Telemedicine Adoption in an NCI-Designated Cancer Center During the COVID-19 Pandemic: A Report on Patient Experience of Care.

BACKGROUND: Patients with cancer require timely access to care so that healthcare providers can prepare an optimal treatment plan with significant implications for quality of life and mortality. The COVID-19 pandemic spurred rapid adoption of telemedicine in oncology, but study of patient experience of care with telemedicine in this population has been limited. We assessed overall patient experience of care with telemedicine at an NCI-designated Comprehensive Cancer Center during the COVID-19 pandemic and examined changes in patient experience over time. PATIENTS AND METHODS: This was a retrospective study of outpatient oncology patients who received treatment at Moffitt Cancer Center. Press Ganey surveys were used to assess patient experience. Data from patients with appointments between April 1, 2020, and June 30, 2021, were analyzed. Patient experience was compared between telemedicine and in-person visits, and patient experience with telemedicine over time was described. RESULTS: A total of 33,318 patients reported Press Ganey data for in-person visits, and 5,950 reported Press Ganey data for telemedicine visits. Relative to patients with in-person visits, more patients with telemedicine visits gave higher satisfaction ratings for access (62.5% vs 75.8%, respectively) and care provider concern (84.2% vs 90.7%, respectively) (P<.001). When adjusted for age, race/ethnicity, sex, insurance, and clinic type, telemedicine visits consistently outperformed in-person visits over time regarding access and care provider concern (P<.001). There were no significant changes over time in satisfaction with telemedicine visits regarding access, care provider concern, telemedicine technology, or overall assessment (P>.05). CONCLUSIONS: In this study, a large oncology dataset showed that telemedicine resulted in better patient experience of care in terms of access and care provider concern compared with in-person visits. Patient experience of care with telemedicine visits did not change over time, suggesting that implementing telemedicine was effective.

Patient and caregiver experience with telehealth for surgical cancer care: A qualitative study.

INTRODUCTION: The COVID-19 pandemic led to telemedicine adoption for many medical specialties, including surgical cancer care. To date, the evidence for patient experience of telemedicine among patients with cancer undergoing surgery is limited to quantitative surveys. Thus, this study qualitatively assessed the patient and caregiver experience of telehealth visits for surgical cancer care. METHODS: We conducted semistructured interviews with 25 patients with cancer and three caregivers who had completed a telehealth visit for preanesthesia or postoperative visits. Interviews covered visit descriptions, overall satisfaction, system experience, visit quality, what roles caregivers had, and thoughts on what types of surgery-related visits would be appropriate through telehealth versus in-person. RESULTS: Telehealth delivery for surgical cancer care was generally viewed positively. Multiple factors influenced the patient experience, including prior experience with telemedicine, ease of scheduling visits, smooth connection experiences, having access to technical support, high communication quality, and visit thoroughness. Participants identified use cases on telehealth for surgical cancer care, including postoperative visits for uncomplicated surgical procedures and educational visits. CONCLUSIONS: Patient experiences with telehealth for surgical care are influenced by smooth system experiences, high-quality patient-clinician communications, and a patient-centered focus. Interventions are needed to optimize telehealth delivery (e.g., improve telemedicine platform usability).

Adoption of emergency department crowding interventions among US hospitals between 2007 and 2020.

BACKGROUND: To deal with emergency department (ED) crowding, the American College of Emergency Physicians (ACEP) established a task force to develop a list of low-cost, high-impact solutions. In this study, we report on the trend in the adoption rate of ACEP-recommended ED crowding interventions by US hospitals. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey data from 2007 to 2020 (N = 3874 hospitals). The primary outcome was whether a hospital adopted each of the ACEP-recommended interventions, which were grouped into three overlapping categories: technology-based, flow modifications, and physical-based (e.g., changing ED layout). RESULTS: On average, the most frequently adopted intervention was bedside registration (85.1%) and the least frequently adopted intervention was kiosk check-in (8.3%). The adoption of ED crowding interventions increased significantly between 2007 and 2020, except for expanding ED treatment space which declined by 45.0% from 30.3% in 2007 to 15.7% in 2020. The largest adoption rate increase occurred in having a separate operating room for ED cases with a 188.5% increase in adoption rate followed by radio-frequency identification (RFID) tracking (151.2%), and kiosk check-in (144.2%). CONCLUSIONS: The adoption rate of ED crowding interventions by hospitals has risen, however most effective ED crowding interventions are still underutilized. The trends for each intervention did not always increase linearly, with certain periods showing greater fluctuations in adoption rate. Hospitals tend to implement technology-based interventions, compared to physical-based interventions and flow modification interventions.

