Depressive Symptoms, Antidepressant Medication Use, and Inflammatory Markers in the Diabetes Prevention Program.

OBJECTIVE: Antidepressant medication use (ADM) has been shown to predict diabetes. This article assessed the role of inflammatory markers in this relationship within the Diabetes Prevention Program (DPP). METHODS: DPP participants randomized to metformin (MET), life-style intervention (ILS), or placebo (PLB) were assessed for depression (Beck Depression Inventory [BDI]) annually, ADM use semiannually, serum inflammatory markers (C-reactive protein [CRP], interleukin 6 [IL-6]) at baseline and year 1, and diagnosis of type 2 diabetes mellitus (T2DM) semiannually (for 3.2 years). RESULTS: At baseline (N = 3187), M (SD) body mass index was 34 (6) kg/m and the median (interquartile range) BDI score was 3 (1-7). One hundred eighty-one (5.7%) reported ADM use and 328 (10%) had BDI scores of 11 or higher. CRP and IL-6 levels did not differ by treatment group. Baseline ADM, but not BDI score, was associated with higher levels of baseline CRP adjusted for demographic, anthropometric variables, and other medications (20% higher, p = .01). Year 1 CRP decreased for non-ADM users in the MET (-13.2%) and ILS (-34%) groups and ADM users in the ILS group (-29%). No associations were found with IL-6. CRP and continuous use of ADM predicted incident T2DM in the PLB group. In the ILS group, continuous and intermittent ADM, but not CRP, predicted T2DM. In the MET group, CRP predicted incident T2DM. CRP did not mediate the risk of T2DM with ADM use in any group. CONCLUSIONS: ADM was significantly associated with elevated CRP and incident T2DM. In the PLB group, ADM and CRP independently predicted onset of T2DM; however, CRP did not significantly mediate the effect of ADM.

Longitudinal assessments in continuing specialty certification and lifelong learning.

Longitudinal assessment (LA) involves the regular, spaced delivery of a limited number of questions on practice relevant content on a computer or mobile internet platform. Depending on the platform, participants may indicate relevance of the content to their practice and confidence in their answer prior to receiving immediate feedback (including critiques) on each question. Individual dashboards may be included to assist participants in tracking progress and identifying areas of strength and weaknesss across a content blueprint. This paper provides an overview of the theoretical underpinnings underlying LA programs, briefly describes current uses of LA in medicine and suggests areas for evaluating the role of LA in continuing medical specialty certification and continuing professional development.

Recidivism to uncontrolled blood pressure in patients with previously controlled hypertension.

BACKGROUND: Control of hypertension has improved nationally with focus on identifying and treating elevated blood pressures (BPs) to guideline recommended levels. However, once BP control is achieved, the frequency in which BP falls out of control and the factors associated with BP recidivism is unknown. In this retrospective cohort study conducted at 2 large, integrated health care systems we sought to examine rates and predictors of BP recidivism in adults with controlled hypertension. No change for methods, results and conclusion. METHODS: Patients with a prior diagnosis of hypertension based on a combination of International Classification of Diseases, Ninth Revision, codes, receipt of antihypertensive medications, and/or elevated BP readings were eligible to be included. We defined controlled hypertension as normotensive BP readings (<140/90 mmHg or <130/80 mmHg in those with diabetes) at 2 consecutive primary care visits. We then followed up patients for BP recidivism defined by the date of the second of 2 consecutive BP readings >140/90 mmHg (>130/80 mmHg for diabetes or chronic kidney disease) during a median follow-up period of 16.6 months. Cox proportional hazards regression assessed the association between patient characteristics, comorbidities, medication adherence, and provider medication management with time to BP recidivism. RESULTS: A total of 23,321 patients with controlled hypertension were included in this study. The proportion of patients with hypertension recidivism was 24.1% over the 16.6-month study period. For those with BP recidivism, the median time to relapse was 7.3 months. In multivariate analysis, those with diabetes (hazard ratio [HR] 3.99, CI 3.67-4.33), high normal baseline BP (for systolic BP HR 1.03, CI 1.03-1.04), or low antihypertensive medication adherence (HR 1.20, CI 1.11-1.29) had significantly higher rates of hypertension recidivism. Limitations of this work include demographics of our patient sample, which may not reflect other communities in addition to the intrinsic limitations of office-based BP measurements. CONCLUSIONS: Hypertensive recidivism occurs in a significant portion of patients with previously well-controlled BP and accounts for a substantial fraction of patients with poorly controlled hypertension. Systematic identification of those most at risk for recidivism and implementation of strategies to minimize hypertension recidivism may improve overall levels of BP control and hypertension-related quality measures.

