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OBJECTIVES: The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care. MATERIALS AND METHODS: Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics. We examined differences in timely completion ("loop closure") of tests/referrals for (1) patients who used the portal and read ≥1 note (Portal + Notes); (2) those with a portal account but who did not read notes (Portal Account Only); and (3) those who did not register for the portal (No Portal). We estimated the predictive probability of loop closure in each group after adjusting for socio-demographic and clinical factors using multivariable logistic regression. RESULTS: Among 12 849 tests/referrals, loop closure was more common among Portal+Note-readers compared to their counterparts for all tests/referrals (54.2% No Portal, 57.4% Portal Account Only, 61.6% Portal+Notes, P < .001). In adjusted analysis, compared to the No Portal group, the odds of loop closure were significantly higher for Portal Account Only (OR 1.2; 95% CI, 1.1-1.4), and Portal+Notes (OR 1.4; 95% CI, 1.3-1.6) groups. Beyond portal registration, note reading was independently associated with loop closure (P = .002). DISCUSSION AND CONCLUSION: Compared to no portal registration, the odds of loop closure were 20% higher in tests/referrals for patients with a portal account, and 40% higher in tests/referrals for note readers, after controlling for sociodemographic and clinical factors. However, important safety gaps from unclosed loops remain, requiring additional engagement strategies.
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Portais do Paciente , Humanos , Leitura , Estudos Retrospectivos , Registros Eletrônicos de Saúde , Testes Diagnósticos de Rotina , Atenção Primária à SaúdeRESUMO
Wild lagomorphs can act as reservoirs of several pathogens of public and animal health concern. However, the number of studies assessing the presence of Anaplasma spp. in these species is scarce. The aim of the present study was to molecularly identify Anaplasma spp. in wild rabbits (Oryctolagus cuniculus) and Iberian hares (Lepus granatensis) from Southern Spain and assess their epidemiological role in the maintenance of the bacterium. During 2017-2021, spleen samples of 394 wild rabbits and 145 Iberian hares were collected. Anaplasma DNA was detected using different PCR assays (16S rRNA and groEL) and phylogenetic analyses were carried out by Bayesian approach. The possible influence of lagomorph species, age and sex on the prevalence of Anaplasma spp. was evaluated by a multiple logistic regression model. The 9.4% of the rabbits were positive to Anaplasma bovis, but all the hares were negative. No significant differences were found in Anaplasma spp. prevalence regarding to age or sex. This is the first report of A. bovis in lagomorphs from Europe. The phylogenetic analysis of A. bovis confirms the existence of different clusters suggesting the existence of several lineages. In addition, a high divergence of nucleotide identity was observed within the lineage 4, which could result in the under-detection of some strains when using A. bovis-specific PCR, hindering its detection and characterization. Since this analysis is based on a limited number of nucleotide bases and sequences, more studies are needed for further characterize A. bovis, as well as its relationship with other Anaplasma spp.
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Lebres , Lagomorpha , Animais , Coelhos , Espanha/epidemiologia , Lagomorpha/genética , Filogenia , RNA Ribossômico 16S/genética , Teorema de Bayes , Anaplasma/genética , NucleotídeosRESUMO
BACKGROUND: A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure. METHODS: This retrospective cohort study included all patient visits from January 1, 2018, to December 31, 2021, at two academic medical center-based primary care practices where residents and faculty practice in the same setting. The primary outcome was prevalence of failure to close the loop for (1) dermatology referrals, (2) colonoscopy, and (3) cardiac stress testing. The primary predictor was resident vs. faculty status of the ordering provider. The authors present an unadjusted analysis and the results of a multivariable logistic regression analysis incorporating all patient factors to determine their association with loop closure. RESULTS: Of 12,282 orders for referrals and tests for the three studied areas, 1,929 (15.7%) were ordered by a resident physician. Of resident orders for all three tests, 52.9% were completed within the designated time vs. 58.4% for orders placed by attending physicians (p < 0.01). In an unadjusted analysis by test type, a similar trend was seen for colonoscopy (51.4% completion rate for residents vs. 57.5% for attending physicians, p < 0.01) and for cardiac stress testing (55.7% completion rate for residents vs. 61.2% for attending physicians), though a difference was not seen for dermatology referrals (64.2% completion rate for residents vs. 63.7% for attending physicians). In an adjusted analysis, patients with resident orders were less likely than attendings to close the loop for all test types combined (odds ratio 0.88, 95% confidence interval 0.79-0.98), with low rates of test completion for both physician groups. CONCLUSION: Loop closure for three diagnostic interventions was low for patients in both faculty and resident primary care clinics, with lower loop closure rates in resident clinics. Failure to close diagnostic loops presents a safety challenge in primary care and is of particular concern for training programs.