Health Care Providers' and Professionals' Experiences With Telehealth Oncology Implementation During the COVID-19 Pandemic: A Qualitative Study.

BACKGROUND: Rapid implementation of telehealth for cancer care during COVID-19 required innovative and adaptive solutions among oncology health care providers and professionals (HPPs). OBJECTIVE: The aim of this qualitative study was to explore oncology HPPs' experiences with telehealth implementation during the COVID-19 pandemic. METHODS: This study was conducted at Moffitt Cancer Center (Moffitt), an NCI (National Cancer Institute)-Designated Comprehensive Cancer Center. Prior to COVID-19, Moffitt piloted telehealth visits on a limited basis. After COVID-19, Moffitt rapidly expanded telehealth visits. Telehealth visits included real-time videoconferencing between HPPs and patients and virtual check-ins (ie, brief communication with an HPP by telephone only). We conducted semistructured interviews with 40 oncology HPPs who implemented telehealth during COVID-19. The interviews were recorded, transcribed verbatim, and analyzed for themes using Dedoose software (version 4.12). RESULTS: Approximately half of the 40 participants were physicians (n=22, 55%), and one-quarter of the participants were advanced practice providers (n=10, 25%). Other participants included social workers (n=3, 8%), psychologists (n=2, 5%), dieticians (n=2, 5%), and a pharmacist (n=1, 3%). Five key themes were identified: (1) establishing and maintaining patient-HPP relationships, (2) coordinating care with other HPPs and informal caregivers, (3) adapting in-person assessments for telehealth, (4) developing workflows and allocating resources, and (5) future recommendations. Participants described innovative strategies for implementing telehealth, such as coordinating interdisciplinary visits with multiple HPPs and inviting informal caregivers (eg, spouse) to participate in telehealth visits. Health care workers discussed key challenges, such as workflow integration, lack of physical exam and biometric data, and overcoming the digital divide (eg, telehealth accessibility among patients with communication-related disabilities). Participants recommended policy advocacy to support telehealth (eg, medical licensure policies) and monitoring how telehealth affects patient outcomes and health care delivery. CONCLUSIONS: To support telehealth growth, implementation strategies are needed to ensure that HPPs and patients have the tools necessary to effectively engage in telehealth. At the same time, cancer care organizations will need to engage in advocacy to ensure that policies are supportive of oncology telehealth and develop systems to monitor the impact of telehealth on patient outcomes, health care quality, costs, and equity.

Association of Financial Factors and Telemedicine Adoption for Heart Attack and Stroke Care Among Rural and Urban Hospitals: A Longitudinal Study.

Introduction: To examine trends in telemedicine adoption for stroke and cardiac care among U.S. hospitals, specifically associations between hospital financial indicators and adoption of these telemedicine services. Methods: This is a retrospective analysis of data from the Health Information Management and System Society Dorenfest Database and Healthcare Cost Report Information System from 2012 to 2017. We used a pooled ordinary least squares model and reported results as average marginal effects (AMEs). Results: The number of hospitals with stroke or cardiac telemedicine services in urban and rural areas increased through our study period from 153 (7.30%) to 407 (19.42%) and from 127 (6.31%) to 331 (16.45%), respectively. In rural hospitals, being a for-profit hospital (AME = -10.49, 95% confidence interval [CI] = -14.01 to -6.98) and having an increase in Medicare inpatient mix (AME = -0.31, 95% CI = -0.42 to -0.20) were associated with the probability of telemedicine adoption for heart attack and stroke care. A couple of nonfinancial variables included in the model also were associated with adoption, specifically having one more licensed bed (AME = -0.02, 95% CI = -0.04 to -0.00) and higher number of emergency department visits (AME = 5.64, 95% CI = 2.83 to 7.20). In urban hospitals, being a for-profit hospital (AME = -8.94, 95% CI = -11.76 to -6.11) and having a higher total margin (AME = 0.17, 95% CI = 0.08 to 0.26) were associated with the probability of telemedicine adoption for heart attack and stroke care. Two nonfinancial variables also were statistically significant: having one more licensed bed (AME = 0.01, 95% CI = 0.041 to 0.02) and being closer to another telemedicine hospital (AME = 0.81, 95% CI = -1.62 to 0.01). Discussions: Telemedicine adoption rate for cardiac and stroke care has increased significantly in recent years. Financial status may be a bigger driver of adoption for urban hospitals than rural hospitals.

