Artificial Intelligence, Heuristic Biases, and the Optimization of Health Outcomes: Cautionary Optimism.

The use of artificial intelligence (AI) and machine learning (ML) in clinical care offers great promise to improve patient health outcomes and reduce health inequity across patient populations. However, inherent biases in these applications, and the subsequent potential risk of harm can limit current use. Multi-modal workflows designed to minimize these limitations in the development, implementation, and evaluation of ML systems in real-world settings are needed to improve efficacy while reducing bias and the risk of potential harms. Comprehensive consideration of rapidly evolving AI technologies and the inherent risks of bias, the expanding volume and nature of data sources, and the evolving regulatory landscapes, can contribute meaningfully to the development of AI-enhanced clinical decision making and the reduction in health inequity.

Understanding Factors Associated with Quality of Life in Patients with Venous Thromboembolism.

INTRODUCTION: Quality of life (QoL) deficits have been noted among patients with venous thromboembolism (VTE) but understanding of the drivers of that poorer QoL is limited. The objective of this study was to examine associations between a variety of factors and QoL in patients with VTE. METHODS: Adult patients who had experienced at least one VTE episode within the past 2 years completed an online survey between May and July 2016 with responses to a variety of questions designed to ascertain QoL scores, Optum Short Form-12, and potential factors associated with these scores. RESULTS: Most of the 907 patients were female (56.7%) and Caucasian (88.6%). Physical and mental QoL scores below the general population average were present in 76.0 and 56.7% of patients, respectively. Multiple regression modeling revealed several factors associated with below average physical QoL scores including unemployment (odds ratio [OR] 3.77, 95% confidence interval [CI] 1.76-8.05), gastrointestinal bleeding (OR 2.54, 95% CI 1.28-5.01), high depression scores (OR 4.02, 95% CI 1.88-8.58), or difficulty accessing VTE care (OR 4.24, 95% CI 1.77-10.17). Factors associated with below average mental QoL scores included experiencing VTE within the last month (OR 3.85, 95% CI 1.58-9.41), unemployment (OR 2.83, 95% CI 1.30-6.16), or high depression (OR 3.85, 95% CI 1.60-9.28) and/or anxiety (OR 9.17, 95% CI 4.81-17.47) scores. CONCLUSION: Most patients with recently diagnosed VTE reported below average QoL. Many of the factors associated with below average QoL are modifiable, indicating that patients with VTE could potentially benefit from interventions aimed at improving QoL.

Understanding patients' care barriers in the treatment of venous thromboembolism.

Venous thromboembolism (VTE) is a major health care problem. There are common barriers to quality healthcare but are these barriers the same for VTE patients? A national online survey was administered to adults who had experienced a recent VTE event. The survey assessed perceptions of VTE care barriers: (1) Difficulty to meet healthcare costs related to VTE care; (2) difficulty to meet costs for VTE prescription medications; (3) difficulty with transportation to get VTE care; and (4) the degree of support of others needed to get VTE care. Each question was correlated with patient demographics including income level, place of residence, current work status, and health insurance; care related patient harms experienced with the VTE episode; number of lifetime VTE events; beliefs concerning VTE outcomes, and oral anticoagulant therapy type. Logistic regression analysis was used to determine the effect of independent variables on barriers to VTE care. Approximately 30% of VTE patients reported at least one significant barrier to VTE care. Patients rated healthcare costs and VTE prescription medication costs mildly difficult. The odds of reporting barriers were positively associated with the number of DVTs experienced in the previous 2 years. VTE-related depression was also moderately associated with increased odds of reporting significant VTE care barriers. Nearly 1 in 3 VTE sufferers reported significant barriers to VTE care, with healthcare costs and VTE medication costs being the most common. Efforts to identify patients who may experience barriers should be sought early in care.

Pharmacist's Demand for Optimal Primary Care Service Delivery in a Community Pharmacy: The OPTiPharm Study.

