RESUMEN
This study discusses women's representation in interventional cardiology.
RESUMEN
This study assesses career satisfaction, discrepancies between ideal and expected careers, and likelihood of leaving current positions among former K awardees.
Asunto(s)
Satisfacción en el Trabajo , Humanos , Femenino , Masculino , Movilidad Laboral , Adulto , Satisfacción Personal , Distinciones y Premios , Persona de Mediana Edad , Estados Unidos , NiñoRESUMEN
PURPOSE: This study aimed to elucidate the experiences and perceptions of mid-career to senior clinician-scientists in academic medicine regarding pursuing, attaining, or rejecting leadership roles as well as their conceptualization of the influence of leadership in their broader career trajectories. METHOD: The authors conducted a qualitative analysis of in-depth, semistructured interviews conducted in 2022 with a diverse sample of clinician-scientists who received new National Institutes of Health K08 or K23 Career Development Awards between 2006 and 2009. A total of 859 of the 915 survey respondents (94%) were eligible to be recruited for the qualitative study. Qualitative analysis was informed by thematic analysis and used a social constructionist approach to understanding participants' conceptualizations of their experiences. Interview transcripts were coded using an iterative, inductive coding process. Themes were generated by reviewing coded data and identifying common patterns in participant narratives, affording particular attention to participants' discussion of the effect of race and/or gender on their leadership experiences. RESULTS: Sixty clinician-scientists participated in individual interviews. Five themes were generated surrounding participants' conceptualizations of their leadership experiences. Themes were (1) feeling unprepared for leadership roles, (2) reluctance and lack of intention in attaining leadership positions, (3) influence of networks on leadership access and decision-making, (4) impact-related benefits and downsides of leadership, and (5) confining ideas of who leaders are. CONCLUSIONS: The study highlighted the need for formal leadership training in academic medicine and the importance of mentorship and sponsorship in attaining and succeeding in leadership positions. Individuals from communities underrepresented in leadership positions faced additional challenges internalizing a leadership identity. Efforts to encourage current leaders to engage in intentional succession planning and development of faculty towards leadership roles, including expansion of institutional leadership development programs, are needed to promote equitable distribution of leadership opportunities.
RESUMEN
Importance: Studies reveal that most physicians report symptoms of burnout. Less is known about burnout in mid-career medical faculty specifically. Objective: To characterize burnout and its risk factors, particularly differences by gender, among mid-career medical faculty. Design, Setting, and Participants: Between August 2021 and August 2022, a survey was sent to 1430 individuals who received new National Institutes of Health K08 and K23 career development awards from 2006 to 2009. Data were analyzed between June and October 2023. Main Outcomes and Measures: Personal and work-related burnout as evaluated using the Copenhagen Burnout Inventory (CBI). The CBI score ranges from 0 to 100, with a score of 50 or higher indicating a high degree of burnout. Multivariable models were used to investigate associations between burnout and participant characteristics, including race and ethnicity, sexual orientation and gender identity, academic rank, work climate, experiences of workplace sexual harassment, sleep hours, work and domestic caregiving time, and time allocation changes in work and domestic work hours compared with before the COVID-19 pandemic. Work climate was evaluated by a general climate elements scale assessing elements such as friendliness, respect, and collegiality, and a diversity, equity, and inclusion climate elements scale assessing elements such as homogeneity, sexism, and homophobia; higher scores indicated a more favorable view of the climate. Results: In all, 1430 surveys were sent, 926 candidates responded (65% response rate), and the analytic cohort was limited to the 841 respondents who were still in academic medicine (50.7% men). Burnout was significantly more common for women than men (mean [SD] CBI personal scores, 46.6 [19.4] vs 37.5 [17.2]; P < .001; mean [SD] CBI work-related scores, 43.7 [20.4] vs 34.6 [19.7]; P < .001). In multivariable models, personal burnout was significantly more likely for women (adjusted odds ratio [AOR], 2.29 [95% CI, 1.54-3.41]; P < .001) and with more weekly hours of patient care (AOR, 1.07 [95% CI, 1.00-1.15] for each 5-hour increase; P = .04). Personal