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Internato e Residência , Humanos , Estudos Retrospectivos , Centros Médicos Acadêmicos , Encaminhamento e Consulta , Atenção Primária à SaúdeRESUMO
BACKGROUND: Rectal bleeding is the most common presenting symptom of colorectal cancer, and guidelines recommend timely follow-up, usually with colonoscopy to ensure timely diagnoses of colorectal cancer. OBJECTIVE: Identify loop closure rates and vulnerable process points for patients with rectal bleeding. DESIGN: Retrospective cohort study, using medical record review of patients aged ≥ 40 with index diagnosis of rectal bleeding at 2 primary practices-an urban academic practice and affiliated community health center, between January 1, 2018, and December 31, 2020. Patients were classified as having completed recommended follow-up workup ("closed loop") vs. not ("open loop"). Open loop patient cases were categorized into six types of process failures. PARTICIPANTS: A total of 837 patients had coded diagnoses of rectal bleeding within study window. Sixty-seven were excluded based on prior colectomy, clinical presentation more consistent with upper GI bleed, no rectal bleeding documented on chart review, or expired during the follow-up period, leaving 770 patients included. MAIN MEASURES: Primary outcomes were percentages of patient cases classified as "open loops" and distribution of these cases into six categories of process failure that were identified. KEY RESULTS: 22.3% of patients (N = 172) failed to undergo timely recommended workup for rectal bleeding. Largest failure categories were patients for whom no procedure was ordered (N = 62, 36%), followed by patients with procedures ordered but never scheduled (N = 44, 26%) or scheduled but subsequently cancelled or not kept (N = 31, 18%). While open loops increased after the onset of the COVID-19 pandemic, this difference was not significant within our study period. CONCLUSIONS: Significant numbers of patients presenting to primary care with rectal bleeding fail to undergo recommended workup. The majority either have no procedure ordered, or procedure ordered but never scheduled or cancelled and not kept, suggesting these are important failure modes to target in future interventions. Ensuring reliable ordering and processes for timely scheduling and completion of procedures represent critical areas for improving the diagnostic process for patients with rectal bleeding in primary care.
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Importance: Use of telehealth has increased substantially in recent years. However, little is known about whether the likelihood of completing recommended tests and specialty referrals-termed diagnostic loop closure-is associated with visit modality. Objectives: To examine the prevalence of diagnostic loop closure for tests and referrals ordered at telehealth visits vs in-person visits and identify associated factors. Design, Setting, and Participants: In a retrospective cohort study, all patient visits from March 1, 2020, to December 31, 2021, at 1 large urban hospital-based primary care practice and 1 affiliated community health center in Boston, Massachusetts, were evaluated. Main Measures: Prevalence of diagnostic loop closure for (1) colonoscopy referrals (screening and diagnostic), (2) dermatology referrals for suspicious skin lesions, and (3) cardiac stress tests. Results: The study included test and referral orders for 4133 patients (mean [SD] age, 59.3 [11.7] years; 2163 [52.3%] women; 203 [4.9%] Asian, 1146 [27.7%] Black, 2362 [57.1%] White, and 422 [10.2%] unknown or other race). A total of 1151 of the 4133 orders (27.8%) were placed during a telehealth visit. Of the telehealth orders, 42.6% were completed within the designated time frame vs 58.4% of those ordered during in-person visits and 57.4% of those ordered without a visit. In an adjusted analysis, patients with telehealth visits were less likely to close the loop for all test types compared with those with in-person visits (odds ratio, 0.55; 95% CI, 0.47-0.64). Conclusions: The findings of this study suggest that rates of loop closure were low for all test types across all visit modalities but worse for telehealth. Failure to close diagnostic loops presents a patient safety challenge in primary care that may be of particular concern during telehealth encounters.
