Patient Experience Scores for Radiologists: Comparison With Nonradiologist Physicians and Changes After Public Posting in an Institutional Online Provider Directory.

BACKGROUND. Patients are increasingly using online information regarding patient experiences to guide care decisions. OBJECTIVE. The purpose of our study was to compare patient experience scores between radiologists and nonradiologist physicians and to assess changes in scores after their public posting in an online physician directory. METHODS. This retrospective study included data collected from May 1, 2017, to November 30, 2018, at a single large academic medical center. After all institutional outpatient visits, patients were e-mailed the Press Ganey Medical Practice Survey, which included 10 questions (answered using a Likert scale and converted to 100-point range) relating to the patient's experience with the specific provider for the encounter. Surveys were distributed to patients after radiology encounters if involving an image-guided invasive procedure. Mean scores for each question and the mean weighted overall score were displayed on each physician's publicly available profile on the hospital's online physician directory and were updated monthly. Scores were compared between radiologists and nonradiologist physicians; temporal changes were assessed. RESULTS. The response rate was 18.0% (96,057/533,983). After exclusions (23,989 surveys completed without provider ratings; 183 surveys evaluating physician assistants), 71,885 physician surveys were evaluated: 2703 surveys for 65 radiologists, 49,403 surveys for 916 physicians in 17 nonsurgical specialties, and 19,779 surveys for 262 physicians in 13 surgical specialties. Over the study period, the mean overall score was 95.6 for radiologists and 95.9 for nonradiologists (94.6 for surgical specialties, 96.4 for nonsurgical specialties). For the 10 individual questions, scores ranged for radiologists from 94.6 (time spent with patient) to 96.8 (friendliness/courtesy) and for nonradiologists from 94.6 (time spent with patient) to 97.0 (friendliness/courtesy). The mean overall score increased from the first month to the final month for radiologists from 94.2 to 97.1 and for nonradiologists from 95.7 to 96.3. For radiologists, the largest improvement was for instructions regarding postprocedure follow-up care (increased from 91.4 to 97.4). CONCLUSION. Radiologists received high scores on patient experience surveys when evaluated on encounters involving invasive procedures, achieving scores similar to those for other physicians. Scores improved over time, possibly related to online posting of survey results. CLINICAL IMPACT. The findings support the utility of implementing patient experience surveys in radiology.

Low Risk of Coronavirus Disease 2019 (COVID-19) Among Patients Exposed to Infected Healthcare Workers.

Many patients are fearful of acquiring coronavirus disease 2019 (COVID-19) in hospitals and clinics. We characterized the risk of COVID-19 among 226 patients exposed to healthcare workers with confirmed COVID-19. One patient may have been infected, suggesting that the risk of COVID-19 transmission from healthcare workers to patients is generally low.

Capturing anaphylaxis through medical records: Are ICD and CPT codes sufficient?

OBJECTIVE: The identification of anaphylaxis cases is imperative for optimal clinicalprovider knowledge deficiencies in diagnosis and treatment and the efficacy of reimbursement codes, such as International Classification of Diseases (ICD) and current procedural terminology (CPT) codes, in detecting anaphylaxis. DATA SOURCES: Pubmed. STUDY SELECTIONS: Recent and clinically relevant literature on anaphylaxis and provider knowledge, ICD, CPT, Healthcare Common Procedural Coding System (HCPCS), and E-codes were selected and reviewed. RESULTS: Reimbursement codes are used to detect anaphylaxis in administrative claims databases. Inaccurate recognition of the diagnosis by providers, underreporting, and cause identification are challenges faced by health researchers using reimbursement codes for anaphylaxis case identification. Anaphylactic shock-specific ICD codes were noted to have a positive predictive value (PPV) of 52% to 53% of anaphylaxis events compared with physician chart review, which was improved to 63% to 67.3% when used in conjunction with anaphylaxis symptom-specific ICD, CPT, HCPCS, and E-codes 31, 34, and 35. CONCLUSION: Education of providers to properly diagnose and treat anaphylaxis requires systematic and educational investments. The ICD codes specific to anaphylactic shock have suboptimal PPV to identify anaphylaxis in administrative claims databases. Use of algorithms incorporating other reimbursement codes improve the PPV, but they are limited by inaccurate diagnoses and underreporting of anaphylaxis. Future ICD-11 reclassification may improve anaphylaxis detection by reimbursement codes.