burnout was less likely with more nightly sleep hours (AOR, 0.68 [95% CI, 0.56-0.81] for each 1-hour increase; P < .001) and with an improved general work climate rating (AOR, 0.64 [95% CI, 0.48-0.85] for each 1-point increase in general work climate scale score; P = .002). Work-related burnout was also significantly more likely for women than men (AOR, 1.77 [95% CI, 1.17-2.69]; P = .007). Greater work-related burnout was associated with an increase of 8 or more work hours per week compared with before the COVID-19 pandemic (AOR, 1.87 [95% CI, 1.13-3.08]; P = .01), more weekly hours of patient care (AOR, 1.11 [95% CI, 1.03-1.19] for each 5-hour increase; P = .007), and a workplace sexual harassment experience in the past 2 years (AOR, 1.71 [95% CI, 1.11-2.62]; P = .01). Work-related burnout was significantly less likely with more nightly sleep hours (AOR, 0.80 [95% CI, 0.66-0.96] for each 1-hour increase; P = .02) and with an improved general work climate rating (AOR, 0.49; [95% CI, 0.36-0.65] for each 1-point increase in general work climate scale score; P < .001). Conclusions and Relevance: This survey study of K grant awardees revealed substantial rates of burnout among mid-career medical faculty, and burnout rates differed by gender. Evidence-based interventions are needed to realize the benefits of workforce diversity and vitality.
Asunto(s)
Agotamiento Profesional , COVID-19 , Docentes Médicos , Humanos , Agotamiento Profesional/epidemiología , Agotamiento Profesional/psicología , Femenino , Masculino , Docentes Médicos/psicología , Docentes Médicos/estadística & datos numéricos , Adulto , COVID-19/epidemiología , COVID-19/psicología , Persona de Mediana Edad , SARS-CoV-2 , Encuestas y Cuestionarios , Estados Unidos/epidemiología , Factores de Riesgo , Factores Sexuales , Lugar de Trabajo/psicologíaRESUMEN
BACKGROUND: Health care is a major source of greenhouse gas emissions, leading to climate change and public health harms. Changes are needed to improve the environmental sustainability of health-care practices, but such changes should not sacrifice patient outcomes or financial sustainability. Alternative dosing strategies that reduce the frequency with which specialty drugs are administered, without sacrificing patient outcomes, are an attractive possibility for improving environmental sustainability. We sought to inform environmentally sustainable cancer care by estimating and comparing the environmental and financial effects of alternative, clinically equivalent strategies for pembrolizumab administration. METHODS: We conducted a retrospective analysis using a cohort of patients from the Veterans Health Administration (VHA) in the USA who received one or more pembrolizumab doses between May 1, 2020, and Sept 30, 2022. Using baseline, real-world administration of pembrolizumab, we generated simulated pembrolizumab use data under three near-equivalent counterfactual pembrolizumab administration strategies defined by combinations of weight-based dosing, pharmacy-level vial sharing and dose rounding, and extended-interval dosing (ie, every 6 weeks). For each counterfactual dosing strategy, we estimated greenhouse gas emissions related to pembrolizumab use across the VHA cohort using a deterministic environmental impact model that estimated greenhouse gas emissions due to patient travel, drug manufacture, and medical waste as the primary outcome measure. FINDINGS: We identified 7813 veterans who received at least one dose of pembrolizumab-containing therapy in the VHA during the study period. 59â140 pembrolizumab administrations occurred in the study period, of which 46â255 (78·2%) were dosed at 200 mg every 3 weeks, 12â885 (21·8%) at 400 mg every 6 weeks, and 14â955 (25·3%) were coadministered with infusional chemotherapies. Adoption of weight-based, extended-interval pembrolizumab dosing (4 mg/kg every 6 weeks) and pharmacy-level stewardship strategies (ie, dose rounding and vial sharing) for all pembrolizumab infusions would have resulted in 24·7% fewer administration events than baseline dosing (44â533 events vs 59â140 events) and an estimated 200 metric tons less CO2 emitted per year as a result of pembrolizumab use within the VHA (650 tons vs 850 tons of CO2, a relative reduction of 24%), largely due to reductions in distance travelled by patients to receive treatment. Similar results were observed when weight-based and extended-interval dosing were applied only to pembrolizumab monotherapy and pembrolizumab in combination with oral therapies. INTERPRETATION: Alternative pembrolizumab administration strategies might have environmental advantages over the current dosing and compounding paradigms. Specialty medication dosing can be optimised for health-care spending and environmental sustainability without sacrificing clinical outcomes. FUNDING: None.