BACKGROUND: The US population continues to expand providing the need for primary health care services. Community pharmacies integrated with medicine may provide greater access while providing high quality care. OBJECTIVE: To gauge pharmacists' demand for primary health care services delivered through community pharmacies. METHODS: An online survey was administered to determine community pharmacists' preferences for varying primary care services that could be offered in the community pharmacy setting. A Discrete Choice Experiment was employed to show pharmacists competing scenarios with varied primary care service offerings in the community pharmacy setting. Attributes evaluated were operation hours, service provider, medical records, service logistics, physical examinations, point-of-care diagnostic testing, preventative care, and drug prescribing. Respondents chose the scenario most likely to induce switching employment from base pharmacy to one providing advanced services. RESULTS: The optimal service delivery model from 291 community pharmacists comprised: inclusion of patient prescriptions and health information into the patient's medical record; provision of point of care testing and vital sign, including blood pressure, heart rate and breathing rate, and blood sugar and cholesterol measurement; and pharmacists prescribing (under physician oversight). Pharmacists were 4 times more likely to switch employment from their current pharmacy to their choice for advanced pharmacy services. Pharmacist demand was highest among those with a PharmD, less experience, working >40 hours per week, and in rural areas. CONCLUSIONS: This study provides empirical support for the model of pharmacists playing a greater role in the provision of primary care health services through community pharmacy settings.

Factors predicting self-reported medication low adherence in a large sample of adults in the US general population: a cross-sectional study.

OBJECTIVES: The study objective was to determine the level and correlates of self-reported medication low adherence in the US general population. SETTING: A 30 min cross-sectional online survey was conducted with a national sample of adults. PARTICIPANTS: 9202 adults (aged 18+) who had filled at least three or more prescriptions at a community pharmacy in the past 12 months. PRIMARY AND SECONDARY OUTCOME MEASURES: Self-reported medication adherence was measured with the 8-item Morisky Medication Adherence Scale. RESULTS: Low adherence was reported by 42.0%, 29.4% had medium adherence and 28.6% had high adherence. Low adherence was significantly associated with: lower age, being of Hispanic origin or African-American, having difficulty with healthcare, medication or transportation costs, needing the support of others to access primary care, health limiting activity, using multiple providers, infrequent visits to primary care providers and visiting an emergency department >3 times in last 12 months. CONCLUSIONS: A very high level of low medication adherence is seen in the general population, particularly for ethnic minorities, those who use multiple healthcare providers and those who experience barriers to access for regular primary care. As clinical, patient education and counselling, and healthcare policy initiatives are directed to tracking the problem of low medication adherence, these should be priority populations for research and interventions.

Qualitative interviews regarding pharmacist prescribing in the community setting.

PURPOSE: The perceived demand for and barriers to pharmacist prescribing in the community pharmacy setting were studied. METHODS: Qualitative interviews were conducted with 19 consumers, 20 community pharmacists, and 8 reimbursement decision-makers from payer organizations between April and June 2015. Respondents were invited to participate in a daylong interview process online. Interviews with consumers and pharmacists were conducted using online bulletin board technology. Telephone interviews were conducted with reimbursement decision-makers. As with all qualitative research, the sample sizes used were restrictive and sufficient to gauge the perceptions of those respondents only. Interview responses were not intended to be generalizable to the groups or populations from which the respondents came. RESULTS: There was a continuum of interest in pharmacist prescribing across the three constituencies. Consumers were predominantly resistant to the notion; however, one third were more positive about the idea. Community pharmacists were more open, particularly when prescribing was restricted to a limited set of conditions or medications. Reimbursement decision-makers were most receptive to the notion. Key barriers to pharmacist prescribing included low awareness of current pharmacist prescribing authority among consumers, concerns about the adequacy of pharmacist training, potential conflicts of interest when the prescriber was also a dispenser, and potential liability issues. CONCLUSION: Consumer respondents were generally resistant to the notion of pharmacist prescribing, with most viewing pharmacists as dispensers and not prescribers. Community pharmacists were more open to the idea, while reimbursement decision-makers were the most receptive to the notion of pharmacist prescribing.

