Clinical pharmacist practitioners on primary care teams play an important role in caring for complex patients with diabetes.

PURPOSE: To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs). METHODS: In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence. RESULTS: Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays. CONCLUSION: The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients.

Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population.

BACKGROUND: Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations. OBJECTIVE: To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs). METHODS: We conducted semistructured interviews with staff, patients, and family members at 1 CLC to assess their understanding of penicillin allergies and receptiveness to verifying the allergy. We also asked staff about the proposed allergy assessment strategy, including willingness to delabel by history and feasibility of performing oral challenges or skin testing on their unit. RESULTS: From 24 interviews (11 front-line staff, 4 leadership, 3 patients, 6 family members), we identified several facilitators or barriers. Staff recognized the importance of allergy verification and were willing to support and assist in implementing verification strategies. The CLC residents were willing to have their allergy status verified. However, some family members expressed reluctance to verifying their relative's allergy status owing to safety concerns. Front-line staff also expressed concern over having the necessary resources, including time and expertise, to implement the strategy. Staff suggested involving clinical pharmacists and educating staff, patients, and family members as ways to overcome these barriers. CONCLUSIONS: Concerns about safety and staff resources are important potential barriers to implementing verification strategies. Involvement of pharmacists and education of both staff and patients and family members will be important components of any successful intervention.

Colonoscopic findings in patients with pelvic floor dysfunction.

BACKGROUNDY: Colonoscopy is often performed in the initial workup of pelvic floor dysfunction, even in the absence of red flag symptoms. Current guidelines suggest colonoscopy is only required in the presence of rectal bleeding, diarrhoea or change in bowel habit. The aim of this study was to evaluate the prevalence of significant pathology found at colonoscopy in patients with pelvic floor dysfunction. METHODS: Retrospective chart review was performed on all patients presenting to a functional colorectal outpatient clinic between May 2018 and August 2019. Information was collected on presenting symptoms, whether colonoscopy had been performed within 5 years, quality of bowel preparation, withdrawal time, number of polyps detected, histology, presence of diverticular disease, colorectal malignancy, inflammatory bowel disease, solitary rectal ulcer or rectal prolapse. RESULTS: There were 260 patients seen within the study period, of which 67% had undergone recent colonoscopy within the last 5 years. The mean age was 53 and 219 (84%) patients were female. Average withdrawal time was 13 min. Polyps were found in 48.7% and adenomas in 32.4% of all colonoscopies. The adenoma detection rate was 32.7%. None of the colonoscopies found evidence of malignancy. A new diagnosis of inflammatory bowel disease was discovered in two patients. CONCLUSION: There was low rates of serious pathology such as malignancy or inflammatory bowel disease in patients referred to a functional clinic. However, colonoscopy is still useful in workup of pelvic floor dysfunction, as many patients have erratic bowel habits or vague symptoms, and will have adenomas found.

Clinical pharmacy practitioners' semi-visible labor: building referral relationships in interprofessional collaborative care.

Clinical pharmacy practitioners (CPP) in the Veterans Health Administration (VHA) prescribe medications and help manage chronic conditions such as diabetes, and they are increasingly working as part of interprofessional clinical teams. The challenges of integrating a new role in a clinical team are documented, but we know less about strategies new healthcare providers use to overcome these challenges. We studied how clinical pharmacy practitioners integrated into clinical teams. We conducted telephone interviews with clinical pharmacy practitioners (n = 53) and members of their clinical teams (n = 74), which were recorded, transcribed, and coded for concepts and themes. We identified four major themes. We found CPP perceived VHA as a "safe haven" for interprofessional care but found it necessary to build other prescribers' trust and confidence in their clinical skills to establish the referral relationships they needed for full integration. To facilitate their integration, CPP engaged in relational, untracked labor, which we characterize as semi-visible labor. While both CPP and clinical team members perceived CPPs' semi-visible labor as vital for implementing and maintaining strong interprofessional collaborations, such labor may be unsustainable as a long-term strategy for integrating CPP in clinical teams.