Asunto(s)
Anticuerpos Monoclonales Humanizados , Humanos , Anticuerpos Monoclonales Humanizados/administración & dosificación , Estudios Retrospectivos , Estados Unidos , Masculino , Femenino , Antineoplásicos Inmunológicos/administración & dosificación , Antineoplásicos Inmunológicos/efectos adversos , Salud Pública , Persona de Mediana Edad , Anciano , Neoplasias/tratamiento farmacológico , Esquema de MedicaciónRESUMEN
PURPOSE: To understand time allocation of a national medical faculty cohort 1.5-2 years after the COVID-19 pandemic began, compared to before. METHOD: From August 2021-April 2022, the authors conducted a retrospective survey of 1,430 clinician-researchers who received National Institutes of Health career-development awards between 2006-2009 asking about domestic and professional time allocation pre-pandemic and at the time of surveys (TOS). Of 915 respondents (64%), the 830 who remained in academic positions constituted the analytic sample. Multivariable regression models identified demographic factors associated with each time outcome and change in time between pre-pandemic and TOS, and having experienced ≥8-hour increase of total self-reported weekly professional work hours and domestic labor hours. RESULTS: Median self-reported weekly professional work hours were 55 hours/week pre- pandemic and 60 at TOS. On multivariable analysis, significant predictors of self-reported weekly professional work hours at TOS were having a non-child other dependent (+2.6 hours, P = .03), academic rank (associate -3.1 hours, assistant -9.0 hours; P < .001), and specialty (P < .001). Average self-reported TOS weekly domestic-labor hours were 23.1 among men and 30.2 among women (P < .001). Predictors of total self-reported TOS weekly domestic hours were being a woman (+5.6 hours; P < .001) and having children requiring supervision (+10.2 hours; P < .001). Overall, 9.3% of men (42/450) and 21.6% of women (88/407) experienced a ≥ 8 hour increase in domestic labor (P < .001). On multivariable analysis, women had higher odds of substantial domestic-labor increase (OR = 2.33, 95% CI: 1.47, 3.68), as did those with children requiring supervision (OR = 1.93, 95% CI: 1.25, 2.98) or other dependents (OR = 1.83, 95% CI: 1.13, 2.98). CONCLUSIONS: This study illuminates demands on women and faculty with dependents during the COVID-19 pandemic and suggests increased flexibility and resources are of heightened importance.
RESUMEN
This survey study examines gender differences in mid- to senior-career faculty experiences of receiving and providing mentorship and sponsorship during early career development.