Improving Patient Experience in Radiology: Impact of a Multifaceted Intervention on National Ranking.

Purpose To assess the impact of a patient experience improvement program on national ranking in patient experience in a large academic radiology department. Materials and Methods This Health Insurance Portability and Accountability Act-compliant study was exempted from institutional review board approval. After initiating an electronic patient experience survey, 26 210 surveys and 22 213 comments were received from May 2017 to April 2018. During the study period, a multifaceted quality improvement initiative was instituted, focused on improving patient experience in the radiology department. The primary outcome was national percentile ranking as measured with the survey. Secondary outcome was the change in departmental percentile ranking compared with the overall hospital ranking for patient experience measured with a similar survey. Results The overall raw score for the department increased from 92.8 to 93.6 of 100 (P < .001), and the national ranking improved from the 35th to 50th percentile (P = .001). Improvements in raw scores related to personnel were primarily responsible for the increase in overall raw score and ranking. Of the 22 213 comments received, 3458 (15.6%) were negative. The percentage of negative comments was highly correlated with lower monthly percentile ranking (Pearson correlation coefficient of -0.69; P = .01). Conclusion It is feasible to develop a large-scale electronic survey to assess patient experience in the radiology department, to identify improvement opportunities, and to measurably improve patient experience. Changes in the percentage of negative comments were correlated with changes in a practice's national percentile rank in patient experience. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Kruskal and Sarwar in this issue.

An Internet of Things Buttons to Measure and Respond to Restroom Cleanliness in a Hospital Setting: Descriptive Study.

BACKGROUND: Restroom cleanliness is an important factor in hospital quality. Due to its dynamic process, it can be difficult to detect the presence of dirty restrooms that need to be cleaned. Using an Internet of Things (IoT) button can permit users to designate restrooms that need cleaning and in turn, allow prompt response from housekeeping to maintain real-time restroom cleanliness. OBJECTIVE: This study aimed to describe the deployment of an IoT button-based notification system to measure hospital restroom cleanliness reporting system usage and qualitative feedback from housekeeping staff on IoT button use. METHODS: We deployed IoT buttons in 16 hospital restrooms. Over an 8-month period, housekeeping staff received real-time notifications and responded to button presses for restroom cleaning. All button presses were recorded. We reported average button usage by hospital area, time of day, and day of week. We also conducted interviews with housekeeping supervisors and staff to understand their acceptance of and experience with the system. RESULTS: Over 8 months, 1920 requests to clean restrooms in the main hospital lobby and satellite buildings were received. The hospital lobby IoT buttons received over half (N=1055, 55%) of requests for cleaning. Most requests occurred in afternoon hours from 3 PM to midnight. Requests for cleaning remained stable throughout the work week with fewer requests occurring over weekends. IoT button use was sustained throughout the study period. Interviews with housekeeping supervisors and staff demonstrated acceptance of the IoT buttons; actual use was centered around asynchronous communication between supervisors and staff in response to requests to clean restrooms. CONCLUSIONS: An IoT button system is a feasible method to generate on-demand request for restroom cleaning that is easy to deploy and that users will consistently engage with. Data from this system have the potential to enable responsive scheduling for restroom service and anticipate periods of high restroom utilization in a hospital.

Clinical Features of Hereditary Angioedema in Korean Patients: A Nationwide Multicenter Study.

BACKGROUND: Hereditary angioedema (HAE) is a genetically heterogeneous autosomal dominant disorder characterized by recurrent episodes of nonpruritic, nonpitting edema increasing after puberty. It can be fatal due to laryngeal or gastrointestinal (GI) involvement with varied and changing frequency of mortality according to studies published from the Western countries. Epidemiological and clinical data of HAE in Asian countries are sparse. We sought to examine the clinical characteristics of HAE patients in Korea. METHODS: Patients diagnosed with HAE at 15 tertiary hospitals across the country until 2016 were retrospectively reviewed. RESULTS: A total of 65 patients diagnosed with HAE by 2016 were identified. The prevalence of HAE was estimated at 1.3/1,000,000 in Korea. Of the 65 patients, 21 (32.3%) were males. A total of 90.8% patients had type I HAE, while the remaining 9.2% patients had type II HAE. The first symptom developed after 20 years in 73.8% of patients, with a mean age 28.4 ± 14.1 years. The age at diagnosis was 36.5 ± 15.8 years, with a mean time delay of 7.8 ± 10.5 years. While the face (82.3%) and extremities (upper 71.0%, lower 62.9%) were the most frequently involved, the GI tract was affected in 40.5% of Korean HAE patients. Prophylaxis was maintained in 62.5% of patients. There was no reported case of death from HAE so far. CONCLUSIONS: The clinical manifestation and severity of HAE may vary according to ethnicity. HAE is more infrequent and GI involvement is less likely in Korea compared with Western countries.

