Perspectives Regarding Medications for Opioid Use Disorder Among Individuals with Mental Illness.

Most people with co-occurring opioid use disorder (OUD) and mental illness do not receive effective medications for treating OUD. To investigate perspectives of adults in a publicly-funded mental health system regarding medications for OUD (MOUD), we conducted semi-structured telephone interviews with 13 adults with OUD (current or previous diagnosis) receiving mental health treatment. Themes that emerged included: perceiving or using MOUDs as a substitute for opioids or a temporary solution to prevent withdrawal symptoms; negative perceptions about methadone/methadone clinics; and viewing MOUD use as "cheating". Readiness to quit was important for patients to consider MOUDs. All participants were receptive to discussing MOUDs with their mental health providers and welcomed the convenience of receiving care for their mental health and OUD at the same location. In conclusion, clients at publicly-funded mental health clinics support MOUD treatment, signaling a need to expand access and build awareness of MOUDs in these settings.

External Validation of the COVID-NoLab and COVID-SimpleLab Prognostic Tools.

Our objective was to externally validate 2 simple risk scores for mortality among a mostly inpatient population with COVID-19 in Canada (588 patients for COVID-NoLab and 479 patients for COVID-SimpleLab). The mortality rates in the low-, moderate-, and high-risk groups for COVID-NoLab were 1.1%, 9.6%, and 21.2%, respectively. The mortality rates for COVID-SimpleLab were 0.0%, 9.8%, and 20.0%, respectively. These values were similar to those in the original derivation cohort. The 2 simple risk scores, now successfully externally validated, offer clinicians a reliable way to quickly identify low-risk inpatients who could potentially be managed as outpatients in the event of a bed shortage. Both are available online (https://ebell-projects.shinyapps.io/covid_nolab/ and https://ebell-projects.shinyapps.io/COVID-SimpleLab/).

Hidden cues for approach and avoidance motivation: implicit cognitive associations among patients with Nonadherence to HIV treatment.

Although patient motivation related to HIV treatment is widely acknowledged as a key factor related to consistent adherence and engagement with medical care, research has predominantly focused on explicit rather than implicit cognitive processes that underlie motivation. This study identified and examined implicit cognitive processes that influence approach and avoidance treatment motivation in a sample of 30 HIV patients with suboptimal adherence and poor engagement with medical care. Study participants were predominantly African American (87%) and gay/bisexual (63%). We examined 173 thought statements about treatment collected from patients during two previous studies. Thematic analysis described how implicit cognitive associations influenced patients to approach or avoid treatment and medical care. Findings revealed three major contextual categories of treatment-related thoughts: links with routines and habits, connections to physical changes and reactions, and interpersonal associations. Within each category, implicit cognitive associations about treatment in terms of these daily life events and experiences cued approach and avoidance motivational tendencies without the patient's awareness. Findings from this study support the need for interventions that use implicit, less effortful approaches aimed at promoting adherence and improving the retention of patients with poor engagement.

Post-Visit Patient Understanding About Newly Prescribed Medications.

BACKGROUND: Good patient understanding of basic medication-related information such as directions for use and side effects promotes medication adherence, but information is lacking about how well patients understand basic medication-related information after their office visits. OBJECTIVE: The purpose of this study is to investigate post-visit patient understanding about newly prescribed medications. DESIGN: Secondary mixed methods analysis comparing patient survey responses about newly prescribed medications to information conveyed by physicians during office visits (from audio recordings of office visits). PARTICIPANTS: Eighty-one patients aged 50 and older who discussed newly prescribed medications during an outpatient office visit. MAIN MEASURES: Accurate patient identification of medication dose, number of pills, frequency of use, duration of use, and potential side effects. KEY RESULTS: The 81 patients in this study received 111 newly prescribed medications. For over 70% of all newly prescribed medications, patients correctly identified the number of pills, frequency of use, duration of use, and dose, regardless of whether the physician mentioned the information during the office visit. However, for 34 of 62 medications (55%) for which side effects were not conveyed and 11 of 49 medications (22%) for which physicians discussed side effects, patients reported that the medication lacked side effects. Analysis of transcribed office visits showed that potential reasons for this finding included failure of physicians to mention or to use the term "side effects" during visits, the prescription of multiple medications during the visit, and lack of patient engagement in the conversation. CONCLUSIONS: Many patients correctly identified information related to directions for taking a newly prescribed medication, even without physician counseling, but when physicians failed to convey potential medication side effects, many assumed that a medication had no side effects. It may be sufficient for physicians to provide written information about medication directions and dosing, and tailor their limited time to discussing medication side effects.