Asunto(s)
Docentes Médicos , Mentores , Humanos , Factores SexualesRESUMEN
Importance: Use of low-value care is common among older adults. It is unclear how to best engage clinicians and older patients to decrease use of low-value services. Objective: To test whether the Committing to Choose Wisely behavioral economic intervention could engage primary care clinicians and older patients to reduce low-value care. Design, Setting, and Participants: Stepped-wedge cluster randomized clinical trial conducted at 8 primary care clinics of an academic health system and a private group practice between December 12, 2017, and September 4, 2019. Participants were primary care clinicians and older adult patients who had diabetes, insomnia, or anxiety or were eligible for prostate cancer screening. Data analysis was performed from October 2019 to November 2023. Intervention: Clinicians were invited to commit in writing to Choosing Wisely recommendations for older patients to avoid use of hypoglycemic medications to achieve tight glycemic control, sedative-hypnotic medications for insomnia or anxiety, and prostate-specific antigen tests to screen for prostate cancer. Committed clinicians had their photographs displayed on clinic posters and received weekly emails with alternatives to these low-value services. Educational handouts were mailed to applicable patients before scheduled visits and available at the point of care. Main Outcomes and Measures: Patient-months with a low-value service across conditions (primary outcome) and separately for each condition (secondary outcomes). For patients with diabetes, or insomnia or anxiety, secondary outcomes were patient-months in which targeted medications were decreased or stopped (ie, deintensified). Results: The study included 81 primary care clinicians and 8030 older adult patients (mean [SD] age, 75.1 [7.2] years; 4076 men [50.8%] and 3954 women [49.2%]). Across conditions, a low-value service was used in 7627 of the 37â¯116 control patient-months (20.5%) and 7416 of the 46â¯381 intervention patient-months (16.0%) (adjusted odds ratio, 0.79; 95% CI, 0.65-0.97). For each individual condition, there were no significant differences between the control and intervention periods in the odds of patient-months with a low-value service. The intervention increased the odds of deintensification of hypoglycemic medications for diabetes (adjusted odds ratio, 1.85; 95% CI, 1.06-3.24) but not sedative-hypnotic medications for insomnia or anxiety. Conclusions and Relevance: In this stepped-wedge cluster randomized clinical trial, the Committing to Choose Wisely behavioral economic intervention reduced low-value care across 3 common clinical situations and increased deintensification of hypoglycemic medications for diabetes. Use of scalable interventions that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored more broadly. Trial Registration: ClinicalTrials.gov Identifier: NCT03411525.
Asunto(s)
Diabetes Mellitus , Neoplasias de la Próstata , Trastornos del Inicio y del Mantenimiento del Sueño , Masculino , Humanos , Anciano , Economía del Comportamiento , Detección Precoz del Cáncer , Atención de Bajo Valor , Trastornos del Inicio y del Mantenimiento del Sueño/tratamiento farmacológico , Antígeno Prostático Específico , Diabetes Mellitus/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Hipnóticos y Sedantes/uso terapéuticoRESUMEN
Importance: Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults. Objective: To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening. Design, Setting, and Participants: Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023. Intervention: The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening. Main Outcomes and Measures: The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months. Results: A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp). Conclusions and Relevance: In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening. Trial Registration: ClinicalTrials.gov Identifier: NCT02027545.
Asunto(s)
Neoplasias Colorrectales , Detección Precoz del Cáncer , Humanos , Masculino , Anciano , Femenino , Empleo , Neoplasias Colorrectales/diagnóstico , Instituciones de Atención Ambulatoria , Tamizaje MasivoRESUMEN
INTRODUCTION: Chronic kidney disease (CKD) affects 30 million Americans. Early management focused on blood pressure (BP) control decreases cardiovascular morbidity and mortality. Less than 40% of patients with CKD achieve recommended BP targets due to many barriers. These barriers include a lack of understanding of the implications of their diagnosis and how to optimise their health.This cluster randomised control trial hypothesises that the combination of early primary care CKD education, and motivational interviewing (MI)-based health coach support, will improve patient behaviours aligned with BP control by increasing patient knowledge, self-efficacy and motivation. The results will aid in sustainable interventions for future patient-centric education and coaching support to improve quality and outcomes in patients with CKD stages 3-5. Outcomes in patients with CKD stages 3-5 receiving the intervention will be compared with similar patients within a control group. Continuous quality improvement (CQI) and systems methodologies will be used to optimise resource neutrality and leverage existing technology to support implementation and future dissemination. The innovative approach of this research focuses on the importance of a multidisciplinary team, including off-site patient coaching, that can intervene early in the CKD care continuum by supporting patients with education and coaching. METHODS AND ANALYSIS: We will test impact of BP control when clinician-delivered education is followed by 12 months of MI-based health coaching. We will compare outcomes in 350 patients with CKD stages 3-5 between intervention and control groups in primary care. CQI and systems methodologies will optimise education and coaching for future implementation and dissemination. ETHICS AND DISSEMINATION: This study was approved by the University of Michigan Institutional Review Boards (IRBMED) HUM00136011, HUM00150672 and SITE00000092 and the results of the study will be published on ClinicalTrials.gov, in peer-reviewed journals, as well as conference abstracts, posters and presentations. TRIAL REGISTRATION NUMBER: NCT04087798.