Automated identification of an aspirin-exacerbated respiratory disease cohort.

BACKGROUND: Aspirin-exacerbated respiratory disease (AERD) is characterized by 3 clinical features: asthma, nasal polyposis, and respiratory reactions to cyclooxygenase-1 inhibitors (nonsteroidal anti-inflammatory drugs). Electronic health records (EHRs) contain information on each feature of this triad. OBJECTIVE: We sought to determine whether an informatics algorithm applied to the EHR could electronically identify patients with AERD. METHODS: We developed an informatics algorithm to search the EHRs of patients aged 18 years and older from the Partners Healthcare system over a 10-year period (2004-2014). Charts with search terms for asthma, nasal polyps, and record of respiratory (cohort A) or unspecified (cohort B) reactions to nonsteroidal anti-inflammatory drugs were identified as "possible AERD." Two clinical experts reviewed all charts to confirm a diagnosis of "clinical AERD" and classify cases as "diagnosed AERD" or "undiagnosed AERD" on the basis of physician-documented AERD-specific terms in patient notes. RESULTS: Our algorithm identified 731 "possible AERD" cases, of which 638 were not in our AERD patient registry. Chart review of cohorts A (n = 511) and B (n = 127) demonstrated a positive predictive value of 78.4% for "clinical AERD," which rose to 88.7% when unspecified reactions were excluded. Of those with clinical AERD, 12.4% had no mention of AERD by any treating caregiver and were classified as "undiagnosed AERD." "Undiagnosed AERD" cases were less likely than "diagnosed AERD" cases to have been seen by an allergist/immunologist (38.7% vs 93.2%; P < .0001). CONCLUSIONS: An informatics algorithm can successfully identify both known and previously undiagnosed cases of AERD with a high positive predictive value. Involvement of an allergist/immunologist significantly increases the likelihood of an AERD diagnosis.

Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship.

BACKGROUND: Reported penicillin allergy rarely reflects penicillin intolerance. Failure to address inpatient penicillin allergies results in more broad-spectrum antibiotic use, treatment failures, and adverse drug events. OBJECTIVE: We aimed to determine the optimal approach to penicillin allergies among medical inpatients. METHODS: We evaluated internal medicine inpatients reporting penicillin allergy in 3 periods: (1) standard of care (SOC), (2) penicillin skin testing (ST), and (3) computerized guideline application with decision support (APP). The primary outcome was use of a penicillin or cephalosporin, comparing interventions to SOC using multivariable logistic regression. RESULTS: There were 625 patients: SOC, 148; ST, 278; and APP, 199. Of 278 ST patients, 179 (64%) were skin test eligible; 43 (24%) received testing and none were allergic. In the APP period, there were 292 unique Web site views; 112 users (38%) completed clinical decision support. Although ST period patients did not have increased odds of penicillin or cephalosporin use overall (adjusted odds ratio [aOR] 1.3; 95% CI, 0.8-2.0), we observed significant increased odds of penicillin or cephalosporin use overall in the APP period (aOR, 1.8; 95% CI, 1.1-2.9) and in a per-protocol analysis of the skin tested subset (aOR, 5.7; 95% CI, 2.6-12.5). CONCLUSIONS: Both APP and ST-when completed-increased the use of penicillin and cephalosporin antibiotics among inpatients reporting penicillin allergy. While the skin tested subset showed an almost 6-fold impact, the computerized guideline significantly increased penicillin or cephalosporin use overall nearly 2-fold and was readily implemented.

Immune-mediated reactions to vancomycin: A systematic case review and analysis.