Provider Recommendations in the Face of Scientific Uncertainty: An Analysis of Audio-Recorded Discussions about Vitamin D.

BACKGROUND: Little is known about how providers communicate recommendations when scientific uncertainty exists. OBJECTIVES: To compare provider recommendations to those in the scientific literature, with a focus on whether uncertainty was communicated. DESIGN: Qualitative (inductive systematic content analysis) and quantitative analysis of previously collected audio-recorded provider-patient office visits. PARTICIPANTS: Sixty-one providers and a socio-economically diverse convenience sample of 603 of their patients from outpatient community- and academic-based primary care, integrative medicine, and complementary and alternative medicine provider offices in Southern California. MAIN MEASURES: Comparison of provider information-giving about vitamin D to professional guidelines and scientific information for which conflicting recommendations or insufficient scientific evidence exists; certainty with which information was conveyed. RESULTS: Ninety-two (15.3 %) of 603 visit discussions touched upon issues related to vitamin D testing, management and benefits. Vitamin D deficiency screening was discussed with 23 (25 %) patients, the definition of vitamin D deficiency with 21 (22.8 %), the optimal range for vitamin D levels with 26 (28.3 %), vitamin D supplementation dosing with 50 (54.3 %), and benefits of supplementation with 46 (50 %). For each of the professional guidelines/scientific information examined, providers conveyed information that deviated from professional guidelines and the existing scientific evidence. Of 166 statements made about vitamin D in this study, providers conveyed 160 (96.4 %) with certainty, without mention of any equivocal or contradictory evidence in the scientific literature. No uncertainty was mentioned when vitamin D dosing was discussed, even when recommended dosing was higher than guideline recommendations. CONCLUSIONS AND RELEVANCE: Providers convey the vast majority of information and recommendations about vitamin D with certainty, even though the scientific literature contains inconsistent recommendations and declarations of inadequate evidence. Not communicating uncertainty blurs the contrast between evidence-based recommendations and those without evidence. Providers should explore best practices for involving patients in decision-making by acknowledging the uncertainty behind their recommendations.

Do physicians communicate the adverse effects of medications that older patients want to hear?

BACKGROUND AND OBJECTIVES: Physicians routinely discuss adverse effects of medications, but whether discussions match older patients' desire for information is unexplored. This study compares patient preferences for adverse effect discussions with reported physician practice. METHODS: Cross-sectional survey of a convenience sample of 100 practicing primary care physicians from 9 medical groups and 178 patients recruited from 11 senior centers in the Los Angeles metropolitan area. Physicians listed the adverse effects they typically discuss when prescribing an ACE inhibitor. Patients were given a hypothetical scenario about a new medication prescription, and were asked to circle the three adverse effects they most wanted to hear about from a list. RESULTS: More than 90 % of patients wanted a physician to discuss medication adverse effects: they wanted information about both dangerous (75 % of patients) and common (66 % of patients) adverse effects. However, patients most commonly chose to hear about adverse effects occurring for < 1 % of patients and selected a wide range of adverse effects for discussion. Physicians reported most frequently educating patients about more common and life-threatening adverse effects. Patients who wanted to discuss more adverse effects were more worried about adverse effects than those wishing to hear fewer (4.0 vs. 3.4 on a 5-point Likert scale; p = 0.02). CONCLUSIONS: For the studied medication, there was little concordance between the medication adverse effects physicians say they discuss and what patients want to hear. Physicians cannot practically verbally satisfy patients' information desires about the adverse effects of new medications during time-compressed office visits. Innovative solutions are needed.

Provider and patient expectations for dietary supplement discussions.

