Patient Preferences for Preventive Healthcare During the COVID-19 Pandemic in a Large Integrated Health System.

The COVID-19 pandemic caused healthcare systems and patients to cancel or postpone healthcare services, particularly preventive care. Many patients still have not received these services raising concerns about the potential for preventable morbidity and mortality. At Sutter Health, a large integrated healthcare system in Northern California, we conducted a population-based email survey in August 2020 to evaluate perceptions and preferences about where, when, and how healthcare is delivered during the COVID-19 pandemic. In total, 3351 patients completed surveys, and 42.6% reported that they would "wait until they felt safe" before receiving a colonoscopy as compared to 22.4% for a mammogram. The doctor's office was the most common preferred location for receiving vaccines/shots (79.9%), though many also reported preferring an outdoor setting or in a car (63.7%). With over 40% of patients reporting that they would "wait until they feel safe" for a colonoscopy, healthcare systems could focus on promoting other evidence-based options such a fecal-occult blood test to ensure timely colon cancer screening.

Effects of Behavioral Economics-Based Messaging on Appointment Scheduling Through Patient Portals and Appointment Completion: Observational Study.

BACKGROUND: Behavioral economics-based techniques have been an increasingly utilized method in health care to influence behavior change by modifying language in patient communication (through choice architecture and the framing of words). Patient portals are a key tool for facilitating patient engagement in their health, and interventions deployed via patient portals have been effective in improving utilization of preventive health services. OBJECTIVE: We examined the impacts of behavioral economics-based nudge health maintenance reminders on appointment scheduling through a patient portal and appointment completion for 2 preventive services: Medicare wellness visits and Pap smear. METHODS: We conducted a retrospective observational study using electronic health record data from an integrated health care system in Northern California. Nudge health maintenance reminders with behavioral economics-based language were implemented for all sites in November 2017 for Medicare wellness visits and for selected sites in February 2018 for Pap smears. We analyzed 125,369 health maintenance reminders for Medicare wellness visits, and 585,358 health maintenance reminders for Pap smear sent between January 2017 and February 2020. The primary outcomes were rate of appointments scheduled through the patient portal and appointment completion rate. We compared the outcomes between those who received the new, behavioral economics-based health maintenance reminders (the nudge group) and those who received the original, standard health maintenance reminders (the control group). We used segmented regression with interrupted time series to assess the immediate and gradual effect of the nudge for Medicare wellness visits, and we used logistic regression to assess the association of nudge health maintenance reminders, adjusting for the propensity to receive a nudge health maintenance reminder, for Pap smear. RESULTS: The rates of appointments scheduled through the patient portal were higher for nudge health maintenance reminder recipients than those for control health maintenance reminder recipients (Medicare wellness visits-nudge: 12,537/96,839, 13.0%; control: 2,769/28,530, 9.7%, P<.001; Pap smear-nudge: 8,239/287,149, 2.9%; control: 1,868/120,047, 1.6%; P<.001). Rates of appointment completion were higher for nudge health maintenance reminders for Pap smear (nudge: 67,399/287,149, 23.5% control: 20,393/120,047, 17.0%; P<.001) but were comparable for Medicare wellness visits (nudge: 49,835/96,839, 51.5% control: 14,781/28,530, 51.8%; P=.30). There was a marginally gradual effect of nudge on number of appointments scheduled through the patient portal for the overall Medicare wellness visits sample (at a monthly rate of 0.26%, P=.09), and a significant gradual effect among scheduled appointments (at a monthly rate of 0.46%, P=.04). For Pap smear, nudge health maintenance reminders were positively associated with number of appointments scheduled through the patient portal (overall sample: propensity adjusted odds ratio [OR] 1.62; 95% CI 1.50-1.74; among scheduled appointments: propensity adjusted OR 1.61, 95% CI 1.47-1.76) and with appointment completion (propensity adjusted OR 1.07; 1.04-1.10). CONCLUSIONS: Nudges, a behavioral economics-based approach to providing health maintenance reminders, increased the number of appointments scheduled through the patient portal for Medicare wellness visits and Pap smear. Our study demonstrates that a simple approach-framing and modifying language in an electronic message-can have a significant and long-term impact on patient engagement and access to care.

Women, Younger Clinicians', and Caregivers' Experiences of Burnout and Well-being During COVID-19 in a US Healthcare System.