Impact of Asynchronous Electronic Communication-Based Visits on Clinical Outcomes and Health Care Delivery: Systematic Review.

BACKGROUND: Electronic visits (e-visits) involve asynchronous communication between clinicians and patients through a secure web-based platform, such as a patient portal, to elicit symptoms and determine a diagnosis and treatment plan. E-visits are now reimbursable through Medicare due to the COVID-19 pandemic. The state of evidence regarding e-visits, such as the impact on clinical outcomes and health care delivery, is unclear. OBJECTIVE: To address this gap, we examine how e-visits have impacted clinical outcomes and health care quality, access, utilization, and costs. METHODS: We conducted a systematic review; MEDLINE, Embase, and Web of Science were searched from January 2000 through October 2020 for peer-reviewed studies that assessed e-visits' impacts on clinical and health care delivery outcomes. RESULTS: Out of 1859 papers, 19 met the inclusion criteria. E-visit usage was associated with improved or comparable clinical outcomes, especially for chronic disease management (eg, diabetes care, blood pressure management). The impact on quality of care varied across conditions. Quality of care was equivalent or better for chronic conditions, but variable quality was observed in infection management (eg, appropriate antibiotic prescribing). Similarly, the impact on health care utilization varied across conditions (eg, lower utilization for dermatology but mixed impact in primary care). Health care costs were lower for e-visits than those for in-person visits for a wide range of conditions (eg, dermatology and acute visits). No studies examined the impact of e-visits on health care access. It is difficult to draw firm conclusions about effectiveness or impact on care delivery from the studies that were included because many used observational designs. CONCLUSIONS: Overall, the evidence suggests e-visits may provide clinical outcomes that are comparable to those provided by in-person care and reduce health care costs for certain health care conditions. At the same time, there is mixed evidence on health care quality, especially regarding infection management (eg, sinusitis, urinary tract infections, conjunctivitis). Further studies are needed to test implementation strategies that might improve delivery (eg, clinical decision support for antibiotic prescribing) and to assess which conditions can be managed via e-visits.

Association between adopting emergency department crowding interventions and emergency departments' core performance measures.

OBJECTIVES: To estimate the association between adopting emergency department (ED) crowding interventions and emergency departments' core performance measures. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2007 to 2015. The outcome variables are ED length of stay for discharged and admitted patients, boarding time, wait time and percentage of patients who left ED before being seen (LWBS). The independent variables are whether or not a hospital adopted each of the 20 crowding interventions. Controlling for patient-level, hospital level and temporal confounders we analyze and report results using multivariable logit model. RESULTS: Between 2007 and 2015, NHAMCS collected data for 269,721 ED visit encounters, representing a nationwide of about 1.18 billion separate ED visits. Of 20 crowding interventions we tested, using adopting bedside registration (OR = 0.89, 95% CI = 0.75-0.98, P < .05), electronic dashboard (OR = 0.86, 95% CI = 0.76-0.98, P < .05), kiosk check-in technology (OR = 0.56, 95% CI = 0.41-0.83, P < .001), physician based triage (OR = 0.86, 95% CI = 0.73-0.99, P < .05) full capacity protocol (OR = 0.91, 95% CI = 0.79-0.99, P < .05) are associated with decrease in the odds of prolonged wait time. Adopting kiosk check-in (OR = 0.55, 95% CI = 0.35-0.85, P < .05) is associated with a decrease in the odds of prolonged boarding time. Using wireless communication devices (OR = 0.77, 95% CI = 0.57-0.97, P < .05), bedside registration (OR = 0.77, 95% CI = 0.64-0.094, P < .05) and pooled nursing (OR = 0.84, 95% CI = 0.72-0.98, P < .05) are associated with decrease in the odds of a patient LWBS. CONCLUSIONS: Majority of interventions did not significantly associated with ED' core performance measures.

Patient Portal Barriers and Group Differences: Cross-Sectional National Survey Study.