BACKGROUND: Dietary supplement use in the United States is common. Patients can procure supplements without a prescription, and often do not disclose supplement use to their healthcare providers. Providers and patients may be uncertain about what would be appropriate or helpful in discussions of supplements during routine office visits. OBJECTIVE: To explore provider and patient expectations for discussions of dietary supplements. DESIGN: Semi-structured interviews were conducted with a purposeful sample of healthcare providers from three specialties and their patients who reported taking supplements. PARTICIPANTS: Thirty-five outpatient providers (14 primary care, six integrative medicine, and 15 complementary and alternative medicine (CAM) providers) and 107 of their patients. APPROACH: Qualitative analysis of transcripts using grounded theory and iterative review. RESULTS: Both providers and patients raised twelve common topics about dietary supplements that they felt were important to discuss during office visits, such as: supplements taken; supplement risks (interactions, safety/harm, side effects/adverse events); treatment benefits; efficacy; alternative treatments; and patient expectations/preferences for treatment. Some topics were mentioned more frequently by providers than patients, such as how to take, reason for taking, and evidence for use. Providers raised several topics that were mentioned infrequently by patients. Supplement costs and regulations were not brought up by any patients, even though consideration of these topics could influence patient decisions to take supplements. Complementary healthcare providers brought up topics not mentioned by primary care providers, such as the importance of supplement brands and supplement mega-dosing. CONCLUSIONS: Patients and providers have concordant views about the need to discuss patient supplement use and ensure patient safety. Patients may undervalue, be unaware of, or discount information about cost or regulations that could affect their decision-making about supplement use. Future studies could examine the value, acceptability, and influence of a more comprehensive approach to discussions to help patients appropriately evaluate supplements.

COVID-19 Vaccine Acceptance in Pregnant Women in the United States: A Systematic Review and Meta-Analysis.

Purpose: Pregnant women are vulnerable to Coronavirus Disease 2019 (COVID-19) complications, yet may hesitate to get vaccinated. It is important to identify racial/ethnic and other individual characteristics associated with COVID-19 vaccine acceptance in the United States during pregnancy. Methods: We searched PubMed, Embase, and Web of Science for articles published through January 2023 for keywords/terms related to immunization, COVID-19, and pregnancy, and performed a systematic review and meta-analysis to examine characteristics associated with vaccine acceptance. Results: Of 1,592 articles, 23 met inclusion criteria (focused on pregnant women in the United States, and their willingness or hesitation to vaccinate). Twenty-two of the studies examined receipt of ≥1 COVID-19 vaccine dose and/or intention to vaccinate, while one examined vaccine hesitancy. Vaccine acceptance rates ranged from 7% to 78.3%. Meta-analyses demonstrated that compared with Whites, Hispanics (odds ratios [OR] 0.72; 95% confidence interval [CI] 0.58-0.91) and Blacks (OR 0.44; 95% CI 0.30-0.63) had less COVID-19 vaccine acceptance, while Asians (OR 1.78; 95% CI 1.10-2.88) had greater vaccine acceptance. College graduation or more (OR 3.25; 95% CI 2.53-4.17), receipt or intention to receive the influenza vaccine (OR 3.46; 95% CI 2.22-5.41), and at least part-time employment (OR 2.12; 95% CI 1.66-2.72) were significantly associated with vaccine acceptance. Conclusions: COVID-19 vaccine nonacceptance in pregnant women is associated with Hispanic ethnicity and Black race, while acceptance is associated with Asian race, college education or more, at least part-time employment, and acceptance of the influenza vaccine. Future COVID-19 vaccination campaigns can target identified subgroups of pregnant women who are less likely to accept vaccination.

Implementation of Physician Orders for Life Sustaining Treatment in nursing homes in California: evaluation of a novel statewide dissemination mechanism.

BACKGROUND: Implementing Physician Orders for Life Sustaining Treatment (POLST) forms aims to improve communication of life-sustaining treatment preferences across care venues. California enabled this clinical tool in 2009, and a novel intervention of community coalitions was undertaken to advance POLST in localities around the state. Coalitions engaged facilities, including nursing homes (NHs), to foster POLST adoption. Eighteen months after introduction of POLST, we studied POLST implementation in California NHs. METHODS: NHs randomly selected in coalition and non-coalition areas were mailed surveys about POLST preparation and use in 2010. Coalitions identified which NHs they worked with. RESULTS: Of 546 NHs surveyed, 143 (52 %) in coalition areas and 141 (52 %) in non-coalition areas responded. In 82 % of responding NHs, staff received POLST education and 59 % of NHs reported having a formal policy on handling POLST. Two-thirds of NHs had admitted a resident with a POLST, and 15 % of newly admitted residents over the past month had a POLST (range 0-100 %). Eighty-one percent of NHs had completed a POLST with a resident. Fifty-four percent of residents were estimated to have a POLST (range 0-100 %) (coalition area NHs 60 % vs. non- coalition area NHs 48 %, p = 0.02). Within coalition areas, NHs that had worked with coalitions were more likely to have completed a POLST with a resident after admission than NHs that had not worked with coalitions. Few NHs (7 %) reported difficulty following POLST orders, but 38 % noted difficulty involving physicians in POLST completion. CONCLUSION: Less than 2 years after introduction, many California nursing homes report using POLST, although some NHs reported no experience. A novel community coalition intervention facilitated POLST implementation.