Patient Experience of Managing Adherence to Repeat Lung Cancer Screening.

Lung cancer screening (LCS) is a process involving multiple low-dose computed tomography (LDCT) scans over multiple years. While adherence to recommended follow-up is critical in reducing lung cancer mortality, little is known about factors influencing adherence following the initial LDCT scan. The purpose of this study was to examine patients' and providers' depictions of continued screening and their understandings of patients' decisions to return for follow-up. Qualitative methodology involves interviews with patients about their understanding of the screening process and perceptions of lung cancer risk, including motivations to adhere to follow-up screening and surveillance. Analysis of interview transcripts followed the general procedures of grounded theory methodology. Patient adherence to LCS was influenced by their understanding of the process of screening, and their expectations for the next steps. Perceptions of lung cancer risk and associated motivation were not static and changed throughout the screening process. Recognizing that patients' motivations may be dynamic over the course of screening and surveillance will assist providers in helping patients make decisions regarding continued engagement with LCS.

Nursing Home Residents' Relocation to Another Facility: an Exploratory Study of Family Caregiver Experiences.

Over time, family caregivers for older adults may face care transitions for their loved ones. The move from home to residential care facility is a much-studied transition. Yet we know little of family caregiver experiences when their loved ones move from one facility to another. We interviewed family caregivers of nursing home residents and inquired about caregiver experiences in prior facilities and factors that prompted moving to another facility. Our analysis identified three themes: 1) A precursor of moving to another facility was caregivers' assessment of poor fit between their family member and the facility; 2) Executing a move was demanding for the caregiver in instrumental and emotional ways; 3) Once in the new facility, caregivers adapted their caregiving to the capacity of the new facility and fostered resident-facility fit (not interfering with good care and supplementing facility care). Findings suggest that family caregivers continually assess and respond to emerging problems with resident-facility fit, which sometimes escalate and necessitate a move to another facility. Nursing home social workers are well-positioned to help families address emerging care problems, so they do not escalate. Doing so can promote care continuity, which benefits both the resident and the family caregiver.

Perceptions of clinical pharmacy specialists' contributions in mental health clinical teams.

INTRODUCTION: Mental health (MH) clinical pharmacy specialists (CPS) are increasingly functioning as integral providers in MH care teams. MH providers may delegate many medication management tasks to the CPS. As there is a shortage of primary care and specialist MH providers, CPS are increasingly being utilized in MH care clinics. We assess provider and CPS perceptions of the contributions of CPS to MH clinical teams in the Veterans Health Administration. METHODS: We examined the roles and functions of CPS in MH clinics through surveys (n = 374) and semistructured interviews (n = 16) with MH CPS and other members of MH clinical teams (psychiatrists, nurse practitioners, registered nurses, social workers) to gain insight into how CPS were integrated in these settings. We assessed perceptions of CPS contributions to MH teams, interactions between CPS and other providers, and challenges of integrating CPS into MH clinical teams. RESULTS: Contributions of CPS in MH were received positively by clinical team members. Clinical pharmacy specialists providing comprehensive medication management were especially valuable in the management of clozapine. The knowledge and training of CPS reassured providers who frequently referred to them with questions about medication and medication therapy management. MH CPS were also perceived to be received well by patients. DISCUSSION: The integration of MH CPS into MH teams was well received by team members and patients alike. The MH CPS have become important members of the MH team and are widely viewed as being able to improve access, quality, and workflow.

Implementing Automated Text Messaging for Patient Self-management in the Veterans Health Administration: Qualitative Study Applying the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability Framework.