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Telemedicina , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Boston/epidemiologia , Encaminhamento e Consulta , Estudos Retrospectivos , IdosoRESUMO
The growing recognition of differences in health outcomes across populations has led to a slow but increasing shift towards transparent reporting of patient outcomes. In addition, pay-for-equity initiatives, such as those proposed by the Centers for Medicare and Medicaid, will require the reporting of health outcomes across subgroups over time. Dashboards offer one means of visualising data in the health-care context that can highlight essential disparities in clinical outcomes, guide targeted quality-improvement efforts, and ultimately improve health equity. In this Viewpoint, we evaluate all studies that have reported the successful development of a disparity dashboard and share the data collected and unintended consequences reported. We propose a framework for systematic equality improvement through incentivisation of the collecting and reporting of health data and through implementation of reward systems to reduce health disparities.
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Equidade em Saúde , Idoso , Humanos , Estados Unidos , Medicare , Atenção à Saúde , Melhoria de Qualidade , Instalações de SaúdeRESUMO
Resumen: El artículo analiza la situación de estudiantes con necesidades educativas especiales (NEE) quienes han limitado sus actividades físicas (AF) debido al confinamiento, situación que obliga al personal docente a diseñar nuevas prácticas educativas adaptadas a la virtualidad. Objetivo: Analizar las prácticas educativas de la educación física (EF) para estudiantes del nivel primario con NEE durante la pandemia en la República Dominicana. Metodología: Se utilizó el enfoque cualitativo, exploratorio de corte transversal mediante la encuesta, empleando un muestreo no probabilístico y un análisis de contenidos con redes semánticas. El estudio consta de 45 docentes, quienes proporcionaron las informaciones sobre su formación académica docente, la matrícula estudiantil asistida, las metodologías, estrategias empleadas y los recursos del proceso de enseñanza. Resultados: Los resultados reflejan el interés del personal docente por su actividad profesional, en contraposición a la falta de apoyo de especialistas en el aula y un bajo conocimiento de la enseñanza, de las metodologías y estrategias usadas desde la virtualidad para la EF dirigida a estudiantes con NEE. Por otra parte, la mayoría de los docentes no usaron las instalaciones educativas para las actividades físicas, se utilizó la tecnología con la asistencia guiada por la familia y los adultos en el hogar, en especial con actividades físicas grupales en familia. Conclusiones: Las actividades académicas fueron realizadas desde el hogar y han sido afectadas por la falta de condiciones idóneas para un espacio académico y la falta de recursos tecnológicos. Se debe promover la capacitación de docentes en el área de la EF para estudiantes con NEE.
Abstract: The article analyzes the situation of students with special educational needs (SEN) who have limited their physical activities (PA) due to confinement; this situation that forces teachers to design new educational practices adapted to virtuality. Objective: To analyze the educational practices of physical education (PE) for primary school students with SEN during the pandemic in the Dominican Republic. Methodology: A qualitative, exploratory, cross-sectional, qualitative approach was used by means of a survey, using nonprobabilistic sampling and content analysis with semantic networks. The study consisted of 45 teachers who provided information on their academic teacher training, student enrollment, methodologies, strategies used, and resources of the teaching process. Results: The results reflect the teachers' interest in their professional activity, as opposed to the lack of support from specialists in the classroom and low knowledge of teaching, methodologies, and strategies used in virtuality for PE aimed at students with SEN. On the other hand, most teachers did not use educational facilities for physical activities; technology was used with assistance guided by families and adults at home, especially with group physical activities in families. Conclusions: Academic activities were carried out from home and have been affected by the lack of suitable conditions for academic space and the lack of technological resources. Teacher training in the area of PE for students with SEN should be promoted.