BACKGROUND: Past studies examining barriers to patient portal adoption have been conducted with a small number of patients and health care settings, limiting generalizability. OBJECTIVE: This study had the following two objectives: (1) to assess the prevalence of barriers to patient portal adoption among nonadopters and (2) to examine the association between nonadopter characteristics and reported barriers in a nationally representative sample. METHODS: Data from this study were obtained from the 2019 Health Information National Trends Survey. We calculated descriptive statistics to determine the most prevalent barriers and conducted multiple variable logistic regression analysis to examine which characteristics were associated with the reported barriers. RESULTS: The sample included 4815 individuals. Among these, 2828 individuals (58.73%) had not adopted a patient portal. Among the nonadopters (n=2828), the most prevalent barriers were patient preference for in-person communication (1810/2828, 64.00%), no perceived need for the patient portal (1385/2828, 48.97%), and lack of comfort and experience with computers (735/2828, 25.99%). Less commonly, individuals reported having no patient portal (650/2828, 22.98%), no internet access (650/2828, 22.98%), privacy concerns (594/2828, 21.00%), difficulty logging on (537/2828, 18.99%), and multiple patient portals (255/2828, 9.02%) as barriers. Men had significantly lower odds of indicating a preference for speaking directly to a provider compared with women (odds ratio [OR] 0.75, 95% CI 0.60-0.94; P=.01). Older age (OR 1.01, 95% CI 1.00-1.02; P<.001), having a chronic condition (OR 1.83, 95% CI 1.44-2.33; P<.001), and having an income lower than US $20,000 (OR 1.61, 95% CI 1.11-2.34; P=.01) were positively associated with indicating a preference for speaking directly to a provider. Hispanic individuals had significantly higher odds of indicating that they had no need for a patient portal (OR 1.59, 95% CI 1.24-2.05; P<.001) compared with non-Hispanic individuals. Older individuals (OR 1.05, 95% CI 1.04-1.06; P<.001), individuals with less than a high school diploma (OR 3.15, 95% CI 1.79-5.53; P<.001), and individuals with a household income of less than US $20,000 (OR 2.78, 95% CI 1.88-4.11; P<.001) had significantly higher odds of indicating that they were uncomfortable with a computer. CONCLUSIONS: The most common barriers to patient portal adoption are preference for in-person communication, not having a need for the patient portal, and feeling uncomfortable with computers, which are barriers that are modifiable and can be intervened upon. Patient characteristics can help predict which patients are most likely to experience certain barriers to patient portal adoption. Further research is needed to tailor implementation approaches based on patients' needs and preferences.

Implementation Strategies for Telestroke: A Qualitative Study of Telestroke Networks in North Carolina.

Background: Telestroke services allow under-resourced hospitals to gain access to stroke specialists to improve the timeliness and quality of stroke care. However, limited research is available on how telestroke networks are developed, implemented, and sustained. Understanding the process of telestroke network implementation is critical for developing implementation guidance and for evaluating determinants of implementation effectiveness. Objective: This study examines the adoption decision process and strategies employed during telestroke network development, implementation, and sustainability. Research Design: We interviewed representatives from five telestroke networks in North Carolina. Each network consisted of a distant site from which stroke consultation was provided and multiple originating sites at which the patient presented. Subjects: The sample included 24 telestroke representatives (i.e., 5 network representatives and 19 hospital representatives) and 4 hospital representatives who do not participate in telestroke (i.e., nonadopters). Measures: The qualitative measures used in this study were based on Roger's stages of the innovation process in organizations. Stages included agenda setting and matching (pre-implementation), restructuring, redefining, and clarifying (implementation), and routinizing (sustainability). Results: Distant and originating sites employed various strategies in the pre-implementation, implementation, and sustainability stages. Although there are many commonalities across networks, there are also important differences, for example in terms of network structure, quality monitoring, and performance feedback. Some nonadopter hospitals reported difficulty accessing information about telestroke, suggesting that some hospitals are not reached by telestroke network marketing efforts. Conclusions: Identifying and/or tailoring strategies to support the needs of hospitals in different telestroke network models should be a priority for future research.

Telehealth Interventions Designed for Women: an Evidence Map.