Intervention to enhance communication about newly prescribed medications.

PURPOSE: Physicians prescribing new medications often do not convey important medication-related information. This study tests an intervention to improve physician-patient communication about newly prescribed medications. METHODS: We conducted a controlled clinical trial of patients in 3 primary care practices, combining data from patient surveys with audio-recorded physician-patient interactions. The intervention consisted of a 1-hour physician-targeted interactive educational session encouraging communication about 5 basic elements regarding a new prescription and a patient information handout listing the 5 basic elements. Main outcome measures were the Medication Communication Index (MCI), a 5-point index assessed by qualitative analysis of audio-recorded interactions (giving points for discussion of medication name, purpose, directions for use, duration of use, and side effects), and patient ratings of physician communication about new prescriptions. RESULTS: Twenty-seven physicians prescribed 113 new medications to 82 of 256 patients. The mean MCI for medications prescribed by physicians in the intervention group was 3.95 (SD = 1.02), significantly higher than that for medications prescribed by control group physicians (2.86, SD = 1.23, P <.001). This effect held regardless of medication type (chronic vs nonchronic medication). Counseling about 3 of the 5 MCI components was significantly higher for medications prescribed by physicians in the intervention group, as were patients' ratings of new medication information transfer (P = .02). Independent of intervention or control groups, higher MCI scores were associated with better patient ratings about information about new prescriptions (P = .003). CONCLUSIONS: A physician-targeted educational session improved the content of and enhanced patient ratings of physician communication about new medication prescriptions. Further work is required to assess whether improved communication stimulated by the intervention translates into better clinical outcomes.

Reasons for Nonadherence to the Direct Oral Anticoagulant Apixaban: A Cross-Sectional Survey of Atrial Fibrillation Patients.

Background: Nonadherence to direct oral anticoagulants to prevent stroke occurs in up to 40% of atrial fibrillation patients. Underlying reasons are poorly understood. Objectives: This study quantified patient-reported reasons for nonadherence and identified strategies to improve adherence. Methods: This is a cross-sectional survey of atrial fibrillation patients in 2 academic health systems who reported apixaban nonadherence. We examined patient-reported reasons for nonadherence and level of nonadherence (assessed by a validated 3-item adherence measure) using a multivariable logistic regression model. Results: Of 419 study patients, 41.5% were women. The mean age was 71.1 ± 10 years and mean CHA2DS2VASc score was 3.2 ± 1.6. About two-thirds had adherence scores ≥80 (mild nonadherence) and one-third scores <80 (poor adherence). In all groups, forgetfulness contributed to nonadherence. Attitudes/beliefs associated with adherence score <80 included: not believing apixaban was needed (odds ratio [OR]: 12.24 [95% CI: 2.25-66.47]); medication cost (OR: 3.97 [95% CI: 1.67-9.42]); and fear of severe bleeding (OR: 3.28 [95% CI: 1.20-8.96]). Strategies that patients with adherence scores <80 selected as helping "a great deal/a lot" to increase adherence included bloodwork to evaluate efficacy (56%), physician counseling about adherence (55%), and having a reversal agent (39%). Almost one-half of all patients did not disclose nonadherence to their providers. Conclusions: Patients may not disclose their nonadherence to prescribers, and attitudes related to apixaban nonadherence differ among patients with mild nonadherence versus poor adherence. While all patients may benefit from strategies to address forgetfulness, concerns related to the purpose of apixaban, cost, and bleeding risk may require special attention in those with poor adherence.

Outcomes of A Virtual Practice-Tailored Medicare Annual Wellness Visit Intervention.