Resumo: O artigo analisa a situação dos estudantes com necessidades educacionais especiais (NEE) que limitaram suas atividades físicas (AF) devido ao confinamento, uma situação que obriga os professores a projetar novas práticas educacionais adaptadas à virtualidade. Objetivo: Analisar as práticas educacionais de educação física (EF) para estudantes do ensino fundamental com NEE durante a pandemia na República Dominicana. Metodologia: Utilizamos uma abordagem qualitativa, exploratória, transversal, por meio de uma pesquisa, utilizando amostragem não-probabilística e análise de conteúdo com redes semânticas. O estudo consistiu em 45 professores, que forneceram informações sobre sua formação acadêmica de professores, matrícula de alunos, metodologias, estratégias utilizadas e recursos para o processo de ensino. Resultados: Os resultados refletem o interesse dos professores em sua atividade profissional, ao contrário da falta de apoio de especialistas em sala de aula e um baixo conhecimento do ensino, das metodologias e das estratégias utilizadas a partir da virtualidade para a educação física destinada aos alunos com necessidades educativas especiais. Por outro lado, a maioria dos professores não utilizava instalações educacionais para atividades físicas, a tecnologia era utilizada com assistência orientada pela família e adultos em casa, especialmente com atividades físicas grupais em família. Conclusões: As atividades acadêmicas eram baseadas em casa e foram afetadas pela falta de condições adequadas para um espaço acadêmico e pela falta de recursos tecnológicos. Deve ser promovido o treinamento de professores na área de Educação Física para alunos com NEE.
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Humanos , Masculino , Feminino , Educação Física e Treinamento , Pessoas com Deficiência , Educação a Distância/métodos , Formulário , República DominicanaRESUMO
Ideally, urgent dermatology referrals for evaluation of a lesion concerning for skin cancer should be triaged and processed with appropriate urgency by primary care and dermatology, respectively. We performed a retrospective single-institution study by conducting chart reviews of all dermatology referrals designated by primary care as urgent for evaluation of a lesion concerning for skin cancer. We identified 320 referrals placed between January 1 and December 31, 2018. Dermatology encounters for these patients occurred on or before 30 days for 50.6% of referrals and on or after 31 days for 38.4% of referrals, with 10.9% never completed. The percentage of all races excluding whites, non-Hispanic in the delayed appointment group (≥ 31 days) was 15.1% higher (95% CI 5.3-24.9) than in the timely appointment group (≤ 30 days). Similarly, the percentage of non-English languages in the delayed group was 7.1% higher (95% CI 0.5-13.7) than in the timely group. Overall, 15.8% of these referrals yielded diagnoses of malignancy, while 76.8% and 7.4% resulted in benign and pre-malignant diagnoses, respectively. The primary care team documented referral status (i.e., completed, incomplete, or pending) during their subsequent visits with the patients in only 37.5% of these referrals. Our findings demonstrate the need to improve the reliability of urgent referrals to ensure they occur in a timely manner with confirmation of "referral loop" closure at the referring clinician's end.
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Dermatologia , Neoplasias Cutâneas , Humanos , Dermatologia/métodos , Estudos Retrospectivos , Reprodutibilidade dos Testes , Neoplasias Cutâneas/diagnóstico , Encaminhamento e Consulta , Atenção Primária à SaúdeRESUMO
BACKGROUND: Sharing outpatient notes with patients may bring clinically important benefits, but notes may sometimes cause patients to feel judged or offended, and thereby reduce trust. OBJECTIVE: As part of a larger survey examining the effects of open notes, we sought to understand how many patients feel judged or offended due to something they read in outpatient notes, and why. DESIGN: We analyzed responses from a large Internet survey of adult patients who used secure patient portals and had at least 1 visit note available in a 12-month period at 2 large academic medical systems in Boston and Seattle, and in a rural integrated health system in Pennsylvania. PARTICIPANTS: Adult ambulatory patients with portal accounts in health systems that offered open notes for up to 7 years. APPROACH: (1) Quantitative analysis of 2 dichotomous questions, and (2) qualitative thematic analysis of free-text responses on what patients found judgmental or offensive. KEY RESULTS: Among 22,959 patient respondents who had read at least one note and answered the 2 questions, 2,411 (10.5%) reported feeling judged and/or offended by something they read in their note(s). Patients who reported poor health, unemployment, or inability to work were more likely to feel judged or offended. Among the 2,411 patients who felt judged and/or offended, 2,137 (84.5%) wrote about what prompted their feelings. Three thematic domains emerged: (1) errors and surprises, (2) labeling, and (3) disrespect. CONCLUSIONS: One in 10 respondents reported feeling judged/offended by something they read in an outpatient note due to the perception that it contained errors, surprises, labeling, or evidence of disrespect. The content and tone may be particularly important to patients in poor health. Enhanced clinician awareness of the patient perspective may promote an improved medical lexicon, reduce the transmission of bias to other clinicians, and reinforce healing relationships.