BACKGROUND: Vancomycin is a broad-spectrum antibiotic whose use may be limited by adverse drug reactions (ADRs). Although vancomycin toxic effects are known, there are limited data on vancomycin hypersensitivity reactions (HSRs). OBJECTIVE: To understand the most commonly reported vancomycin HSRs through systematic case review. METHODS: We performed a literature search for English-language case reports and series from 1982 through 2015 (last search July 31, 2015) on Ovid MEDLINE and PubMed. The search included the subject heading vancomycin with the subheading adverse effects and separate text searches for vancomycin with a list of specified HSRs. References of identified articles were reviewed to find additional articles. Clinical data were collected and summarized. RESULTS: Of 201 identified articles, 84 were screened and 57 fully assessed; these 57 articles contained 71 vancomycin HSR cases that were included in analysis. Vancomycin HSRs were immediate (anaphylaxis, n = 7) and nonimmediate (n = 64). Nonimmediate HSRs included linear IgA bullous dermatosis (LABD, n = 34), drug rash eosinophilia and systemic symptoms (DRESS) syndrome (n = 16), acute interstitial nephritis (AIN, n = 8), and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN, n = 6). Median times of vancomycin therapy before HSR onset was 7 days (interquartile range [IQR], 4-10 days) for LABD, 9 days (IQR, 9-22 days) for SJS/TEN, 21 days (IQR, 17-28 days) for DRESS syndrome, and 26 days (IQR, 7-29 days) for AIN. Overall, 11 patients (16%) died, and 4 (6%) had deaths attributed to the HSR. CONCLUSION: Vancomycin causes a variety of HSRs; the most commonly identified were nonimmediate HSRs, with LABD being most frequent. We observed a high frequency of HSR mortality. Further data are needed to understand the frequency and severity of vancomycin HSRs.

Immediate Drug Hypersensitivity.

Drug allergy affects a large percentage of the general population. A listed drug allergy can also have broad implications for many aspects of patient care. Here, we will review recent advances in the arena of drug allergies with a focus on antibiotics, monoclonals, NSAIDs, and chemotherapeutics.

At-home hemoglobin A1c testing during COVID-19 improved glycemic control.

OBJECTIVES: COVID-19 has exacerbated barriers to routine testing for chronic disease management. This study investigates whether a home hemoglobin A1c (HbA1c) test kit intervention increases frequency of HbA1c testing and leads to changes in HbA1c 6 months post testing and whether self-reinforcement education improves maintenance of HbA1c testing. STUDY DESIGN: Retrospective analysis of a randomized, controlled quality improvement intervention among members with type 2 diabetes (T2D) in a large commercial health plan. METHODS: Participants were 41,214 commercial fully insured members with T2D without an HbA1c test in the past 6 months or with only 1 HbA1c test in the last 12 months. Members were randomly assigned to either a control group or an at-home HbA1c testing intervention group consisting of either an opt-in test or a direct-to-member opt-out HbA1c test kit shipment. A third cohort of members was assigned to a self-reinforcement group to encourage continued testing twice per year. Main outcomes were HbA1c testing rates and HbA1c levels (in %). RESULTS: A total of 11.1% (508 of 4590) at-home HbA1c kits were completed. At-home HbA1c test kits increased testing rates by 4.9% compared with controls (P < .001). Members with an HbA1c level of at least 7% who requested and completed at-home HbA1c testing had a 0.38% reduction in HbA1c in the 6 months post intervention when controlling for baseline HbA1c (P < .001). Members who received self-reinforcement messaging had a 0.37% HbA1c reduction post intervention (P = .015). CONCLUSIONS: This novel, at-home approach to test HbA1c is an effective intervention to increase testing rates and facilitate HbA1c reduction over time in patients with T2D.

Development of a Pipeline for Removing Allergy Labels in Patients Undergoing Hematopoietic Stem Cell Transplantation.

