effectiveness research (CER). Other scientific disciplines have a history of stakeholder engagement, yet few empirical examples exist of how these stakeholders can inform and enrich CER. Here we present a case study which includes the methods used to engage stakeholders, what we learned from them, and how we incorporated their ideas in a CER project. We selected stakeholders from key groups, built relationships with them and collected their feedback through interviews, observation and ongoing meetings during the four research process phases: proposal development, adapting study methods, understanding the context and information technology tool design and refinement.

Strategies and Opportunities to STOP Colon Cancer in Priority Populations: design of a cluster-randomized pragmatic trial.

BACKGROUND: Colorectal cancer is the second-leading cause of cancer deaths in the United States. The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) in Priority Populations study is a pragmatic trial and a collaboration between two research institutions and a network of more than 200 safety net clinics. The study will assess the effectiveness of a system-based intervention designed to improve the rates of colorectal-cancer screening using fecal immunochemical testing (FIT) in federally qualified health centers in Oregon and Northern California. MATERIAL AND METHODS: STOP CRC is a cluster-randomized comparative-effectiveness pragmatic trial enrolling 26 clinics. Clinics will be randomized to one of two arms. Clinics in the intervention arm (1) will use an automated, data-driven, electronic health record-embedded program to identify patients due for colorectal screening and mail FIT kits (with pictographic instructions) to them; (2) will conduct an improvement process (e.g. Plan-Do-Study-Act) to enhance the adoption, reach, and effectiveness of the program. Clinics in the control arm will provide opportunistic colorectal-cancer screening to patients at clinic visits. The primary outcomes are: proportion of age- and screening-eligible patients completing a FIT within 12months; and cost, cost-effectiveness, and return on investment of the intervention. CONCLUSIONS: This large-scale pragmatic trial will leverage electronic health record information and existing clinic staff to enroll a broad range of patients, including many with historically low colorectal-cancer screening rates. If successful, the program will provide a model for a cost-effective and scalable method to raise colorectal-cancer screening rates.

Characterizing the use and contents of free-text family history comments in the Electronic Health Record.

The detailed collection of family history information is becoming increasingly important for patient care and biomedical research. Recent reports have highlighted the need for efforts to better understand collection and use of this information in resources such as the Electronic Health Record (EHR). This two-part study involved characterizing the use and contents of free-text comments within the family history section of an EHR. Based on a manual review of a subset of 11,456 cancer-related family history entries, 20 "reasons for use" were identified and the distribution across these reasons determined. A semi-automated analysis of the 3,358 unique comments associated with these entries was then performed to identify and quantify key categories of information. Implications of this study include guiding efforts for the improved use, collection, and subsequent analysis of family history information in the EHR.

Wilderness event medicine: planning for mass gatherings in remote areas.

BACKGROUND: An increasing number of large recreational events are taking place in remote environments where medical care is far away. Such events include adventure races and large outdoor trips. Wilderness event medicine (WEM) has been previously defined as the healthcare response at any discrete event with more than 200 persons located more than 1h from hospital treatment. However, there is little literature describing the steps for providing medical care at such events. METHODS: This article provides a framework for planning and executing WEM. It reviews the published data on wilderness injury and illness rates and describes the nature of injuries as they relate to specific activities. The article then discusses the three stages of WEM: pre-event planning, medical treatment at the event, and post-event tasks. RESULTS: Wilderness events include myriad activities, including orienteering, mountain biking, mountaineering, and whitewater paddling. The injury and illness rates are in the range of 1-10 per 1000 person-days of exposure, with rates one order of magnitude greater for events which last many days, include extremes of environment (heat, altitude), or are competitive in nature. Professional adventure racers may present for medical evaluation at rates as high as 1000 encounters per 1000 racer-days. Injuries depend largely on activity. Illnesses are mostly gastrointestinal, 'flu-like' malaise, or related to the event environment, such as humidity or altitude. Providing medical care requires the proper staff, equipment, and contingency plans. The remoteness of these events mandates different protocols than would be used at an urban mass gathering. CONCLUSIONS: WEM will likely continue to grow and evolve as a specialty. Additional reports from wilderness events, perhaps facilitated through a web-based incident reporting system, will allow medical providers to improve the quality of care given at remote events. Research into wilderness activity physiology will also be useful in understanding the prevention and treatment of injuries and illnesses encountered.

Wilderness event medicine.

OBJECTIVES: Wilderness Event Medicine (WEM), that is, the care of large groups of people participating in events in remote areas, is a rapidly growing subspecialty of wilderness medicine. Our goals are to report the injury rates from one wilderness event and to suggest ways to advance this emerging field. METHODS: We describe a 1-day wilderness hike and compare the injury rates from this one event with rates from other urban and wilderness events. RESULTS: Of the total 350 hikers, 6 persons presented for medical evaluation (5 dehydration and 1 orthopedic), yielding a rate of 17 evaluations per 1000 person-days of exposure. Only 1 person (or 2.9 per 1000) required medical assistance beyond oral rehydration. These rates are comparable to rates reported for urban events and other wilderness activities. CONCLUSIONS: According to very limited reports, the rates of injuries in wilderness events are similar to those for urban events. We recommend defining a wilderness event as an event with more than 200 participants and where the time from injury to care at a medical facility is likely to be greater than 1 hour. We also suggest the creation of a database of wilderness events, including standardized terms for the descriptions of activities, terrain, injuries, and medical response. Such a database could be used to help event planners anticipate and perhaps prevent injuries and to prepare effectively for those injuries that do occur.