Asunto(s)
Hipertensión , Tutoría , Insuficiencia Renal Crónica , Humanos , Tutoría/métodos , Presión Sanguínea , Hipertensión/terapia , Insuficiencia Renal Crónica/terapia , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
Immune checkpoint inhibitors, a class of drugs used in approximately forty unique cancer indications, are a sizable component of the economic burden of cancer care in the US. Instead of personalized weight-based dosing, immune checkpoint inhibitors are most commonly administered at "one-size-fits-all" flat doses that are higher than necessary for the vast majority of patients. We hypothesized that personalized weight-based dosing along with common stewardship efforts at the pharmacy level, such as dose rounding and vial sharing, would lead to reductions in immune checkpoint inhibitor use and lower spending. Using data from the Veterans Health Administration (VHA) and Medicare drug prices, we estimated reductions in immune checkpoint inhibitor use and spending that would be associated with pharmacy-level stewardship strategies, in a case-control simulation study of individual patient-level immune checkpoint inhibitor administration events. We identified baseline annual VHA spending for these drugs of approximately $537 million. Combining weight-based dosing, dose rounding, and pharmacy-level vial sharing would generate expected annual VHA health system savings of $74 million (13.7 percent). We conclude that adoption of pharmacologically justified immune checkpoint inhibitor stewardship measures would generate sizable reductions in spending for these drugs. Combining these operational innovations with value-based drug price negotiation enabled by recent policy changes may improve the long-term financial viability of cancer care in the US.
Asunto(s)
Neoplasias , Farmacias , Farmacia , Anciano , Humanos , Estados Unidos , Inhibidores de Puntos de Control Inmunológico , Medicare , Estudios de Casos y Controles , Costos de los Medicamentos , Neoplasias/tratamiento farmacológicoRESUMEN
Importance: The culture of academic medicine may foster mistreatment that disproportionately affects individuals who have been marginalized within a given society (minoritized groups) and compromises workforce vitality. Existing research has been limited by a lack of comprehensive, validated measures, low response rates, and narrow samples as well as comparisons limited to the binary gender categories of male or female assigned at birth (cisgender). Objective: To evaluate academic medical culture, faculty mental health, and their relationship. Design, Setting, and Participants: A total of 830 faculty members in the US received National Institutes of Health career development awards from 2006-2009, remained in academia, and responded to a 2021 survey that had a response rate of 64%. Experiences were compared by gender, race and ethnicity (using the categories of Asian, underrepresented in medicine [defined as race and ethnicity other than Asian or non-Hispanic White], and White), and lesbian, gay, bisexual, transgender, queer (LGBTQ+) status. Multivariable models were used to explore associations between experiences of culture (climate, sexual harassment, and cyber incivility) with mental health. Exposures: Minoritized identity based on gender, race and ethnicity, and LGBTQ+ status. Main Outcomes and Measures: Three aspects of culture were measured as the primary outcomes: organizational climate, sexual harassment, and cyber incivility using previously developed instruments. The 5-item Mental Health Inventory (scored from 0 to 100 points with higher values indicating better mental health) was used to evaluate the secondary outcome of mental health. Results: Of the 830 faculty members, there were 422 men, 385 women, 2 in nonbinary gender category, and 21 who did not identify gender; there were 169 Asian respondents, 66 respondents underrepresented in medicine, 572 White respondents, and 23 respondents who did not report their race and ethnicity; and there were 774 respondents who identified as cisgender