BACKGROUND: The Veterans Health Administration (VHA) is deploying an automated texting system (aTS) to support patient self-management. OBJECTIVE: We conducted a qualitative evaluation to examine factors influencing national rollout of the aTS, guided by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, which is intended to support the evaluation of novel technologies. METHODS: Semistructured interviews were conducted with 33 staff and 38 patients who were early adopters of the aTS. Data were analyzed following deductive and inductive approaches using a priori codes and emergent coding based on the NASSS. RESULTS: We identified themes across NASSS domains: (1) Condition: The aTS was considered relevant for a range of patient needs; however, perceptions of patient suitability were guided by texting experience and clinical complexity rather than potential benefits. (2) Technology: Onboarding of the aTS presented difficulty and the staff had different opinions on incorporating patient-generated data into care planning. (3) Value: Supply-side value relied on the flexibility of the aTS and its impact on staff workload whereas demand-side value was driven by patient perceptions of the psychological and behavioral impacts of the aTS. (4) Adopters: Limited clarity on staff roles and responsibilities presented challenges in incorporating the aTS into clinical processes. (5) Organization: Staff were willing to try the aTS; however, perceptions of leadership support and clinic readiness hindered usage. (6) Wider system: Staff focused on enhancing aTS interoperability with the electronic medical record. (7) Embedding and adaptation over time: The interplay of aTS versatility, patient and staff demands, and broader societal changes in preferences for communicating health information facilitated aTS implementation. CONCLUSIONS: VHA's new aTS has the potential to further engage patients and expand the reach of VHA care; however, patients and staff require additional support to adopt, implement, and sustain the aTS. The NASSS highlighted how the aTS can be better embedded into current practices, which patients might benefit most from its functionality, and which aspects of aTS messages are most relevant to self-management. TRIAL REGISTRATION: ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349.

Introducing clinical pharmacy specialists into interprofessional primary care teams: Assessing pharmacists' team integration and access to care for rural patients.

ABSTRACT: Clinical pharmacy specialists (CPS) were deployed nationally to improve care access and relieve provider burden in primary care.The aim of this study was to assess CPS integration in primary care and the Clinical Pharmacy Specialist Rural Veteran Access (CRVA) initiative's effectiveness in improving access.Concurrent embedded mixed-methods evaluation of participating CRVA CPS and their clinical team members (primary care providers, others).Health care providers on primary care teams in Veterans Health Administration (VHA).Perceived CPS integration in comprehensive medication management assessed using the MUPM and semi-structured interviews, and access measured with patient encounter data.There were 496,323 medical encounters with CPS in primary care over a 3-year period. One hundred twenty-four CPS and 1177 other clinical team members responded to a self-administered web-based questionnaire, with semi-structured interviews completed by 22 CPS and clinicians. Survey results indicated that all clinical provider groups rank CPS as making major contributions to CMM. CPS ranked themselves as contributing more to CMM than did their physician team members. CPS reported higher job satisfaction, less burn out, and better role fit; but CPS gave lower scores for communication and decision making as clinic organizational attributes. Themes in provider interviews focused on value of CPS in teams, relieving provider burden, facilitators to integration, and team communication issues.This evaluation indicates good integration of CPS on primary care teams as perceived by other team members despite some communication and role clarification challenges. CPS may play an important role in improving access to primary care.

Clinical Pharmacist Integration Into Veterans' Primary Care: Team Members Perspectives.

BACKGROUND: With the restructuring of primary care into patient-centered medical homes (PCMH), researchers have described role transformations that accompany the formation of core primary care teamlets (eg, primary care provider, registered nurse care manager, licensed practical nurse, medical support assistant). However, few studies offer insight into how primary care teamlets, once established, integrate additional extended team members, and the factors that influence the quality of their integration. METHODS: We examine the process of integrating Clinical Pharmacy Specialists (CPS) into primary care teams in the Veterans Health Administration (VHA). We conducted semi-structured interviews with CPS (n = 6) and clinical team members (n = 16) and performed a thematic analysis of interview transcripts. RESULTS: We characterize 2 ways CPS are integrated into primary care teamlets: in consultative roles and collaborative roles. CPS may be limited to consultative roles by team members' misconceptions about their competencies (ie, if CPS are perceived to handle only medication-related issues like refills) and by primary care providers' opinions about distributing responsibilities for patient care. Over time, teams may correct misconceptions and integrate the CPS in a more collaborative role (ie, CPS helps manage disease states with comprehensive medication management). CONCLUSIONS: CPS integrated into collaborative roles may have more opportunities to optimize their contributions to primary care, underscoring the importance of clarifying roles as part of adequately integrating advanced practitioners in interprofessional teams.

Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids.

INTRODUCTION: Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD). METHODS: We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%). RESULTS: The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient's fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a 'security blanket'. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication. CONCLUSIONS: While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change.

De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations. OBJECTIVE: We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative. DESIGN: We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys. PARTICIPANTS: We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems. MAIN MEASURES: Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared. KEY RESULTS: Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate. CONCLUSIONS: Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.

Automated Text Messaging With Patients in Department of Veterans Affairs Specialty Clinics: Cluster Randomized Trial.

BACKGROUND: Acceptability of mobile phone text messaging as a means of asynchronous communication between health care systems and patients is growing. The US Department of Veterans Affairs (VA) has adopted an automated texting system (aTS) for national rollout. The aTS allows providers to develop clinical texting protocols to promote patient self-management and allows clinical teams to monitor patient progress between in-person visits. Texting-supported hepatitis C virus (HCV) treatment has not been previously tested. OBJECTIVE: Guided by the Practical, Robust Implementation and Sustainability Model (PRISM), we developed an aTS HCV protocol and conducted a mixed methods, hybrid type 2 effectiveness implementation study comparing two programs supporting implementation of the aTS HCV protocol for medication adherence in patients with HCV. METHODS: Seven VA HCV specialty clinics were randomized to usual aTS implementation versus an augmented implementation facilitation program. Implementation process measures included facilitation metrics, usability, and usefulness. Implementation outcomes included provider and patient use of the aTS HCV protocol, and effectiveness outcomes included medication adherence, health perceptions and behaviors, and sustained virologic response (SVR). RESULTS: Across the seven randomized clinics, there were 293 facilitation events using a core set of nine implementation strategies (157 events in augmented implementation facilitation, 136 events in usual implementation). Providers found the aTS appropriate with high potential for scale-up but not without difficulties in startup, patient selection and recruitment, and clinic workflow integration. Patients largely found the aTS easy to use and helpful; however, low perceived need for self-management support contributed to high declination. Reach and use was modest with 197 patients approached, 71 (36%) enrolled, 50 (25%) authenticated, and 32 (16%) using the aTS. In augmented implementation facilitation clinics, more patients actively used the aTS HCV protocol compared with usual clinic patients (20% vs 12%). Patients who texted reported lower distress about failing HCV treatment (13/15, 87%, vs 8/15, 53%; P=.05) and better adherence to HCV medication (11/15, 73%, reporting excellent adherence vs 6/15, 40%; P=.06), although SVR did not differ by group. CONCLUSIONS: The aTS is a promising intervention for improving patient self-management; however, augmented approaches to implementation may be needed to support clinician buy-in and patient engagement. Considering the behavioral, social, organizational, and technical scale-up challenges that we documented, successful and sustained implementation of the aTS may require implementation strategies that operate at the clinic, provider, and patient levels. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349.

Qualitative study of patient experiences of responsibility in warfarin therapy.

PURPOSE: Results of a study to characterize the experiences of warfarin-treated patients, including their experiences in taking medication, communicating with clinical pharmacists, and International Normalized Ratio (INR) monitoring, are reported. METHODS: A qualitative analysis of data obtained during interviews with 40 patients at a Veterans Affairs medical center warfarin clinic was conducted. In semistructured interviews, the patients were asked to describe the process whereby their INR values were monitored by pharmacists and their understanding of self-management responsibilities, including medication adherence and implementation of lifestyle modifications that might influence the effectiveness of anticoagulation therapy. RESULTS: Analysis of interview results indicated that patients' experience in the event of variation in INR levels is characterized by misperceptions of the instructions regarding appropriate dietary and lifestyle behaviors, misattribution of responsibility for abnormal readings, and provider uncertainty in ascertaining causation for out-of-range INR values. Patients frequently reported that they interpret pharmacist questions to imply that they are responsible for variable INR values. This perception may indirectly lead to adverse consequences such as withholding of information from anticoagulation care providers and skipping clinic appointments, which could in turn result in suboptimal clinical outcomes. CONCLUSION: Analysis of results of qualitative interviews of patients receiving warfarin indicated that patients may interpret routine questioning about INR variation as implying that they are to blame for poor anticoagulation control.