INTRODUCTION: Interventions are needed to promote utilization of the Medicare Annual Wellness Visit (AWV), an underused opportunity to perform screenings and plan individualized preventive health services. METHOD: Using remote practice redesign and electronic health record (EHR) support, we implemented the Practice-Tailored AWV intervention in 2021 (during the COVID-19 pandemic) in 3 small community-based practices. The intervention combines EHR-based tools with practice redesign approaches and resources. Outcomes included completion of AWV and fulfillment of recommended preventive services. RESULTS: At baseline the 3 practices had 1,513 Medicare patients with at least 1 visit in the past 12 months. AWV utilization went from 7% at baseline to 54% 8 months postintervention implementation; advance care planning increased 10.7% (from 7.9% to 18.6%); depression screening increased 16.3% (from 51.7% to 68.0%); and alcohol misuse screening increased 17.3% (from 42.6% to 59.9%). Every individual preventive health service was received more often by patients with an AWV than those without. At the patient level, fulfillment of all eligible preventive services (of a maximum of 12 evaluated) went from 47.5% to 53.8% (P < .001). Subgroup analyses showed that patients with AWVs completed a greater percentage of their total recommended preventive health services than those without an AWV. CONCLUSION: Virtual implementation of an intervention that combined EHR-based tools with practice redesign approaches increased AWV and preventive services utilization in Medicare patients. Given the success of this intervention during the COVID-19 pandemic (when practices had many competing demands), greater consideration should be given to delivering future interventions virtually.

Development of the patient approach and views toward healthcare communication (PAV-COM) measure among older adults.

BACKGROUND: This study examines the psychometric properties of 9 items on the Patient Activation component of the Medicare Current Beneficiary Survey (MCBS) that assess how patients approach and communicate with their physicians. The MCBS is a nationally representative, cross-sectional survey of Medicare beneficiaries. METHODS: We analyzed MCBS data collected in 2002 and 2005 from 15,165 adults aged 65 and older. Exploratory factor analysis was conducted using maximum likelihood to estimate a polychoric correlation matrix on the 2002 data, and confirmatory factor analysis was performed using the 2005 data. RESULTS: Exploratory factor analysis of the 2002 data showed a 2-factor solution: approach to interactions (5 items) and views about physician's healthcare communication (6 items). Findings were confirmed using the 2005 data. Items were combined to form the Patient Approach and Views toward Healthcare Communication (PAV-COM) scale (range 1 to 100; Cronbach's alpha of 0.75, and item-rest correlations between 0.33 and 0.54). Higher PAV-COM scores were associated with greater fulfillment of preventive health behaviors such as vaccinations and cancer screenings. CONCLUSIONS: The PAV-COM measure is a valid tool for assessing patient approaches and views toward communication with physicians. This measure can be used to evaluate interventions to improve patient participation during healthcare encounters.

Influence of synchronous primary care telemedicine versus in-person visits on diabetes, hypertension, and hyperlipidemia outcomes: a systematic review.

BACKGROUND: Telemedicine can be used to manage various health conditions, but there is a need to investigate its effectiveness for chronic disease management in the primary care setting. This study compares the effect of synchronous telemedicine versus in-person primary care visits on patient clinical outcomes. METHODS: A systematic review of studies published in PubMed and Web of Science between 1996 and January 2021 was performed using keywords related to telemedicine, diabetes, hypertension, and hyperlipidemia. Included studies compared synchronous telemedicine versus in-person visits with a primary care clinician, and examined outcomes of hemoglobin A1c (HbA1c), blood pressure, and/or lipid levels. RESULTS: Of 1724 citations screened, 7 publications met our inclusion criteria. Included studies were published between 2000 and 2018. Three studies were conducted in the United States, 2 in Spain, 1 in Sweden, and 1 in the United Kingdom. The telemedicine interventions investigated were multifaceted. All included synchronous visits with a primary care provider through videoconferencing and/or telephone, combined with other components such as asynchronous patient data transmission. Five studies reported on HbA1c changes, 5 on blood pressure changes, and 3 on changes in lipid levels. Compared to usual care with in-person visits, telemedicine was associated with greater reductions in HbA1c at 6 months and similar HbA1c outcomes at 12 months. Telemedicine conferred no significant differences in blood pressure and lipid levels compared to in-person clinic visits. CONCLUSIONS: A systematic review of the literature found few studies comparing clinical outcomes resulting from synchronous telemedicine versus in-person office visits, but the existing literature showed that in the primary care setting, telemedicine was not inferior to in-person visits for the management of diabetes, hypertension, or hypercholesterolemia. These results hold promise for continued use of telemedicine for chronic disease management.

Opioid Use Disorder Among Clients of Community Mental Health Clinics: Prevalence, Characteristics, and Treatment Willingness.

