The My Diabetes Care Patient Portal Intervention: Usability and Pre-Post Assessment.

BACKGROUND: My Diabetes Care (MDC) is a novel, multifaceted patient portal intervention designed to help patients better understand their diabetes health data and support self-management. MDC uses infographics to visualize and summarize patients' diabetes health data, incorporates motivational strategies, and provides literacy level-appropriate educational resources. OBJECTIVES: We aimed to assess the usability, acceptability, perceptions, and potential impact of MDC. METHODS: We recruited 69 participants from four clinics affiliated with Vanderbilt University Medical Center. Participants were given 1 month of access to MDC and completed pre- and post-questionnaires including validated measures of usability and patient activation, and questions about user experience. RESULTS: Sixty participants completed the study. Participants' mean age was 58, 55% were females, 68% were Caucasians, and 48% had limited health literacy (HL). Most participants (80%) visited MDC three or more times and 50% spent a total of ≥15 minutes on MDC. Participants' median System Usability Scale (SUS) score was 78.8 [Q1, Q3: 72.5, 87.5] and significantly greater than the threshold value of 68 indicative of "above average" usability (p < 0.001). The median SUS score of patients with limited HL was similar to those with adequate HL (77.5 [72.5, 85.0] vs. 82.5 [72.5, 92.5]; p = 0.41). Participants most commonly reported the literacy level-appropriate educational links and health data infographics as features that helped them better understand their diabetes health data (65%). All participants (100%) intended to continue to use MDC. Median Patient Activation Measure® scores increased postintervention (64.3 [55.6, 72.5] vs. 67.8 [60.6, 75.0]; p = 0.01). CONCLUSION: Participants, including those with limited HL, rated the usability of MDC above average, anticipated continued use, and identified key features that improved their understanding of diabetes health data. Patient activation improved over the study period. Our findings suggest MDC may be a beneficial addition to existing patient portals.

Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients.

Importance: For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications. Objective: To test the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications than patients whose surgeons generate fewer coworker reports. Design, Setting, and Participants: This retrospective cohort study assessed data from 2 geographically diverse academic medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. Patients included in the NSQIP database who underwent inpatient or outpatient operations at 1 of the 2 participating sites from January 1, 2012, through December 31, 2016, were eligible. Patients were excluded if they were younger than 18 years on the date of the operation or if the attending surgeon had less than 36 months of monitoring for coworker reports preceding the date of the operation. Data were analyzed from August 8, 2018, through April 9, 2019. Exposures: Coworker reports about unprofessional behavior by the surgeon in the 36 months preceding the date of the operation. Main Outcomes and Measures: Postoperative surgical or medical complications, as defined by the NSQIP, within 30 days of the operation. Results: Among 13 653 patients in the cohort (54.0% [7368 ] female; mean [SD] age, 57 [16] years) who underwent operations performed by 202 surgeons (70.8% [143] male), 1583 (11.6%) experienced a complication, including 825 surgical (6.0%) and 1070 medical (7.8%) complications. Patients whose surgeons had more coworker reports were significantly more likely to experience any complication (0 reports, 954 of 8916 [10.7%]; ≥4 reports, 294 of 2087 [14.1%]; P < .001), any surgical complication (0 reports, 516 of 8916 [5.8%]; ≥4 reports, 159 of 2087 [7.6%]; P < .01), or any medical complication (0 reports, 634 of 8916 [7.1%]; ≥4 reports, 196 of 2087 [9.4%]; P < .001). The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports (P = .05). Conclusions and Relevance: Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient's operation appeared to be at increased risk of surgical and medical complications. These findings suggest that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients' risk for adverse outcomes.

Cognitive Skills Assessment for the Aging Orthopaedic Surgeon: AOA Critical Issues.

Physician leaders are increasingly confronted with the challenge of evaluating the performance of surgical colleagues during the last phase of their careers. Identification of physicians with declining cognitive and clinical skills must be balanced against awareness of laws protecting colleagues from discrimination. Responding successfully to this challenge requires appropriate policies, reliable data, standardized evaluation tools, consistent documentation, and the development of compassionate and effective solutions that avoid discriminatory practices. Surgical champions are essential for promoting self-regulation. Performance evaluations should comply with medical staff bylaws and institutional wellness policies.

An intervention model that promotes accountability: peer messengers and patient/family complaints.