Depressive symptoms, antidepressant medication use, and new onset of diabetes in participants of the diabetes prevention program and the diabetes prevention program outcomes study.

OBJECTIVE: To assess in the Diabetes Prevention Program and Diabetes Prevention Program Outcomes Study whether diagnosis of diabetes predicted elevated depressive symptoms (DS) or use of antidepressant medicine (ADM) following diagnosis; whether diabetes status or duration had significant effect on DS or ADM use; and to determine the associations between A1C, fasting plasma glucose (FPG), normalization of FPG, and DS or ADM use after diagnosis. METHODS: Diabetes Prevention Program participants in three treatment arms (intensive life style, metformin, placebo) were assessed for diabetes, glucose control, ADM use, and DS, measured using the Beck Depression Inventory (BDI). Among 3234 participants, 1285 developed diabetes. Depression levels were measured before and after diabetes diagnosis. RESULTS: Neither DS nor use of ADM increased after diagnosis; higher FPG was associated with greater ADM use in the intensive life style arm; a 10-mg/dl rise in FPG is associated with greater odds of ADM use. Higher FPG and A1C were associated with higher BDI scores in all three arms; A 10-mg/dl rise in FPG had a 0.07 increase in BDI. A 1% higher A1c was associated with a 0.21-point increase in BDI. Normalization of FPG was associated with lower BDI. When FPG had normalized, there was a decrease of 0.30 points in the BDI score compared when FPG had not normalized. CONCLUSIONS: Contrary to clinical attributions, diabetes diagnosis did not show an immediate impact on BDI scores or ADM use. Higher glucose levels after diagnosis were associated with a small but significantly higher BDI score and more ADM use. TRIAL REGISTRATION: DPPOS: NCT00038727; DPP: NCT00004992.

Facilitators and Barriers to Implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Primary Care in Integrated Health Care Settings.

BACKGROUND: Substance abuse in the United States is a serious public health concern impacting morbidity and mortality. However, systematic screening and intervention has not been widely adopted into routine practice by health care organizations and routine screening and intervention is not currently in place for primary care at Kaiser Permanente Colorado. Therefore, a formative evaluation was conducted to explore and enhance implementation of the Substance Abuse and Mental Health Services Administration (SAMHSA) screening, brief intervention, and referral to treatment (SBIRT) approach in the organization. METHODS: Key clinical stakeholders, including internal and family medicine physicians, primary care nurses, mental health therapists, chemical dependency clinicians, and clinic-based psychologists provided feedback. Two focus groups were also conducted with patient stakeholders: one in English and one in Spanish. RESULTS: All clinical stakeholders promoted clinic-based psychologists to conduct brief intervention and determine referral to treatment as the optimal implementation program. Inclusion of the patient perspective also highlighted the importance of considering this perspective in implementation. Both patient groups were generally supportive of SBIRT, especially the educational value of screening questions defining healthy drinking limits; however, English-speaking patients noted privacy concerns and Spanish-speaking patients noted frequently being asked about drug or alcohol use. Organizationally, systems exist to facilitate drug and alcohol use screening, intervention, and referral to treatment. However, physician time, alignment with other priorities, and lack of consistent communication were noted potential barriers to SBIRT implementation. CONCLUSIONS: Clinicians expressed concerns about competing priorities and the need for organizational leadership involvement for successful SBIRT implementation. A unique suggestion for successful implementation is to utilize existing primary care clinic-based psychologists to conduct brief intervention and facilitate referral to treatment. Patient stakeholders supported universal screening, but cultural differences in opinions and current experience were noted, indicating the importance of including this perspective when evaluating implementation potential.

An investigation of associations between clinicians' ethnic or racial bias and hypertension treatment, medication adherence and blood pressure control.