OBJECTIVE: The authors examined the prevalence of co-occurring opioid use disorder and willingness to engage in treatment among clients of eight Los Angeles County Department of Mental Health outpatient clinics. METHODS: Adults presenting for an appointment over a 2-week period were invited to complete a voluntary, anonymous health survey. Clients who indicated opioid use in the past year were offered a longer survey assessing probable opioid use disorder. Willingness to take medication and receive treatment also was assessed. RESULTS: In total, 3,090 clients completed screening. Among these, 8% had a probable prescription (Rx) opioid use disorder and 2% a probable heroin use disorder. Of the clients with probable Rx opioid use or heroin use disorder, 49% and 25% were female, respectively. Among those with probable Rx opioid use disorder, 43% were Black, 33% were Hispanic, and 12% were White, and among those with probable heroin use disorder, 24% were Black, 22% were Hispanic, and 39% were White. Seventy-eight percent of those with Rx opioid use disorder had never received any treatment, and 82% had never taken a medication for this disorder; 39% of those with heroin use disorder had never received any treatment, and 39% had never received a medication. The strongest predictor of willingness to take a medication was believing that it would help stop opioid use (buprenorphine, ß=13.54, p=0.003, and naltrexone long-acting injection, ß=15.83, p<0.001). CONCLUSIONS: These findings highlight the need to identify people with opioid use disorder and to educate clients in mental health settings about medications for these disorders.

Development and Validation of a Two-Step Predictive Risk Stratification Model for Coronavirus Disease 2019 In-hospital Mortality: A Multicenter Retrospective Cohort Study.

Objectives: An accurate prognostic score to predict mortality for adults with COVID-19 infection is needed to understand who would benefit most from hospitalizations and more intensive support and care. We aimed to develop and validate a two-step score system for patient triage, and to identify patients at a relatively low level of mortality risk using easy-to-collect individual information. Design: Multicenter retrospective observational cohort study. Setting: Four health centers from Virginia Commonwealth University, Georgetown University, the University of Florida, and the University of California, Los Angeles. Patients: Coronavirus Disease 2019-confirmed and hospitalized adult patients. Measurements and Main Results: We included 1,673 participants from Virginia Commonwealth University (VCU) as the derivation cohort. Risk factors for in-hospital death were identified using a multivariable logistic model with variable selection procedures after repeated missing data imputation. A two-step risk score was developed to identify patients at lower, moderate, and higher mortality risk. The first step selected increasing age, more than one pre-existing comorbidities, heart rate >100 beats/min, respiratory rate ≥30 breaths/min, and SpO2 <93% into the predictive model. Besides age and SpO2, the second step used blood urea nitrogen, absolute neutrophil count, C-reactive protein, platelet count, and neutrophil-to-lymphocyte ratio as predictors. C-statistics reflected very good discrimination with internal validation at VCU (0.83, 95% CI 0.79-0.88) and external validation at the other three health systems (range, 0.79-0.85). A one-step model was also derived for comparison. Overall, the two-step risk score had better performance than the one-step score. Conclusions: The two-step scoring system used widely available, point-of-care data for triage of COVID-19 patients and is a potentially time- and cost-saving tool in practice.

A Qualitative Study of Primary Care Physicians' Experiences With Telemedicine During COVID-19.

BACKGROUND: Primary care practices rapidly adopted telemedicine visits because of the COVID-19 pandemic, but information on physician perspectives about these visits is lacking. METHODS: Fifteen semistructured interviews with practicing primary care physicians and physicians-in-training from a Southern California academic health system and group-model health maintenance organization were conducted to assess physician perspectives regarding the benefits and challenges of telemedicine. RESULTS: Physicians indicated that telemedicine improved patient access to care by providing greater convenience, although some expressed concern that certain groups of vulnerable patients were unable to navigate or did not possess the technology required to participate in telemedicine visits. Physicians noted that telemedicine visits offered more time for patient counseling, opportunities for better medication reconciliations, and the ability to see and evaluate patient home environments and connect with patient families. Challenges existed when visits required a physical examination. Physicians were very concerned about the loss of personal connections and touch, which they believed diminished expected rituals that typically strengthen physician-patient relationships. Physicians also observed that careful consideration to physician workflows may be needed to avoid physician burnout. CONCLUSIONS: Physicians reported that telemedicine visits offer new opportunities to improve the quality of patient care but noted changes to their interactions with patients. Many of these changes are positive, but it remains to be seen whether others such as lack of physical examination and loss of physical presence and touch adversely influence provider-patient communication, patient willingness to disclose concerns that may affect their care, and, ultimately, patient health outcomes.