BACKGROUND: Patients and their families are well positioned to partner with health care organizations to help identify unsafe and dissatisfying behaviors and performance. A peer messenger process was designed by the Center for Professional and Patient Advocacy at Vanderbilt University Medical Center (Nashville, Tennessee) to address "high-risk" physicians identified through analysis of unsolicited patient complaints, a proxy for risk of lawsuits. METHODS: This retrospective, descriptive study used peer messenger debriefing results from data-driven interventions at 16 geographically disparate community (n = 7) and academic (n = 9) medical centers in the United States. Some 178 physicians served as peer messengers, conducting interventions from 2005, through 2009 on 373 physicians identified as high risk. RESULTS: Most (97%) of the high-risk physicians received the feedback professionally, and 64% were "Responders." Responders' risk scores improved at least 15%, where Nonresponders' scores worsened (17%) or remained unchanged (19%) (p < or = .001). Responders were more often physicians practicing in medicine and surgery than emergency medicine physicians, had longer organizational tenures, and engaged in lengthier first-time intervention meetings with messengers. Years to achieve responder status correlated positively with initial communication-related complaints (r = .32, p < .001), but all complaint categories were equally likely to change over time. CONCLUSIONS: Peer messengers, recognized by leaders and appropriately supported with ongoing training, high-quality data, and evidence of positive outcomes, are willing to intervene with colleagues over an extended period of time. The physician peer messenger process reduces patient complaints and is adaptable to addressing unnecessary variation in other quality/safety metrics.

Sustained improvement in hand hygiene adherence: utilizing shared accountability and financial incentives.

OBJECTIVE: To evaluate the impact of an institutional hand hygiene accountability program on healthcare personnel hand hygiene adherence. DESIGN: Time-series design with correlation analysis. SETTING: Tertiary care academic medical center, including outpatient clinics and procedural areas. PARTICIPANTS: Medical center healthcare personnel. METHODS: A comprehensive hand hygiene initiative was implemented in 2 major phases starting in July 2009. Key facets of the initiative included extensive project planning, leadership buy-in and goal setting, financial incentives linked to performance, and use of a system-wide shared accountability model. Adherence was measured by designated hand hygiene observers. Adherence rates were compared between baseline and implementation phases, and monthly hand hygiene adherence rates were correlated with monthly rates of device-associated infection. RESULTS: A total of 109,988 observations were completed during the study period, with a sustained increase in hand hygiene adherence throughout each implementation phase (P < .001) as well as from one phase to the next (P < .001), such that adherence greater than 85% has been achieved since January 2011. Medical center departments were able to reclaim some rebate dollars allocated through a self-insurance trust, but during the study period, departments did not achieve full reimbursement. Hand hygiene adherence rates were inversely correlated with device-associated standardized infection ratios (R(@) = 0.70). CONCLUSIONS: Implementation of this multifaceted, observational hand hygiene program was associated with sustained improvement in hand hygiene adherence. The principles of this program could be applied to other medical centers pursuing improved hand hygiene adherence among healthcare personnel.

Medical malpractice claims risk in urology: an empirical analysis of patient complaint data.

PURPOSE: Patient complaints are associated with physician risk management experience, including medical malpractice claims risk, and small proportions of physicians account for disproportionate shares of claims. We investigated whether patient complaint experience differs among urologists, and whether urological subspecialists generate distinct quantities and types of complaints. MATERIALS AND METHODS: This retrospective study examined 1,516 unsolicited patient complaints filed against 268 urologists. Patient complaint and urological subspecialty data were collected from January 1, 2004 through December 31, 2007 for 15 geographically diverse health systems. The cohort urologists were assigned medical malpractice claims risk scores and complaint type profiles. A weighted sum algorithm produced risk scores from 4 consecutive years of complaint data and complaint type profiles were generated using a standardized coding system. Statistical analyses tested the associations among risk score, complaint type profile and urological subspecialty. Complaint type profile and subspecialty distribution were assessed for urologists in the cohort top decile for risk scores. RESULTS: Overall 125 (47%) urologists were associated with 0 patient complaints, while 30 (11%) urologists were associated with 758 (50%) of the patient complaints. Subspecialty and distribution of risk scores were significantly associated (p <0.001). Calculi and oncology subspecialist distributions suggest greater overall risk. Complaint types also varied among subspecialists (p = 0.02). There was no association between top decile urologists and complaint type profile (p = 0.19). CONCLUSIONS: Unsolicited patient complaints were nonrandomly distributed among urologists and urological subspecialties. Monitoring patient complaints may allow for early identification of and intervention with high risk urologists before malpractice claims accumulate.