BACKGROUND: Few studies have directly investigated the association of clinicians' implicit (unconscious) bias with health care disparities in clinical settings. OBJECTIVE: To determine if clinicians' implicit ethnic or racial bias is associated with processes and outcomes of treatment for hypertension among black and Latino patients, relative to white patients. RESEARCH DESIGN AND PARTICIPANTS: Primary care clinicians completed Implicit Association Tests of ethnic and racial bias. Electronic medical records were queried for a stratified, random sample of the clinicians' black, Latino and white patients to assess treatment intensification, adherence and control of hypertension. Multilevel random coefficient models assessed the associations between clinicians' implicit biases and ethnic or racial differences in hypertension care and outcomes. MAIN MEASURES: Standard measures of treatment intensification and medication adherence were calculated from pharmacy refills. Hypertension control was assessed by the percentage of time that patients met blood pressure goals recorded during primary care visits. KEY RESULTS: One hundred and thirty-eight primary care clinicians and 4,794 patients with hypertension participated. Black patients received equivalent treatment intensification, but had lower medication adherence and worse hypertension control than white patients; Latino patients received equivalent treatment intensification and had similar hypertension control, but lower medication adherence than white patients. Differences in treatment intensification, medication adherence and hypertension control were unrelated to clinician implicit bias for black patients (P = 0.85, P = 0.06 and P = 0.31, respectively) and for Latino patients (P = 0.55, P = 0.40 and P = 0.79, respectively). An increase in clinician bias from average to strong was associated with a relative change of less than 5 % in all outcomes for black and Latino patients. CONCLUSIONS: Implicit bias did not affect clinicians' provision of care to their minority patients, nor did it affect the patients' outcomes. The identification of health care contexts in which bias does not impact outcomes can assist both patients and clinicians in their efforts to build trust and partnership.

Machine Learning to Identify Clusters in Family Medicine Diplomate Motivations and Their Relationship to Continuing Certification Exam Outcomes: Findings and Potential Future Implications.

BACKGROUND: The potential for machine learning (ML) to enhance the efficiency of medical specialty boards has not been explored. We applied unsupervised ML to identify archetypes among American Board of Family Medicine (ABFM) Diplomates regarding their practice characteristics and motivations for participating in continuing certification, then examined associations between motivation patterns and key recertification outcomes. METHODS: Diplomates responding to the 2017 to 2021 ABFM Family Medicine continuing certification examination surveys selected motivations for choosing to continue certification. We used Chi-squared tests to examine difference proportions of Diplomates failing their first recertification examination attempt who endorsed different motivations for maintaining certification. Unsupervised ML techniques were applied to generate clusters of physicians with similar practice characteristics and motivations for recertifying. Controlling for physician demographic variables, we used logistic regression to examine the effect of motivation clusters on recertification examination success and validated the ML clusters by comparison with a previously created classification schema developed by experts. RESULTS: ML clusters largely recapitulated the intrinsic/extrinsic framework devised by experts previously. However, the identified clusters achieved a more equal partitioning of Diplomates into homogenous groups. In both ML and human clusters, physicians with mainly extrinsic or mixed motivations had lower rates of examination failure than those who were intrinsically motivated. DISCUSSION: This study demonstrates the feasibility of using ML to supplement and enhance human interpretation of board certification data. We discuss implications of this demonstration study for the interaction between specialty boards and physician Diplomates.

Differences in Physician Performance and Self-rated Confidence on High- and Low-Stakes Knowledge Assessments in Board Certification.

INTRODUCTION: Evidence links assessment to optimal learning, affirming that physicians are more likely to study, learn, and practice skills when some form of consequence ("stakes") may result from an assessment. We lack evidence, however, on how physicians' confidence in their knowledge relates to performance on assessments, and whether this varies based on the stakes of the assessment. METHODS: Our retrospective repeated-measures design compared differences in patterns of physician answer accuracy and answer confidence among physicians participating in both a high-stakes and a low-stakes longitudinal assessment of the American Board of Family Medicine. RESULTS: After 1 and 2 years, participants were more often correct but less confident in their accuracy on a higher-stakes longitudinal knowledge assessment compared with a lower-stakes assessment. There were no differences in question difficulty between the two platforms. Variation existed between platforms in time spent answering questions, use of resources to answer questions, and perceived question relevance to practice. DISCUSSION: This novel study of physician certification suggests that the accuracy of physician performance increases with higher stakes, even as self-reported confidence in their knowledge declines. It suggests that physicians may be more engaged in higher-stakes compared with lower-stakes assessments. With medical knowledge growing exponentially, these analyses provide an example of the complementary roles of higher- and lower-stakes knowledge assessment in supporting physician learning during continuing specialty board certification.

Assessment of biases against Latinos and African Americans among primary care providers and community members.