Forming and activating an internal facilitation group for successful implementation: A qualitative study.

BACKGROUND: This study focuses on an implementation facilitation strategy to improve the delivery of anticoagulation care within pharmacy-run clinics across 8 Veterans Health Administration (VA) medical centers. Other studies have explored various models of implementation facilitation, including external facilitation (EF), internal facilitation (IF), and blended facilitation (BF) combining both approaches. This study focuses on the use of an internal facilitation team of anticoagulation coordinators representing 8 VA anticoagulation clinics to enhance the implementation process. This study examines how the team became instrumental in the successful implementation of evidence-based practice change. METHODS: Semi-structured interviews were conducted annually over 4 years with representatives from each site, the internal facilitators (site champions), at 8 VA hospitals (47 interviews). Additionally, five external facilitators, experts in quality improvement and anticoagulation care who guided the implementation, were interviewed. Analysis drew on a deductive approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and emergent thematic analysis to identify factors related to effectiveness of the internal facilitation team. RESULTS: Key findings are that the following factors enhanced successful uptake of the anticoagulation initiative: 1) Regular participation by the site champion in the internal facilitation team; 2) Champion strongly committed to being an agent of change; and 3) Champion received greater support from their supervisors. The first and second factors are interrelated, as internal facilitators who actively and regularly participated in the internal facilitation team often became truly committed to the improvement project. Both factors relate to the third, as supervisor support not only facilitated changes in practice, but also facilitated regular team attendance and stronger participation. CONCLUSIONS: Our study adds to implementation science by detailing how internal facilitators learn their skills over time, and how a group of internal facilitators can help each other succeed. These findings can guide those who wish to incorporate internal facilitation teams as an implementation strategy, and demonstrate how sites can build capacity for implementation efforts. SYNOPSIS: This study focuses on an implementation facilitation strategy to improve the delivery of anticoagulation care within pharmacy-run clinics across 8 Veterans Health Administration medical centers. Internal facilitators (IFs) guided by and supported by an external facilitators (EF), successfully implemented the clinical innovation. This study examines how the IF group became instrumental in the successful implementation of evidence-based practice change.

Unexpected complication after radical (inguinal) orchidectomy: trans-sphincteric anoscrotal fistula.

Anoscrotal fistula is an extremely rare condition involving an epithelialised tract between the anal canal and scrotal wall. It is more commonly seen as a congenital phenomenon in the paediatric population, and has not previously been described in the literature in adults. We present the case of a man aged 52 years who developed a complex anoscrotal fistula after a radical inguinal orchidectomy for an intratesticular seminoma. A postsurgical wound-site infection developed into a chronically discharging wound refractory to antibiotic treatment prompting further investigation. By way of MRI, a 10 cm long trans-sphincteric anoscrotal fistula was found. The patient was successfully treated by fistuloscopic curettage, internal closure using an Ovesco clip, and negative pressure dressing. We present for the first time a rare anoscrotal fistula in an adult.

The risk experience: the social effects of health screening and the emergence of a proto-illness.

Those who undergo health screening often experience physical and emotional effects as a result of the screening process. However, the effects of health screening go beyond these physical and mental complications, often having profound social effects for those who are screened. This study explores the social implications of health screening for people who undergo it and are designated as being at risk for potential disease. Through a qualitative analysis of the experiences of individuals with elevated cholesterol levels and men with elevated prostate-specific antigen (PSA) levels, this research offers a description of the experience of being at risk, identifying three primary components: increased medical contact, a restructuring of everyday routines and altered social relationships. Whereas the at-risk health status engendered by current clinical approaches to screening and surveillance has been characterised as proto-disease, this study develops a companion definition of proto-illness to characterise the social experience of life with an identified health risk. Those who are at risk act in ways that are similar to those who are ill. The concept of proto-illness implies that the experience of risk is parallel to the experience of illness and contributes to the sociology of medical screening by establishing a much needed bridge between the two experiences.