Using Virtual Visits to Care for Primary Care Patients With COVID-19 Symptoms.

PURPOSE: Examine use of office resources by primary care patients who were initially evaluated through telehealth, telephone, or in-person encounters. METHODS: Retrospective electronic health record review on patients seen in March 2020 for evaluation of potential COVID-19 symptoms, to assess the total number of interactions with physicians and office staff. RESULTS: Of 202 patients, 89 (44%) had initial telehealth, 55 (27%) telephone, and 52 (26%) in-person encounters. Patients initially evaluated through telehealth, telephone, and in-person encounters had a mean of 6.1 (S.D. = 3.7), 5.2 (S.D. = 3.6), and 4.5 (S.D. = 3.0) total interactions with the office, respectively (P = .03), and 9%, 12.7%, and 19.2%, respectively, had a subsequent in-person or emergency department visit (P = .22). Multivariable analysis showed no differences in number of office interactions based on initial visit type; older patients (95% CI = 0.00-0.07) and those with subjective fevers (95% CI = 1.01-3.01) or shortness of breath (95% CI = 0.23-2.28) had more interactions with the office. CONCLUSION: Primary care providers used virtual visits to care for most patients presenting with potential COVID-19 symptoms, with many patients choosing telephone over telehealth visits. Virtual visits can successfully limit patient exposure to other people, and consideration could be given to increasing its use for patients with potential symptoms of COVID-19.

Perceptions of Patients with Primary Nonadherence to Statin Medications.

BACKGROUND: Despite emphasis on efforts to prevent cardiovascular disease (CVD), 13% to 34% of people never fill a prescribed statin (primary nonadherence). This study determined perceptions of adults with primary nonadherence to statins. METHODS: Ten focus groups were conducted with 61 adults reporting primary nonadherence to statins (93% without known CVD). Participants were recruited from an academic medical center and nationwide Internet advertisements. RESULTS: Major themes related to primary nonadherence were 1) desire to pursue alternatives before starting a statin (eg, diet and/or exercise, dietary supplements), 2) worry about risks and adverse effects of statins, 3) perceptions of good personal health (suggesting that a statin was not needed), and 4) doubt about the benefits of statins in the absence of disease. Additional themes included mistrust of the pharmaceutical industry, mistrust of prescribing providers, inadequate provider communication about statins, and negative prior experiences with medication. Although rare, a few patients said that high cholesterol does not require treatment if it is genetic. One third noted during focus group discussions that they did not communicate their decision not to take a statin to providers. CONCLUSIONS: Adults with primary nonadherence to statins describe seeking alternatives, avoiding perceived risks of statins, poor acceptance/understanding of CVD risk estimates, and doubts about the benefits of statins. Many do not disclose their decisions to providers, thus highlighting the need for provider awareness of the potential for primary nonadherence at the point of prescribing, and the need for future work to develop strategies to identify patients with potential primary nonadherence.

Development and Validation of the COVID-NoLab and COVID-SimpleLab Risk Scores for Prognosis in 6 US Health Systems.

PURPOSE: Develop and validate simple risk scores based on initial clinical data and no or minimal laboratory testing to predict mortality in hospitalized adults with COVID-19. METHODS: We gathered clinical and initial laboratory variables on consecutive inpatients with COVID-19 who had either died or been discharged alive at 6 US health centers. Logistic regression was used to develop a predictive model using no laboratory values (COVID-NoLab) and one adding tests available in many outpatient settings (COVID-SimpleLab). The models were converted to point scores and their accuracy evaluated in an internal validation group. RESULTS: We identified 1340 adult inpatients with complete data for nonlaboratory parameters and 741 with complete data for white blood cell (WBC) count, differential, c-reactive protein (CRP), and serum creatinine. The COVID-NoLab risk score includes age, respiratory rate, and oxygen saturation and identified risk groups with 0.8%, 11.4%, and 40.4% mortality in the validation group (AUROCC = 0.803). The COVID-SimpleLab score includes age, respiratory rate, oxygen saturation, WBC, CRP, serum creatinine, and comorbid asthma and identified risk groups with 1.0%, 9.1%, and 29.3% mortality in the validation group (AUROCC = 0.833). CONCLUSIONS: Because they use simple, readily available predictors, developed risk scores have potential applicability in the outpatient setting but require prospective validation before use.