BACKGROUND: Telehealth employs technology to connect patients to the right healthcare resources at the right time. Women are high utilizers of healthcare with gender-specific health issues that may benefit from the convenience and personalization of telehealth. Thus, we produced an evidence map describing the quantity, distribution, and characteristics of evidence assessing the effectiveness of telehealth services designed for women. METHODS: We searched MEDLINE® (via PubMed®) and Embase® from inception through March 20, 2018. We screened systematic reviews (SRs), randomized trials, and quasi-experimental studies using predetermined eligibility criteria. Articles meeting inclusion criteria were identified for data abstraction. To assess emerging trends, we also conducted a targeted search of ClinicalTrials.gov . RESULTS: Two hundred thirty-four primary studies and three SRs were eligible for abstraction. We grouped studies into focused areas of research: maternal health (n = 96), prevention (n = 46), disease management (n = 63), family planning (n = 9), high-risk breast cancer assessment (n = 10), intimate partner violence (n = 7), and mental health (n = 3). Most interventions focused on phone as the primary telehealth modality and featured healthcare team-to-patient communication and were limited in duration (e.g., < 12 weeks). Few interventions were conducted with older women (≥ 60 years) or in racially/ethnically diverse populations. There are few SRs in this area and limited evidence regarding newer telehealth modalities such as mobile-based applications or short message service/texting. Targeted search of clinical.trials.gov yielded 73 ongoing studies that show a shift in the use of non-telephone modalities. DISCUSSION: Our systematic evidence map highlights gaps in the existing literature, such as a lack of studies in key women's health areas (intimate partner violence, mental health), and a dearth of relevant SRs. With few existing SRs in this literature, there is an opportunity for examining effects, efficiency, and acceptability across studies to inform efforts at implementing telehealth for women.

Medical Ethics in Qisas (Eye-for-an-Eye) Punishment: An Islamic View; an Examination of Acid Throwing.

Physicians in Islamic countries might be requested to participate in the Islamic legal code of qisas, in which the victim or family has the right to an eye-for-an-eye retaliation. Qisas is only used as a punishment in the case of murder or intentional physical injury. In situations such as throwing acid, the national legal system of some Islamic countries asks for assistance from physicians, because the punishment should be identical to the crime. The perpetrator could not be punished without a physician's participation, because there is no way to guarantee that the sentence would be carried out without inflicting more injury than the initial victim had suffered. By examining two cases of acid throwing, this paper discusses issues related to physicians' participation in qisas from the perspective of medical ethics and Islamic Shari'a law. From the standpoint of medical ethics, physicians' participation in qisas is not appropriate. First, qisas is in sharp contrast to the Hippocratic Oath and other codes of medical ethics. Second, by physicians' participation in qisas, medical practices are being used improperly to carry out government mandates. Third, physician participation in activities that cause intentional harm to people destroys the trust between patients and physicians and may adversely affect the patient-physician relationship more generally. From the standpoint of Shari'a, there is no consensus among Muslim scholars whether qisas should be performed on every occasion. We argue that disallowing physician involvement in qisas is necessary from the perspectives of both medical ethics and Shari'a law.

Assessing the Validity of the Centers for Medicare & Medicaid Services Measure in Identifying Potentially Preventable Emergency Department Visits by Patients With Cancer.

PURPOSE: The Centers for Medicare & Medicaid Services (CMS) implemented chemotherapy measures (OP-35) to reduce potentially preventable emergency department visits (PPEDVs) and hospitalizations. This study evaluated the validity of the OP-35 measure in identifying PPEDVs among patients with cancer. METHODS: This is a cross-sectional study, which used data from the 2012-2022 National Hospital Ambulatory Medical Care Survey. ED visits are assessed and compared on the basis of three measures: immediacy using Emergency Severity Index (ESI), disposition (discharge v hospitalization), and OP-35 criteria. RESULTS: Between 2012 and 2022, a weighted sample of 46,723,524 ED visits were made by patients with cancer. Among reported ESI cases, 25.2% (8,346,443) was high urgency. In addition, 30.3% (14,135,496) of ED visits among patients with cancer led to hospitalizations. Using the OP-35 measure, it was found that 20.85% (9,743,977) was PPEDVs. A 21.9% (10,232,102) discrepancy between discharge diagnosis (CMS billing codes) and chief complaints was identified. Further analysis showed that 19.2% (1,872,556) of potentially preventable ED visits (CMS OP-35) were high urgency and 32.6% (3,181,280) resulted in hospitalization. CONCLUSION: The CMS approach to identifying PPEDVs has limitations. First, it may overcount preventable visits by including high-urgency or hospitalization-requiring cases. Second, relying on final diagnoses for retrospective preventability judgment can be misleading as they may not reflect the initial reason for the visit. In addition, differentiating causes for ED visits in patients with cancer undergoing various treatments is challenging as the approach does not distinguish between chemotherapy-related complications and others. Identification inconsistencies arise because of varying coding practices and chosen preventable conditions, lacking consensus and alignment with specific hospital or patient needs. Finally, the model fails to consider crucial nonclinical factors like social support, economic barriers, and alternative care access, potentially unfairly penalizing hospitals serving underserved populations.