Patient complaints and malpractice risk in a regional healthcare center.

OBJECTIVE: To study the association between physicians' complaint records and their risk management experiences in a regional healthcare center. DATA SOURCES: Patient complaints about physicians in a large border state medical center's hospital and outpatient clinics were recorded and coded. The study period was from January 2001 through December 2003. These records were linked to the counterpart physicians' data covered by the institutions' risk management plan through June 2004. STUDY DESIGN AND DATA COLLECTION: All physicians at the institution who had contact with patients during the study period were identified as surgeons or non-surgeons. Complaints for these physicians were recorded by the institution's Office of Patient Relations (OPR) and independently coded using a standardized protocol to characterize the nature of the problem and to uniquely identify the person complained about. The complaint records were then linked to the risk management files (RMFs) for the defined physician cohort. In addition, these data were supplemented with clinical service values (RVUs) which were available for 338 members (76%) of the 445 member cohort. PRINCIPAL FINDINGS: Both patient complaints and risk management events were higher for surgeons than for non-surgeons. This was true for the number of RMFs, those involving expenditures, and for lawsuits. Logistic regression was used to assess the effects of complaint counts, practice type and volume of clinical activity. All were statistically significant in predicting the number of RMF openings, RMF openings with expenditures and lawsuits. Predictive concordance was 75% or greater for each of the three risk management outcomes. CONCLUSIONS: Expressions of patient dissatisfaction and practice type are significantly related to risk management experiences in a regional medical center. Associations of risk management experiences with volume of clinical activity (RVUs) for surgeons in the regional medical center environment were not as strong as those found in a similar study reported from an academic medical center.

Health care access of Hispanic young adults in the United States.

PURPOSE: Hispanic persons in the United States experience higher rates of many chronic conditions than non-Hispanic whites. Access to care, especially during young adulthood, may afford opportunities for prevention or early management of these conditions. Given the heterogeneity of the Hispanic population, the specific aims of this study were to assess health insurance coverage and health care access and utilization for different Hispanic subgroups young adults in the U.S. METHODS: We analyzed data from 5189 Hispanic and 13,214 white young adults (19-29 years old) completing the National Health Interview Survey (NHIS) from 1999-2002. Health care access/utilization measures included reports of 1) uninsurance, 2) lacking a usual source of care, 3) no health professional contact, and 4) delaying needed care because of cost. Multivariate analyses were used to estimate the risk of access barriers after adjusting for sociodemographic variables and citizenship. RESULTS: Young adults of Central/South American, Mexican, or Puerto Rican origins were more likely than whites to be uninsured (28%-64% vs. 22%; p < .01) and this was especially true for noncitizens. Central/South American and Mexican young adults without U.S. citizenship were most likely to be uninsured (63% and 73%, respectively). The majority of noncitizens also lacked a usual source of care and had no health professional contact in the prior year. After adjustment, the risk of uninsurance was 60% higher for Mexican and Central/South American young adults relative to white peers. Mexican young adults also had higher risk of lacking a usual source of care and having no health professional contact. CONCLUSIONS: Substantial variability in rates of uninsurance and health care access/utilization measures exist among subgroups of Hispanic young adults participating in the NHIS. U.S. citizenship and sociodemographic factors explain much, but not all of the differences.

Characteristics of families that complain following pediatric emergency visits.

OBJECTIVE: The voicing of unsolicited observations by patients and families is a form of participation in the health care system. We investigated whether visits by patients of different race/ethnicities were equally represented in unsolicited complaints filed with a medical center's Office of Patient Affairs (OPA) regarding pediatric emergency visits. METHODS: We conducted a population-based retrospective study, including pediatric emergency visits, at a large academic medical center between January 1999 and December 2002. We identified complaints to the OPA and conducted bivariate and multivariable analyses to determine whether patient race/ethnicity was associated with filing a complaint. RESULTS: Among 105 322 total visits, the overall complaint rate was 1.22/1000 visits. Visits by white children had a complaint rate of 1.78/1000 visits compared with 0.37/1000 visits by African American children (P < .001). In multivariable analysis, visits by African American children remained less likely to be associated with a complaint to the OPA compared with visits by white children (adjusted odds ratio 0.30, 95% CI 0.17-0.55) after controlling for factors such as payer status. CONCLUSIONS: Emergency-department visits by African American children were less likely to be associated with a complaint than visits by white children. Programs that use complaints in service recovery, quality assurance, and risk management efforts may unintentionally exclude segments of the patient population served by the institution.