Penicillin allergy is reported by 10% to 20 % of patients, but when evaluated only 1% to 2% may have a true allergy. Patients undergoing hematopoietic stem cell transplantation (HSCT) have a high likelihood of requiring beta-lactam antibiotics due to increased infection risk, which can be limited by a penicillin allergy label. When a penicillin allergy is recorded, alternatives are needed, including more expensive broader-spectrum antibiotics, with increases in drug-resistant bacteria, longer hospital stays, higher expenditures, and increases in nosocomial infections, such as Clostridium difficile colitis. This group of patients already undergoes extensive pretreatment testing and would especially benefit from allergy delabeling. This study aimed to develop a self-sustaining, low-cost pipeline between an HSCT clinic and an allergy clinic to identify and successfully delabel low-risk patients who endorse an allergy to penicillin, amoxicillin, amoxicillin-clavulanate, piperacillin-tazobactam, or ampicillin before admission to the hospital. We developed a survey to triage allergy risk, identified key stakeholders in building the pipeline, and underwent 4 plan, do, study, act (PDSA) cycles. Changes were made in each of the PDSA cycles to minimize cost and uncompensated provider time, as well as to increase patient retention throughout the pipeline by increasing appointment availability and decreasing reliance on patients to independently progress through the pathway. Of the 410 patients with planned HSCT who were screened over 11 months, 89 (21.7%) were listed as having a penicillin and/or beta lactam allergy. All but 1 (66 of 67; 98.5%) of the participants completed the survey accurately when confirmed by an allergist, and the survey was 100% accurate in predicting delabeling success in low-risk patients. Of eligible patients, 43.8% (n = 39) were successfully delabeled before their transplant date, and 97.4% of these (n = 38) have undergone HSCT to date. This pipeline is maintained by approximately 5 hours of work per week (1 hour of allergy physician time, 4 hours of nurse and/or clinical coordinator time), with no other direct costs. There is an estimated direct savings of at least $1914.93 per patient delabeled. We successfully designed and implemented a pipeline between the HSCT clinic and the allergy clinic as a quality improvement initiative to identify and address high rates of reported beta-lactam allergies. We identified and addressed patient-based factors, logistical, temporal, and financial barriers that impacted patient retention and sustainability. This model is expected to yield significant and sustained cost savings for the healthcare system as well as to improve patient outcomes, and this hypothesis is currently undergoing formal analysis. We anticipate that this model can be used to create a similar pipeline in other healthcare systems for HSCT recipients, as well as patients in other clinical settings, such as oncology and chimeric antigen receptor T cell therapy.

How Likes and Retweets Impacted Our Patients During the COVID-19 Pandemic.

The growing dependence on social media for health-related information boomed during the COVID-19 pandemic, posing unprecedented challenges in navigating the vast amounts of information available right at our fingertips. Social media had a major impact on clinical decision-making affecting individuals, communities, and societies at large. In this review, we discuss the role of social media in amplifying information and misinformation as well as factors contributing to its reliance and prevalence. We review how medical providers have been impacted by this changing landscape, useful communication strategies to employ with in-office patient encounters, and how we can be active players in using social media as a tool for health promotion, correcting misinformation, and preparing for future pandemics.

Ambulatory Virtual Care During a Pandemic: Patient Safety Considerations.

BACKGROUND: The COVID-19 pandemic prompted sudden and fundamental changes in health care, including a rapid rise in the utilization of telehealth services in the ambulatory setting. With the unprecedented and significant decline in traditional office-based visits and procedures, novel patient safety risks and challenges emerged. METHODS: The ambulatory practices at our quaternary care, academic medical center experienced a 200-fold increase in virtual visit volume between February and April 2020. We convened a multidisciplinary working group dedicated to evaluating quality and safety when providing virtual visits during a pandemic. Our primary outcome was patient experience with virtual care delivery, which was assessed by leveraging patient complaint data and patient satisfaction survey data. RESULTS: For our main focus of patient experience and satisfaction, survey data were analyzed from the approximately 76,616 virtual visit encounters that occurred between March 1, 2020, and April 21, 2020. During this period, 5 patient complaints were filed to the Patient Advocacy Department. Overall, patient satisfaction with telehealth remained stable and high at >93% from February to May 2020. As we assessed these data each month, our working group developed risk mitigation strategies in response to the novel challenges presented by the use of telemedicine due to the COVID-19 pandemic while working to maintain patient satisfaction with care. We identified quality and safety issues around patient factors including optimal triage of patients and use of technology. We also evaluated accessibility to virtual platforms and logistics such as coordination of care for diagnostic testing. Finally, a guidance document was created and communicated to our diverse ambulatory practices to support clinicians. CONCLUSIONS: Ambulatory virtual care delivery requires a dynamic, flexible model of care through continuous rapid-cycle process improvement to mitigate patient safety risks during a pandemic, incorporating both provider and patient perspectives.