Pulmonologists' Reported Use of Guidelines and Shared Decision-making in Evaluation of Pulmonary Nodules: A Qualitative Study.

BACKGROUND: Selecting a strategy (surveillance, biopsy, resection) for pulmonary nodule evaluation can be complex given the absence of high-quality data comparing strategies and the important tradeoffs among strategies. Guidelines recommend a three-step approach: (1) assess the likelihood of malignancy, (2) evaluate whether the patient is a candidate for invasive intervention, and (3) elicit the patient's preferences and engage in shared decision-making. We sought to characterize how pulmonologists select a pulmonary nodule evaluation strategy and the extent to which they report following the guideline-recommended approach. METHODS: We conducted semistructured qualitative interviews with 14 pulmonologists who manage patients with pulmonary nodules at four clinical sites. Transcripts of audiorecorded interviews were analyzed using the principles of grounded theory. RESULTS: Pulmonologists reported consistently performing steps 1 and 2 but described diverse approaches to step 3 that ranged from always engaging the patient in decision-making to never doing so. Many described incorporating patients' preferences only in particular circumstances, such as when the patient appeared particularly anxious or was aggressive in questioning management options. Indeed, other factors, including convenience, physician preferences, physician anxiety, malpractice concerns, and physician experience, appeared to drive decision-making as much as, if not more than, patient preferences. CONCLUSIONS: Although pulmonologists appear to routinely personalize pulmonary nodule evaluation strategies based on the individual patient's risk-benefit tradeoffs, they may not consistently take patient preferences into account during the decision-making process. In the absence of high-quality evidence regarding the optimal methods of pulmonary nodule evaluation, physicians should strive to ensure that management decisions are consistent with patients' values.

Pathological reporting of malignant colorectal polyps.

AIM: The pathological reporting of malignant colorectal polyps plays an important role in determining whether definitive surgical resection is required following endoscopic polypectomy. This study aims to assess the adequacy of reporting on malignant polyp specimens at Auckland Hospital and whether synoptic reporting results in an improvement. METHOD: The pathology database at Auckland Hospital was accessed using a search strategy to identify all malignant polyps diagnosed between 1999 and 2011. Pathology reports were reviewed retrospectively. RESULTS: In total 121 malignant polyps were found. Of these, 73 were colonoscopic polypectomies, 41 were colectomy specimens, and seven transanal resections. Of the 41 colectomy specimens, 19 (46%) were reported in synoptic format compared with none of the colonoscopic polypectomies or transanal resections. The status of the margin of excision, differentiation, and presence of lymphovascular invasion were given in 100% of synoptic reports compared with 51% of non-synoptic reports. CONCLUSION: Synoptic reporting does improve the completeness of pathological reporting in malignant colorectal polyps. Currently none of the colonoscopically excised malignant polyps are reported in this format at Auckland Hospital. The development and routine use of a synoptic system for reporting on malignant polyps would give clinicians more information on which to base decisions.

The experience of risk as 'measured vulnerability': health screening and lay uses of numerical risk.

As clinical and epidemiological research turns increasingly to statistical probabilities in the identification and management of disease, numerous risk factors have emerged that are applied to individual health surveillance. However, the application of statistical risk is interpreted differently by lay persons from the way it is by public health or medical professionals. This paper examines the experience of being designated as at risk of a serious health condition. Specifically, an examination of the experiences of people with elevated blood cholesterol levels and men with elevated prostate-specific antigen (PSA) levels is presented in order to characterise the risk experience. This paper deals primarily with how being at risk symbolically alters health identities, with an introduction to the concept of measured vulnerability. Measured vulnerability refers to the capacity for scientifically-derived statistical measures that are intended to tame randomness and provide certainty in managing risk to, instead, produce uncertainty and anxiety in those to whom the statistic is applied.