Gaps in enrollment from a Medicaid managed care program: effects on emergency department visits and hospitalizations for children with asthma.

BACKGROUND: For high-risk children with asthma enrolled in Medicaid, loss of Medicaid coverage is a potential threat to access to quality asthma care. OBJECTIVE: We sought to quantify the effect of gaps in enrollment on emergency department visits and hospitalizations for children with asthma in TennCare, Tennessee's managed care program for Medicaid-eligible and uninsured children. METHODS: Children with asthma were identified from a research database of files maintained by the state. Gaps in enrollment in the state insurance program were measured between 1998 and 2002. Children with gaps were compared with children without gaps with respect to emergency department visits and hospitalizations for asthma, respiratory illnesses, croup, and other diagnoses. RESULTS: Among children who met study definitions of asthma, 2373 experienced a gap in enrollment during the study period (10.4%). The rate of hospitalizations and emergency department visits for children with gaps (7402/10,000 person years) was significantly lower than the rate of study events for children with no gaps (9230/10,000 person years) (adjusted incidence rate ratio 0.88; 95% confidence interval 0.81-0.96). The rate of hospitalizations for asthma and other respiratory conditions was not different between the 2 groups; however, there was a significantly lower rate of hospitalizations for other reasons for children with gaps (adjusted incidence rate ratio 0.59; 95% confidence interval 0.41-0.86). CONCLUSIONS: Children with asthma who had gaps in a Medicaid managed care insurance program had no increase in asthma related emergency department visits and hospitalizations. Children who had gaps did have fewer nonrespiratory emergency department visits and hospitalizations than their non-gap counterparts. Further study is needed to explore the reasons for this unexpected finding.

New users of antipsychotic medications among children enrolled in TennCare.

BACKGROUND: The use of antipsychotic medications in children and adolescents for indications other than psychosis or Tourette syndrome is controversial. Newer atypical antipsychotics with profiles of adverse effects that differ from those of traditional antipsychotics may lead providers to prescribe antipsychotics more frequently than in the past for behavioral indications not strongly supported by clinical study. OBJECTIVE: To identify population-based new use of antipsychotics among patients aged 2 to 18 years. DESIGN: Retrospective cohort study, January 1, 1996, through December 31, 2001. SETTING: Tennessee's managed care program for Medicaid enrollees and the uninsured (TennCare). MAIN OUTCOME MEASURES: New use of antipsychotic medications and indications for use by the child's diagnosis, adjusted for age, sex, race, county of residence, enrollment category, and income. RESULTS: The proportion of TennCare children who were new users of antipsychotics, adjusted for demographic characteristics, nearly doubled from 23/10 000 in 1996 to 45/10 000 in 2001 (adjusted incidence rate ratio, 1.98; 95% confidence interval, 1.82-2.16). In 1996, 6.8% of new users received an atypical antipsychotic; by 2001, this had increased to 95.9%. New use for attention-deficit/hyperactivity disorder and affective disorders increased 2.5-fold. New use of antipsychotics for schizophrenia, acute psychotic reaction, Tourette syndrome, and mental retardation or autism remained relatively constant. Secular trends of increasing use were most pronounced for those aged 6 to 12 years (93% increase) and 13 to 18 years (116% increase), although use among preschool children increased 61% during the study period. CONCLUSION: The proportion of TennCare children who became new users of antipsychotics nearly doubled from 1996 to 2001, with a substantial increase in use of antipsychotics for attention-deficit/hyperactivity disorder, conduct disorder, and affective disorders.

Family reports of care denials for children enrolled in TennCare.