Mental healthcare access among US adults with vision impairment and depression and/or anxiety symptoms.

BACKGROUND: Although individuals with vision impairment are at greater risk for depression and anxiety, there has been limited study of mental healthcare utilization among this population. OBJECTIVES: To address this gap, this pooled cross-sectional study estimates the prevalence of mental healthcare utilization among individuals with vision impairment during the COVID-19 pandemic. METHODS: We calculated adjusted relative risk ratios and 95% confidence intervals of depression and/or anxiety symptoms and mental healthcare utilization using multinomial logistic regression, accounting for demographics, social determinants of health, and survey week. The population-based, U.S. Census Bureau Household Pulse Survey was administered April 2021-March 2022. Participants included 800,935 US adults (weighted population: 174,598,530) RESULTS: Adjusting for other factors, adults with vision impairment were more likely to report depression symptoms (RRR: 2.33; 95% CI: 2.03-2.68), anxiety symptoms (RRR: 2.12; 95% CI: 1.94-2.33, and comorbid depression and anxiety symptoms (RRR: 3.77; 95% CI: 3.51-4.04) compared with individuals with no vision impairment. Among individuals reporting anxiety or depression symptoms, individuals with vision impairment (RRR: 1.46; 95% CI: 1.35-1.59) were more likely to lack of mental healthcare utilization compared with individuals with no vision impairment. CONCLUSION: Findings suggest that individuals with vision impairment are at increased risk for depression and/or anxiety symptoms and report reduced mental healthcare utilization compared with individuals without vision impairment. Additional programs and policies are needed to improve mental healthcare utilization among individuals with vision impairment and depression and/or anxiety symptoms, such as increased telehealth accessibility and coordination of behavioral health and ophthalmology services.

Electronic Health Record Nudges and Health Care Quality and Outcomes in Primary Care: A Systematic Review.

Importance: Nudges have been increasingly studied as a tool for facilitating behavior change and may represent a novel way to modify the electronic health record (EHR) to encourage evidence-based care. Objective: To evaluate the association between EHR nudges and health care outcomes in primary care settings and describe implementation facilitators and barriers. Evidence Review: On June 9, 2023, an electronic search was performed in PubMed, Embase, PsycINFO, CINAHL, and Web of Science for all articles about clinician-facing EHR nudges. After reviewing titles, abstracts, and full texts, the present review was restricted to articles that used a randomized clinical trial (RCT) design, focused on primary care settings, and evaluated the association between EHR nudges and health care quality and patient outcome measures. Two reviewers abstracted the following elements: country, targeted clinician types, medical conditions studied, length of evaluation period, study design, sample size, intervention conditions, nudge mechanisms, implementation facilitators and barriers encountered, and major findings. The findings were qualitatively reported by type of health care quality and patient outcome and type of primary care condition targeted. The Risk of Bias 2.0 tool was adapted to evaluate the studies based on RCT design (cluster, parallel, crossover). Studies were scored from 0 to 5 points, with higher scores indicating lower risk of bias. Findings: Fifty-four studies met the inclusion criteria. Overall, most studies (79.6%) were assessed to have a moderate risk of bias. Most or all descriptive (eg, documentation patterns) (30 of 38) or patient-centeredness measures (4 of 4) had positive associations with EHR nudges. As for other measures of health care quality and patient outcomes, few had positive associations between EHR nudges and patient safety (4 of 12), effectiveness (19 of 48), efficiency (0 of 4), patient-reported outcomes (0 of 3), patient adherence (1 of 2), or clinical outcome measures (1 of 7). Conclusions and Relevance: This systematic review found low- and moderate-quality evidence that suggested that EHR nudges were associated with improved descriptive measures (eg, documentation patterns). Meanwhile, it was unclear whether EHR nudges were associated with improvements in other areas of health care quality, such as effectiveness and patient safety outcomes. Future research is needed using longer evaluation periods, a broader range of primary care conditions, and in deimplementation contexts.