National evaluation of prescriber drug dispensing.

OBJECTIVE: To describe the legal, professional, and consumer status of prescribers dispensing legend and over-the-counter drugs in the United States. METHODS: Legal and academic databases were searched to identify those states that permit prescribers to dispense medications to patients and any limitations on such practice. In addition, prescribers and patients-consumers were surveyed to learn about the prevalence and perceptions of such practice. The use of drug samples was explicitly excluded from the study. MAIN RESULTS: Surveys were obtained from 556 physicians, 64 NPs, and 999 patient-consumers of drugs dispensed by prescribers. Forty-four states authorize prescriber dispensing. Midlevel practitioners (i.e., NPs and physician assistants) are authorized to dispense in 43 states. Thirty-two states do not require dispensing prescribers to compete additional registration to dispense medications, and 30 states require some level of compliance with pharmacy practice requirements. Prescriber dispensing is common, independent of patient age or insurance coverage. Prescriber dispensing appears driven by physician and patient perceptions of convenience and cost reductions. Future dispensing is likely to increase due to consumers' satisfaction with the practice. Consumer self-reported adverse drug reactions (ADRs) were equivalent between pharmacist- and physician-dispensed drugs, but urgent and emergency clinic ADR consultations were slightly lower with physician dispensing. CONCLUSIONS: Prescriber dispensing is firmly entrenched in the U.S. health care system, is likely to increase, does not appear to increase ADRs, and may reduce urgent care and emergency department visits. The reduction in urgent care and emergency department visits requires further study to confirm these preliminary findings.

Intimate partner violence within a cohort of Pacific mothers living in New Zealand.

Maternal reports of intimate partner violence (IPV) were obtained from a cohort of Pacific mothers living in New Zealand. The Conflict Tactics Scale was completed by 1,095 women who had given birth in the past 12 months, and who were married or living with a partner as married. The 12-month prevalence of "victimization" through verbal aggression was 77%, 21% for "minor" physical violence, and 11% for "severe" physical violence. The 12-month prevalence of "perpetration" of verbal aggression against a partner was 90%, 35% for "minor" physical violence, and 19% for "severe" violence towards their partner. The experience of social inequality and acculturation are associated with IPV, albeit differentially across the experience of victimization and perpetration. Factors significantly associated with victimization are ethnicity, maternal education, social marital status and household income. Factors significantly associated with perpetration are ethnicity, cultural alignment, maternal birthplace and alcohol consumption since the birth of the child.

Pacific Islands Families: First Two Years of Life Study--design and methodology.

AIMS: Knowledge about the health, psychosocial, and behavioural characteristics of Pacific peoples with young children resident in New Zealand is limited. The Pacific Islands Families: First Two Years of Life (PIF) Study was designed to redress this knowledge gap. This paper describes the design and methodology of the PIF Study. METHODS: Mothers of Pacific infants born at Middlemore Hospital between 15 March and 17 December 2000 were recruited. Maternal home interviews covering sociodemographic, cultural, environmental, child development, family and household dynamics, childcare, lifestyle, and health issues were undertaken at approximately 6-weeks, 12-months, and 24-months postpartum. Paternal home interviews and child development assessments were conducted at approximately 12-months and 24-months postpartum. Information from Middlemore's Hospital Discharge Summary records and Plunket's 6-week and 6-month assessments was also captured. RESULTS: 1708 mothers were identified, 1657 were invited to participate, 1590 (96%) consented to a home visit; and, of these, 1,477 (93%) were eligible for the PIF study. Of those eligible, 1,376 (93%) participated at 6-weeks, 1224 (83%) participated at 12-months, and 1144 (77%) participated at 24-months. No important differential attrition was observed. Paternal interviews and child assessments were conducted on 825 fathers and 1241 infants at 12-months and on 757 fathers and 1064 children at 24-months. CONCLUSIONS: The PIF study is a large, scientifically and culturally robust longitudinal study that has achieved respectable participation rates in a historically hard-to-reach population. We believe that results from this study will inform future policy development within New Zealand.