OBJECTIVES: We assessed implicit and explicit bias against both Latinos and African Americans among experienced primary care providers (PCPs) and community members (CMs) in the same geographic area. METHODS: Two hundred ten PCPs and 190 CMs from 3 health care organizations in the Denver, Colorado, metropolitan area completed Implicit Association Tests and self-report measures of implicit and explicit bias, respectively. RESULTS: With a 60% participation rate, the PCPs demonstrated substantial implicit bias against both Latinos and African Americans, but this was no different from CMs. Explicit bias was largely absent in both groups. Adjustment for background characteristics showed the PCPs had slightly weaker ethnic/racial bias than CMs. CONCLUSIONS: This research provided the first evidence of implicit bias against Latinos in health care, as well as confirming previous findings of implicit bias against African Americans. Lack of substantive differences in bias between the experienced PCPs and CMs suggested a wider societal problem. At the same time, the wide range of implicit bias suggested that bias in health care is neither uniform nor inevitable, and important lessons might be learned from providers who do not exhibit bias.

Clinicians' implicit ethnic/racial bias and perceptions of care among Black and Latino patients.

PURPOSE: We investigated whether clinicians' explicit and implicit ethnic/racial bias is related to black and Latino patients' perceptions of their care in established clinical relationships. METHODS: We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians' interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales. RESULTS: Levels of explicit bias were low among clinicians and unrelated to patients' perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians' implicit bias (P = .98). CONCLUSIONS: This is among the first studies to investigate clinicians' implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians' implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine's suggestion that clinician bias may contribute to health disparities. Latinos' overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.

To Effectively Address Complex Healthcare Problems, Continuing Professional Development Must Evolve.

ABSTRACT: Continuing professional development aims to provide health professionals with the knowledge, skills, and competencies needed to improve care. Physicians and other clinicians increasingly practice within complex health care delivery organizations aiming to improve the care of populations of patients with multiple problems and differing needs. These organizations are composed of local units in different departments and venues; these teams and the patients they care for change over time. Improving outcomes within constantly changing complex organizations delivering population care takes time and persistence. It takes time to equip critical masses of clinicians and other personnel with knowledge and skills to effect change. Although some changes might be simple, those involving new workflows require implementation support. Not all change will be smooth; individuals need opportunities to learn from and adjust their early intervention efforts, measure effectiveness of change, and sustain successful practices. Longitudinal support is necessary to affect change over complex organizations. This essay proposes that to be more supportive and valuable to health care delivery organizations, continuing professional development needs to intentionally participate in longitudinal, collaborative, context-specific, team-based interventions. An expanded menu of evaluation approaches will better describe the role of continuing professional development in helping health care professionals and organizations address increasingly complex health care delivery problems and improve patient and population outcomes. Selected concepts to achieve these ends are introduced at a high level in this article. Readers are invited to explore concepts that resonate with their current situation in further detail.

Development of eConsult reflective learning tools for healthcare providers: a pragmatic mixed methods approach.

BACKGROUND: Electronic consultation (eConsult) programs are crucial components of modern healthcare that facilitate communication between primary care providers (PCPs) and specialists. eConsults between PCPs and specialists. They also provide a unique opportunity to use real-world patient scenarios for reflective learning as part of professional development. However, tools that guide and document learning from eConsults are limited. The purpose of this study was to develop and pilot two eConsult reflective learning tools (RLTs), one for PCPs and one for specialists, for those participating in eConsults. METHODS: We performed a four-phase pragmatic mixed methods study recruiting PCPs and specialists from two public health systems located in two countries: eConsult BASE in Canada and San Francisco Health Network eConsult in the United States. In phase 1, subject matter experts developed preliminary RLTs for PCPs and specialists. During phase 2, a Delphi survey among 20 PCPs and 16 specialists led to consensus on items for each RLT. In phase 3, we conducted cognitive interviews with three PCPs and five specialists as they applied the RLTs on previously completed consults. In phase 4, we piloted the RLTs with eConsult users. RESULTS: The RLTs were perceived to elicit critical reflection among participants regarding their knowledge and practice habits and could be used for quality improvement and continuing professional development. CONCLUSION: PCPs and specialists alike perceived that eConsult systems provided opportunities for self-directed learning wherein they were motivated to investigate topics further through the course of eConsult exchanges. We recommend the RLTs be subject to further evaluation through implementation studies at other sites.

Practice Adjustments Made by Family Physicians During the COVID-19 Pandemic.