OBJECTIVE: Twenty-three million people, accounting for >58% of Medicaid enrollees, are enrolled in Medicaid managed care programs. Although the expectation of management in Medicaid managed care programs necessitates restrictions in use of some services sought by patients and families, the circumstances surrounding care denial and related access problems in vulnerable populations of children have not been studied. The objective of this study was to identify experiences with care denial reported by families in TennCare, Tennessee's managed care program for Medicaid enrollees and uninsured. METHODS: Primary caregivers for 399 children who were enrolled in TennCare and presented for care at 21 pediatric and family medicine sites throughout Tennessee participated in a face-to-face interview. RESULTS: Of the 399 caregivers who participated in the study, 146 (36.6%) reported that their child experienced denial of care in the previous 12 months at a physician's office (12.5% of those interviewed), dentist's office (13.8%), or pharmacy (20.0%). For denial of any 1 type of care, families of children with chronic conditions (multivariable odds ratio [OR]: 2.05; 95% confidence interval [CI]: 1.41-2.99) and those whose parents had >12 years of education (OR: 1.80; CI: 1.21-2.70) were more likely to report denial of care; families of black children were less likely to report denial than white children (OR: 0.34; CI: 0.20-0.56). Content analysis of caregiver perceptions identified provider concerns about reimbursement as a factor in denials. Of the children who could not be seen by a physician, caregivers perceived that 12.2% became sicker as a result of the delay in care; 16.3% reported an emergency department visit after the denial. CONCLUSIONS: More than one third of TennCare families reported denials of care for their children in the previous year, and factors surrounding these denials were identified. Given the large number of Americans who receive health care through Medicaid managed care programs like TennCare, more research is needed to understand the implications of denied care for children and families who are enrolled in these programs.

Prescriptions for contraindicated category X drugs in pregnancy among women enrolled in TennCare.

Filling of prescriptions for medications labelled as category X by the United States Food and Drug Administration (considered to be contraindicated for use in pregnancy) was identified among 95 284 women enrolled in TennCare, Tennessee's programme for Medicaid enrollees and individuals without health insurance. Using administrative claims data, 391 women (4.10/1000) were identified as having filled category X prescriptions during pregnancy. This included 118 women (1.24/1000) who filled prescriptions for non-contraceptive oestrogens, 81 (0.85/1000) for sedatives, and 71 (0.75/1000) for statins. While many women had physician visits with a diagnosis consistent with a possible indication for an individual drug outside of pregnancy, none of these indications is included for use during pregnancy. Older women and disabled women were more likely than younger women (P < 0.0001) and women enrolled for other reasons (P < 0.0001) to fill category X prescriptions. Nearly two-thirds of the 391 women filled prescriptions after clinical signs or pregnancy tests would indicate pregnancy; nearly 40% filled a category X prescription after a pregnancy-related physician visit. Although the absolute rate of category X medication use in pregnancy is low, substantial numbers of women and their fetuses are exposed during pregnancy. Women above the age of 35 years and women enrolled in TennCare because of disabilities were more likely to fill prescriptions for category X medications during pregnancy than others, implying that risk communication to practitioners and women should focus on identification of these women to reduce their risk of exposure.

Patient complaints and malpractice risk.

CONTEXT: A small number of physicians experience a disproportionate share of malpractice claims and expenses. If malpractice risk is related in large measure to factors such as patient dissatisfaction with interpersonal behaviors, care and treatment, and access, it might be possible to monitor physicians' risk of being sued. OBJECTIVE: To examine the association between physicians' patient complaint records and their risk management experiences. DESIGN, SETTING, AND PARTICIPANTS: Retrospective longitudinal cohort study of 645 general and specialist physicians in a large US medical group between January 1992 and March 1998, accounting for 2546 physician-years of care. MAIN OUTCOME MEASURES: Computerized records of all unsolicited patient complaints were recorded by the medical center's patient affairs office, coded to characterize the nature of the problem and alleged offender, and compared with each physician's risk management records for the same period. RESULTS: Both patient complaints and risk management events were higher for surgeons than nonsurgeons. Specifically, 137 (32%) of the 426 nonsurgeons had at least 1 risk management file compared with nearly two thirds (137 [63%] of 219) of all surgeons (chi2(1)= 54.7, P<.001). Both complaint and risk management data were positively correlated with physicians' volume of clinical activity. Logistic regression revealed that risk management file openings, file openings with expenditures, and lawsuits were significantly related to total numbers of patient complaints, even when data were adjusted for clinical activity. Predictive concordance of specialty group, complaint count, clinical activity, and sex for risk management file openings was 84%; file openings with expenditures, 83%; lawsuits, 81%; and multiple lawsuits, 87%. CONCLUSIONS: Unsolicited patient complaints captured and recorded by a medical group are positively associated with physicians' risk management experiences.