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Pacientes Ambulatoriais , Portais do Paciente , Adulto , Registros Eletrônicos de Saúde , Humanos , Pennsylvania , Inquéritos e QuestionáriosRESUMO
Health professions educators continuously adapt curricular content in response to new scientific knowledge but can struggle to incorporate content about current social issues that profoundly affect students and learning environments. This article offers recommendations to support innovation and action as students and faculty grapple with ongoing unrest in the United States, including racism, murders of Black people by police, and COVID-19.
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COVID-19/psicologia , Educadores em Saúde , Ocupações em Saúde/educação , Racismo/psicologia , Justiça Social/psicologia , Negro ou Afro-Americano , Etnicidade , Disparidades em Assistência à Saúde , Humanos , Aplicação da Lei , Estados UnidosAssuntos
Antipsicóticos , Transtorno Bipolar , Lesões Encefálicas Traumáticas , Antipsicóticos/uso terapêutico , Aripiprazol/uso terapêutico , Transtorno Bipolar/complicações , Transtorno Bipolar/tratamento farmacológico , Lesões Encefálicas Traumáticas/tratamento farmacológico , Humanos , PiperazinasRESUMO
BACKGROUND: Patients actively involved in their care demonstrate better health outcomes. Using secure internet portals, clinicians are increasingly offering patients access to their narrative visit notes (open notes), but we know little about their understanding of notes written by clinicians. OBJECTIVE: We examined patients' views on the clarity, accuracy, and thoroughness of notes, their suggestions for improvement, and associations between their perceptions and willingness to recommend clinicians to others. DESIGN: We conducted an online survey of patients in 3 large health systems, June-October 2017. We performed a mixed methods analysis of survey responses regarding a self-selected note. PARTICIPANTS: Respondents were 21,664 patients aged 18 years or older who had read at least 1 open note in the previous 12 months. MAIN MEASURES: We asked to what degree the patient recalled understanding the note, whether it described the visit accurately, whether anything important was missing, for suggestions to improve the note, and whether they would recommend the authoring clinician to others. KEY RESULTS: Nearly all patients (96%) reported they understood all or nearly all of the self-selected note, with few differences by clinician type or specialty. Overall, 93% agreed or somewhat agreed the note accurately described the visit, and 6% reported something important missing from the note. The most common suggestions for improvement related to structure and content, jargon, and accuracy. Patients who reported understanding only some or very little of the note, or found inaccuracies or omissions, were much less likely to recommend the clinician to family and friends. CONCLUSIONS: Patients overwhelmingly report understanding their visit notes and usually find them accurate, with few disparities according to sociodemographic or health characteristics. They have many suggestions for improving their quality, and if they understand a note poorly or find inaccuracies, they often have less confidence in their clinicians.
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Registros Eletrônicos de Saúde , Adolescente , Humanos , Inquéritos e QuestionáriosRESUMO
[This corrects the article DOI: 10.2196/13876.].