INTRODUCTION: COVID-19 pandemic-related health care disruptions necessitated rapid adaptation among family physicians to safely meet patient needs while protecting themselves and their staff. On April 1, 2020, the American Board of Family Medicine (ABFM) introduced a COVID Performance Improvement (PI) activity for physicians to report on and receive Family Medicine certification credit for practice adjustments they made during the early stages of the pandemic. We aimed to understand the types of interventions implemented, and lessons physicians learned from the efforts. METHODS: We analyzed data from COVID-PI activities submitted by self-selected family physicians between April 1 and June 30, 2020. We summarized the COVID-related topics chosen for improvement and performed a qualitative content analysis on a random sample of open-text responses about lessons learned. RESULTS: The most common practice changes among 1259 unique COVID-PI activity submissions related to virtualization of patient visits, implementing new workflows, developing screening protocols, and obtaining and preserving personal protective equipment. We identified 12 themes regarding lessons learned, most commonly regarding patient and staff safety, modified practice processes and workflows, positive perceptions of and future plans for virtual visits, access to care, and patient satisfaction. Most submitters noted early successes with their interventions. CONCLUSION: A PI activity template designed for continuous board certification allowed family physicians to report on how they successfully implemented short term practice changes during the early stages of the COVID-19 pandemic. Reflections from this subset of physicians regarding lessons learned may prove useful in informing future COVID-19 related practice changes.

Training Future Family Physicians to Become Master Adaptive Learners.

This article examines the use of a concept that teaches learners how to learn in the context of family medicine residency training. We describe the four phases of this master adaptive learning framework and its place in educational theory and adaptive expertise, its implications for graduate medical education training and Accreditation Council for Graduate Medical Education competencies, as well as its role in imprinting family medicine residents for career-long learning. We lay out pragmatic strategies supporting this concept with a proposed curricular format for training in family medicine, including small group teaching methods, didactics, the clinic visit, faculty development and an optimal learning environment.

Implementing Competency-Based Medical Education in Family Medicine: A Narrative Review of Current Trends in Assessment.

BACKGROUND AND OBJECTIVES: The implementation of effective competency-based medical education (CBME) relies on building a coherent and integrated system of assessment across the continuum of training to practice. As such, the developmental progression of competencies must be assessed at all stages of the learning process, including continuing professional development (CPD). Yet, much of the recent discussion revolves mostly around residency programs. The purpose of this review is to synthesize the findings of studies spanning the last 2 decades that examined competency-based assessment methods used in family medicine residency and CPD, and to identify gaps in their current practices. METHODS: We adopted a modified form of narrative review and searched five online databases and the gray literature for articles published between 2000 and 2020. Data analysis involved mixed methods including quantitative frequency analysis and qualitative thematic analysis. RESULTS: Thirty-seven studies met inclusion criteria. Fourteen were formal evaluation studies that focused on the outcome and impact evaluation of assessment methods. Articles that focused on formative assessment were prevalent. The most common levels of educational outcomes were performance and competence. There were few studies on CBME assessment among practicing family physicians. Thematic analysis of the literature identified several challenges the family medicine educational community faces with CBME assessment. CONCLUSIONS: We recommend that those involved in health education systematically evaluate and publish their CBME activities, including assessment-related content and evaluations. The highlighted themes may offer insights into ways in which current CBME assessment practices might be improved to align with efforts to improve health care.

Nanopolycrystalline materials; a general atomistic model for simulation.

We present a general strategy for generating full atomistic models of nanopolycrystalline materials including bulk and thin film. In particular, models for oxide nanoparticles were constructed using simulated amorphisation and crystallisation and used to populate a library of oxide nanoparticles (amorphous and crystalline) with different radii. Nanoparticles were then taken from this library and positioned, within a specific volume, using Monte Carlo techniques, to facilitate a tight-packed structure. The grain-size distribution of the polycrystalline material was controlled by selecting particular sized nanoparticles from the library. The (randomly oriented) grains facilitated a polycrystalline oxide, which comprised a network of general grain-boundaries. To help validate the model, gas diffusion through the (polycrystalline) oxide material was then simulated and the activation energy calculated directly. Specifically, we explored He transport in UO(2), which is an important material with respect to both civilian and military applications. We found that He transport proceeds much faster through the grain-boundary and grain-junction network compared with intracrystalline UO(2) regions, in accordance with experiment.

Rapid Retooling, Acquiring New Skills, and Competencies in the Pandemic Era: Implications and Expectations for Physician Continuing Professional Development.

The SARS-CoV-2 (COVID 19) pandemic has necessitated changes in health care delivery, including increases in delivery of care through asynchronous or virtual means, and deployment of clinicians in different teams and settings. Physical distancing and redeployment of clinicians has also necessitated changes in health care continuing professional development (CPD). Health care delivery and CPD is unlikely to fully return (in the near term, if at all) to pre-pandemic status. The authors raise questions and opportunities for development and provision of CPD during and after the pandemic.