BACKGROUND: The COVID-19 pandemic brought rapid changes to the work and personal lives of clinicians. OBJECTIVE: To assess clinician burnout and well-being during the COVID-19 pandemic and guide healthcare system improvement efforts. DESIGN: A survey asking about clinician burnout, well-being, and work experiences. PARTICIPANTS: Surveys distributed to 8141 clinicians from June to August 2020 in 9 medical groups and 17 hospitals at Sutter Health, a large healthcare system in Northern California. MAIN MEASURES: Burnout was the primary outcome, and other indicators of well-being and work experience were also measured. Descriptive statistics and multivariate logistic regression analyses were performed. All statistical inferences were based on weighted estimates adjusting for response bias. KEY RESULTS: A total of 3176 clinicians (39.0%) responded to the survey. Weighted results showed 29.2% reported burnout, and burnout was more common among women than among men (39.0% vs. 22.7%, p<0.01). In multivariate models, being a woman was associated with increased odds of reporting burnout (OR=2.19, 95% CI: 1.51-3.17) and being 55+ years old with lower odds (OR=0.54, 95% CI: 0.34-0.87). More women than men reported that childcare/caregiving was impacting work (32.9% vs. 19.0%, p<0.01). Even after controlling for age and gender, clinicians who reported childcare/caregiving responsibilities impacted their work had substantially higher odds of reporting burnout (OR=2.19, 95% CI: 1.54-3.11). Other factors associated with higher burnout included worrying about safety at work, being given additional work tasks, concern about losing one's job, and working in emergency medicine or radiology. Protective factors included believing one's concerns will be acted upon and feeling highly valued. CONCLUSIONS: This large survey found the pandemic disproportionally impacted women, younger clinicians, and those whose caregiving responsibilities impacted their work. These results highlight the need for a holistic and targeted strategy for improving clinician well-being that addresses the needs of women, younger clinicians, and those with caregiving responsibilities.

The human resource costs of implementing autopend clinical decision support to improve health maintenance.

OBJECTIVES: Sutter Health developed a novel autopend, or automated laboratory test ordering, clinical decision support (CDS) tool to coordinate the patient and physician process of completing preventive services. This study estimated the costs of developing and implementing the autopend functionality within an existing electronic health maintenance (HM) reminder system. STUDY DESIGN: Human resource time was measured by triangulating in-depth key informant interviews with Microsoft Outlook Calendar metadata (meetings attended) for managers and hourly data from a time-based project management tool (Project Web App) for Epic programmers. Employee time spent was multiplied by the Bureau of Labor Statistics California state hourly wages. Sutter Health is an integrated health care delivery network with more than 12,000 physicians across 100 communities serving 3 million patients. METHODS: Activity-based costing methodology was used to divide the implementation into activities and the human resources required to complete them. RESULTS: Developing and implementing the autopend CDS took more than 3 years, involved 6 managers and 3 Epic programmers, and cost $201,500 (2013 US$) (2670 total hours), which excluded the costs of implementing the initial HM reminder system. Managers spent 90.5% of the total costs (86.6% of total hours) integrating autopend into the health system compared with 9.5% of the total costs (13.4% of total hours) spent programming the functionality. CONCLUSIONS: The autopend CDS might be similarly costly for other organizations to implement if their managers need to complete comparable activities. However, electronic health record vendors could include autopend as a standard package to reduce development costs and improve the uptake of this promising CDS tool.

Assessment of Accuracy and Usability of a Fee Estimator for Ambulatory Care in an Integrated Health Care Delivery Network.

Importance: Given increased enrollment in high-deductible health insurance plans and mandates from the Patient Protection and Affordable Care Act, individualized price transparency tools are needed. Objective: To assess accuracy and initial user experience of a cost estimation tool for ambulatory procedures delivered via an online patient portal and informed by real-time data feeds from third-party payers. Design, Setting, and Participants: This quality improvement study included patients aged 18 years and older at an integrated health care system in Northern California. Data from patients who used the cost estimator tool from August 21, 2018, to April 9, 2019, and who had matching explanation of benefits statements were used to assess accuracy of the tool. User experience was assessed with a brief survey completed online or via postal mail. Data were analyzed from April 15, 2019, to October 11, 2019. Main Outcomes and Measures: Tool accuracy and user experience and satisfaction. Results: As of April 30, 2019, 4610 estimates (3569 [77.4%] via internet; 1041 [22.6%] via telephone) were produced using the cost estimator tool. Among 342 individuals who had an estimate and a matching explanation of benefits statement, 287 estimates (83.9%) were accurate. All 342 individuals with an estimate and an explanation of benefits statement were invited to participate in a user survey, and 125 individuals completed the survey (36.5% response rate). Survey respondents included 92 (73.6%) women, 72 (57.6%) non-Hispanic white participants , 91 participants (72.8%) with a college degree or higher, and 55 participants (44.0%) with an income of $100 000 per year or higher. Mean (SD) age was 46.8 (13.1) years. Ninety-nine participants (79.2%) found the tool easy to use, 109 participants (87.2%) would use it again, and 100 participants (80.0%) would recommend it to others. Seven participants (5.6%) reported contacting a clinician about the estimate, and 12 participants (9.6%) changed their decision based on the estimate. Conclusions and Relevance: This quality improvement study is the first report of an online cost estimator in an integrated health care delivery network. The findings suggest that the tool, informed by real-time data feeds from third-party payers, was easy to use and provided accurate results. Increasing the number of searchable services and sharing best practices with other health care systems who share the same portal platform are the next steps for the tool.