Trends and Characteristics of Potentially Preventable Emergency Department Visits Among Patients With Cancer in the US.

Importance: An initial step to reducing emergency department (ED) visits among patients with cancer is to identify the characteristics of patients visiting the ED and examine which of those visits could be prevented. Objective: To explore nationwide trends and characteristics of ED visits and examine factors associated with potentially preventable ED visits and unplanned hospitalizations among patients with cancer in the US. Design, Setting, and Participants: This cross-sectional study used data on ED visits from the National Hospital Ambulatory Medical Care Survey from January 1, 2012, to December 31, 2019; US Cancer Statistics reports were used to estimate new cancer cases each year. Frequencies and trends among 35 510 014 ED visits by adult patients (aged ≥18 years) with cancer were calculated. Main Outcomes and Measures: The primary outcome was potentially preventable ED visits, and secondary outcomes were unplanned hospitalizations and the immediacy of the ED visits. Potentially preventable ED visits were identified using the Centers for Medicare & Medicaid Services definition. The Emergency Severity Index, a triage algorithm that ranks patients based on the urgency of their health care condition, was used to measure the immediacy of ED visits (immediate [most urgent], emergent, urgent, less urgent, and nonurgent), with the categories of immediate and emergent classified as high acuity. The Wilcoxon rank sum test was used to calculate trends in ED visits among patients with cancer over time. Multivariable logistic regression analyses were performed to examine the associations of patient, hospital, and temporal factors with potentially preventable ED use and ED use resulting in hospitalization. Results: Among 854 911 106 ED visits, 35 510 014 (4.2%) were made by patients with cancer (mean [SD] age, 66.2 [16.2] years); of those, 55.2% of visits were among women, 73.2% were among non-Hispanic White individuals, 89.8% were among patients living in a private residence, and 54.3% were among Medicare enrollees. A total of 18 316 373 ED visits (51.6%) were identified as potentially preventable, and 5 770 571 visits (21.3%) were classified as high acuity. From 2012 to 2019, potentially preventable ED visits increased from 1 851 692 to 3 214 276. Pain (36.9%) was the most common reason for potentially preventable ED visits. The number of patients who visited an ED because of pain increased from 1 192 197 in 2012 to 2 405 849 in 2019 (a 101.8% increase). Overall, 28.9% of ED visits resulted in unplanned hospitalizations, which did not change significantly over time (from 32.2% in 2012 to 26.6% in 2019; P = .78 for trend). Factors such as residence in a nursing home (odds ratio, 1.73; 95% CI, 1.25-2.41) were positively associated with having a potentially preventable ED visit, and factors such as the presence of more than 1 comorbidity (odds ratio, 1.82; 95% CI, 1.43-2.32) were positively associated with having an unplanned hospitalization. Conclusions and Relevance: In this study, 51.6% of ED visits among patients with cancer were identified as potentially preventable, and the absolute number of potentially preventable ED visits increased substantially between 2012 and 2019. These findings highlight the need for cancer care programs to implement evidence-based interventions to better manage cancer treatment complications, such as uncontrolled pain, in outpatient and ambulatory settings.

Clinical trial knowledge among U.S. adults aged 65 years and up: Findings from a 2020 national survey.

BACKGROUND: Older adults are underrepresented in most clinical trials. As the United States observes growth in the number of older adults over time, it will be critical to include them in clinical trials to improve the generalizability of results across age groups. Although clinical trial participation requires clinical trial knowledge, no study has assessed clinical trial knowledge among older adults. Using a national survey, this study aims to identify the prevalence and determinants of clinical trial knowledge among older adults. METHODS: We used the 2020 Health Information National Trends Survey for secondary data analysis. We restricted the sample to older adults (aged 65 years and up). Our outcome variable was whether respondents reported having any clinical trial knowledge. We controlled for demographics, social determinants of health, healthcare utilization, and comorbidities through multivariable logistic regression models. RESULTS: Using a weighted sample of 27,574,958 adults, we estimated that 61.1% of older adults reported having at least some knowledge of clinical trials. After controlling for other factors, those with one to two (OR = 1.80, 95% CI:1.14-2.84) or three to five (OR = 2.93, 95% CI:1.74-4.95) portal visits compared with no portal visits, those with cancer (OR = 1.92, 95% CI:1.22-3.02), and those with depression (OR = 2.27, 95% CI:1.23-4.20) had greater odds of having clinical trial knowledge. Inversely, those with hypertension (OR = 0.62, 95% CI:0.42-0.92) had lower odds of clinical trial knowledge. CONCLUSIONS: Patient portal recruitment may be a supplemental intervention to improve clinical trial knowledge among older adults. Further research on additional interventions for identifying eligible participants is needed to minimize the burden among clinicians amidst other competing demands during clinic visits.