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Importance: The 21st Century Cures Act of 2016 requires that patients be given electronic access to all the information in their electronic medical records. The regulations for implementation of this law give patients far easier access to information about their care, including the notes their clinicians write. Objective: To assess clinicians' views and experiences with sharing clinical notes (open notes) with patients. Design, Setting, and Participants: Web-based survey study of physicians, advanced practice nurses, registered nurses, physician assistants, and therapists at 3 health systems in Boston, Massachusetts; Seattle, Washington; and rural Pennsylvania where notes have been shared across all outpatient specialties for at least 4 years. Participants were clinicians in hospital-based offices and community practices who had written at least 1 note opened by a patient in the year prior to the survey, which was administered from May 21, 2018, to August 31, 2018. Main Outcomes and Measures: Clinicians' experiences with and perceptions of sharing clinical notes with patients. Results: Invitations were sent to 6064 clinicians; 1628 (27%) responded. Respondents were more likely than nonrespondents to be female (65% vs 55%) and to be younger (mean [SD] age, 42.1 [12.6] vs 44.9 [12.7] years). The majority of respondents were physicians (951 [58%]), female (1023 [65%]), licensed to practice in 2000 or later (940 [61%]), and spent fewer than 40 hours per week in direct patient care (1083 [71%]). Most viewed open notes positively, agreeing they are a good idea (1182 participants [74%]); of 1314 clinicians who were aware that patients were reading their notes, 965 (74%) agreed that open notes were useful for engaging patients. In all, 798 clinicians (61%) would recommend the practice to colleagues. A total of 292 physicians (37%) reported spending more time on documentation, and many reported specific changes in the way they write their notes, the most frequent of which related to use of language that could be perceived as critical of the patient (422 respondents [58%]). Most physicians (1234 [78%]) favored being able to determine readily that their notes had been read by their patients. Conclusions and Relevance: In this survey of clinicians in a wide range of specialties who had several years of experience offering their patients ready access to their notes, more than two-thirds supported this new practice. Even among subgroups of clinicians who were less enthusiastic, most endorsed the idea of sharing notes and believed the practice could be helpful for engaging patients more actively in their care.
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Registros Eletrônicos de Saúde , Disseminação de Informação , Relações Médico-Paciente , Médicos/estatística & dados numéricos , Adulto , Atitude do Pessoal de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Following a 2010-2011 pilot intervention in which a limited sample of primary care doctors offered their patients secure Web-based portal access to their office visit notes, the participating sites expanded OpenNotes to nearly all clinicians in primary care, medical, and surgical specialty practices. OBJECTIVE: The aim of this study was to examine the ongoing experiences and perceptions of patients who read ambulatory visit notes written by a broad range of doctors, nurses, and other clinicians. METHODS: A total of 3 large US health systems in Boston, Seattle, and rural Pennsylvania conducted a Web-based survey of adult patients who used portal accounts and had at least 1 visit note available in a recent 12-month period. The main outcome measures included patient-reported behaviors and their perceptions concerning benefits versus risks. RESULTS: Among 136,815 patients who received invitations, 21.68% (29,656/136,815) responded. Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female, 72.90% (20,982/28,782) were aged 45 years or older, 76.94% (22,146/28,782) were white, and 14.30% (4115/28,782) reported fair or poor health. Among the 22,947 who reported reading 1 or more notes, 3 out of 4 reported reading them for 1 year or longer, half reported reading at least 4 notes, and 37.74% (8588/22,753) shared a note with someone else. Patients rated note reading as very important for helping take care of their health (16,354/22,520, 72.62%), feeling in control of their care (15,726/22,515, 69.85%), and remembering the plan of care (14,821/22,516, 65.82%). Few were very confused (737/22,304, 3.3%) or more worried (1078/22,303, 4.83%) after reading notes. About a third reported being encouraged by their clinicians to read notes and a third told their clinicians they had read them. Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading. Nearly all respondents (22,593/22,947, 98.46%) thought Web-based access to visit notes a good idea, and 62.38% (13,427/21,525) rated this practice as very important for choosing a future provider. CONCLUSIONS: In this first large-scale survey of patient experiences with a broad range of clinicians working in practices in which shared notes are well established, patients find note reading very important for their health management and share their notes frequently with others. Patients are rarely troubled by what they read, and those traditionally underserved in the United States report particular benefit. However, fewer than half of clinicians and patients actively address their shared notes during visits. As the practice continues to spread rapidly in the United States and internationally, our findings indicate that OpenNotes brings benefits to patients that largely outweigh the risks.