and heterosexual, 31 as having LGBTQ+ status, and 25 who did not identify status. Women rated general climate (5-point scale) more negatively than men (mean, 3.68 [95% CI, 3.59-3.77] vs 3.96 [95% CI, 3.88-4.04], respectively, P < .001). Diversity climate ratings differed significantly by gender (mean, 3.72 [95% CI, 3.64-3.80] for women vs 4.16 [95% CI, 4.09-4.23] for men, P < .001) and by race and ethnicity (mean, 4.0 [95% CI, 3.88-4.12] for Asian respondents, 3.71 [95% CI, 3.50-3.92] for respondents underrepresented in medicine, and 3.96 [95% CI, 3.90-4.02] for White respondents, P = .04). Women were more likely than men to report experiencing gender harassment (sexist remarks and crude behaviors) (71.9% [95% CI, 67.1%-76.4%] vs 44.9% [95% CI, 40.1%-49.8%], respectively, P < .001). Respondents with LGBTQ+ status were more likely to report experiencing sexual harassment than cisgender and heterosexual respondents when using social media professionally (13.3% [95% CI, 1.7%-40.5%] vs 2.5% [95% CI, 1.2%-4.6%], respectively, P = .01). Each of the 3 aspects of culture and gender were significantly associated with the secondary outcome of mental health in the multivariable analysis. Conclusions and Relevance: High rates of sexual harassment, cyber incivility, and negative organizational climate exist in academic medicine, disproportionately affecting minoritized groups and affecting mental health. Ongoing efforts to transform culture are necessary.
Asunto(s)
Ciberacoso , Docentes Médicos , Incivilidad , Cultura Organizacional , Acoso Sexual , Lugar de Trabajo , Femenino , Humanos , Masculino , Etnicidad/psicología , Etnicidad/estadística & datos numéricos , Incivilidad/estadística & datos numéricos , Minorías Sexuales y de Género/psicología , Minorías Sexuales y de Género/estadística & datos numéricos , Acoso Sexual/psicología , Acoso Sexual/estadística & datos numéricos , Lugar de Trabajo/organización & administración , Lugar de Trabajo/psicología , Lugar de Trabajo/estadística & datos numéricos , Centros Médicos Académicos/organización & administración , Centros Médicos Académicos/estadística & datos numéricos , Ciberacoso/psicología , Ciberacoso/estadística & datos numéricos , Condiciones de Trabajo/organización & administración , Condiciones de Trabajo/psicología , Condiciones de Trabajo/estadística & datos numéricos , Marginación Social/psicología , Grupos Minoritarios/psicología , Grupos Minoritarios/estadística & datos numéricos , Salud Mental/estadística & datos numéricos , Docentes Médicos/organización & administración , Docentes Médicos/psicología , Docentes Médicos/estadística & datos numéricos , Medicina/organización & administración , Medicina/estadística & datos numéricos , Estados Unidos/epidemiología , Asiático/psicología , Asiático/estadística & datos numéricos , Blanco/psicología , Blanco/estadística & datos numéricos , Encuestas y Cuestionarios , Racismo/psicología , Racismo/estadística & datos numéricos , Sexismo/psicología , Sexismo/estadística & datos numéricos , Prejuicio/etnología , Prejuicio/psicología , Prejuicio/estadística & datos numéricosRESUMEN
BACKGROUND: Decreasing low-value colonoscopy is critical to optimizing access for high-need patients, particularly in resource-constrained environments such as those created by the COVID-19 pandemic. We hypothesized that rates of screening colonoscopy overuse would decline during COVID compared to pre-COVID due to enhanced procedural scrutiny and prioritization in the setting of constrained access. OBJECTIVE: To characterize impacts of COVID-19 on screening colonoscopy overuse DESIGN: Retrospective national cohort study using Veterans Health Administration administrative data PARTICIPANTS: Veterans undergoing screening colonoscopy in Q4 2019 (pre-COVID) and Q4 2020 (COVID) at 109 endoscopy facilities MAIN MEASURES: Rates of screening colonoscopy overuse KEY RESULTS: 18,376 screening colonoscopies were performed pre-COVID, 19% (3,641) of which met overuse criteria. While only 9,360 screening colonoscopies were performed in Q4 