Estimated Carbon Emissions Savings With Shifts From In-Person Visits to Telemedicine for Patients With Cancer.

Importance: While the health care community advocates broadly for climate change policy, medical professionals can look within care practices to assess their contribution to carbon dioxide (CO2) emissions, and provide solutions wherever possible. Telemedicine can help in mitigating climate change by providing care from a distance. Objective: To assess the carbon savings achieved from telemedicine visits. Design, Setting, and Participants: This cross-sectional study of telemedicine visits was conducted at a single-institution National Cancer Institute (NCI)-designated comprehensive cancer center. Eligible patients were aged 18 years and above, completed telemedicine visits from April 1, 2020, to June 20, 2021, and had a Florida mailing address documented in their electronic medical record. Groups were divided between those within driving time of 60 minutes (1-way) to the cancer center vs those living beyond 60 minutes of drive time. Data were analyzed between April 2020 and June 2021. Main Outcomes and Measures: Carbon emission savings from telemedicine, measured in total and average per-visit savings. Results: A total 49 329 telemedicine visits with 23 228 patients were conducted from April 1, 2020, to June 30, 2021. A total 21 489 visits were for patients with driving time of 60 minutes or less (median [IQR] age, 62.0 [52.0-71.0] years; 12 334 [57.4%] female; 1685 [7.8%] Black, 1500 [7.0%] Hispanic, 16 010 [74.5%] non-Hispanic White), while 27 840 visits were for patients with driving time greater than 60 minutes (median [IQR] age, 67.0 [57.0-74.0] years; 14 372 [51.6%] female; 1056 [3.8%] Black, 1364 [5.0%] Hispanic, 22 457 [80.7%] non-Hispanic White). For patients living within a driving time of 60 minutes from the cancer center, 424 471 kg CO2 emissions were saved (mean [SD] emissions savings, 19.8 [9.4] kg CO2 per visit) due to telemedicine-equivalent to 91.5 passenger vehicles driven for 1 year. For patients whose driving distance was greater than 60 minutes, 2 744 248 kg CO2 emissions were saved (mean emissions savings, 98.6 [54.8] kg CO2 per visit)-equivalent to 591 passenger vehicles driven for 1 year. Conclusions and Relevance: Using a large data set, this cross-sectional analysis highlighted the carbon emissions savings due to telemedicine in oncology. This has important implications in reducing health care-related carbon footprint.

Merit-based incentive payment system participation and after-hours documentation among US office-based physicians: Findings from the 2021 National Electronic Health Records Survey.

BACKGROUND: After-hours documentation burden among US clinicians is often uncompensated work and has been associated with burnout, leading health systems to identify root causes and seek interventions to reduce this. A few studies have suggested quality programme participation (e.g., Merit-Based Incentive Payment System [MIPS]) was associated with a higher administrative burden. However, the association between MIPS participation and after-hours documentation has not been fully explored. Thus, this study aims to assess whether participation in the MIPS programme was independently associated with after-hours documentation burden. METHODS: We used 2021 data from the National Electronic Health Records Survey. We used a multivariable ordinal logistic regression model to assess whether MIPS participation was associated with the amount of after-hours documentation burden when controlling for other factors. We controlled for physician age, specialty, sex, number of practice locations, number of physicians, practice ownership, whether team support (e.g., scribes) is used for documentation tasks, and whether the practice accepts Medicaid patients. RESULTS: We included 1801 office-based US physician respondents with complete data for variables of interest. After controlling for other factors, MIPS participation was associated with greater odds of spending a greater number of hours on after-hours documentation (odds ratio = 1.44, 95% confidence interval 1.06-1.95). CONCLUSIONS: MIPS participation may increase after-hours documentation burden among US office-based physicians, suggesting that physicians may require additional resources to more efficiently report data.