2020, 25% met overuse criteria. Overall change in median facility-level overuse during COVID compared to pre-COVID was 6% (95%CI 5%-7%), with significant variability across facilities (IQR: 2%-11%). Of colonoscopies meeting overuse criteria, the top reason for overuse in both periods was screening colonoscopy performed <9 years after previous screening procedure (55% pre-COVID, 49% during COVID). The largest shifts in overuse category were in screening procedures performed <9 years after prior screening colonoscopy (-6% decline COVID vs. pre-COVID) and screening procedures performed in patients below average-risk screening age (i.e., age <40 (5% increase COVID compared to pre-COVID), age 40-44 (4% increase COVID vs. pre-COVID)). Within facility performance was stable over time; 83/109 facilities changed their performance by <=1 quartile during COVID compared to pre-COVID. CONCLUSIONS: Despite pandemic-related resource constraints and enhanced procedural scrutiny and prioritization in the setting of COVID-related backlogs, screening colonoscopy overuse rates remained roughly stable during COVID compared to pre-COVID, with continued variability across facilities. These data highlight the need for systematic and concerted efforts to address overuse, even in the face of strong external motivating factors.
Asunto(s)
COVID-19 , Neoplasias Colorrectales , Prestación Integrada de Atención de Salud , Estados Unidos/epidemiología , Humanos , Adulto , Estudios de Cohortes , Estudios Retrospectivos , Neoplasias Colorrectales/diagnóstico , Pandemias , United States Department of Veterans Affairs , COVID-19/epidemiología , Colonoscopía , Tamizaje Masivo , Detección Precoz del Cáncer/métodosRESUMEN
The COVID-19 pandemic has led to increased use of telephone and video encounters in the Veterans Health Administration and many other healthcare systems. One important difference between these virtual modalities and traditional face-to-face encounters is the different cost-sharing, travel costs, and time costs that patients face. Making the full costs of different visit modalities transparent to patients and their clinicians can help patients obtain greater value from their primary care encounters. From April 6, 2020 to September 30, 2021 the VA waived all copayments for Veterans receiving care from the VA, but since this policy was temporary it is important that Veterans receive personalized information about their expected costs so they can obtain the most value from their primary care encounters. To test the feasibility, acceptability, and preliminary effectiveness of this approach, our team conducted a 12 week pilot project at the VA Ann Arbor Healthcare System from June-August 2021 in which we made personalized estimates of out-of-pocket, travel, and time costs available and transparent to patients and clinicians in advance of scheduled encounters and at the point of care. We found that it was feasible to generate and deliver personalized cost estimates in advance of visits, that this information was acceptable to patients, and that patients who used cost estimates during a visit with a clinician found this information helpful and would want to receive it again in the future. To achieve greater value in healthcare, systems must continue to pursue new ways to provide transparent information and needed support to patients and clinicians. This means ensuring clinical visits provide the highest levels of access, convenience, and return on patients' healthcare-associated spending while minimizing financial toxicity.
Asunto(s)
COVID-19 , Telemedicina , Veteranos , Humanos , Proyectos Piloto , Pandemias , Atención Primaria de SaludRESUMEN
BACKGROUND: Few performance measures assess presurgical value (quality and utilization). OBJECTIVES: Using carpal tunnel syndrome (CTS) as a case study: (1) develop a model to evaluate presurgical quality and utilization and (2) identify opportunities for value improvement. RESEARCH DESIGN: A retrospective cohort study utilizing Veterans Affairs (VA) national administrative data. SUBJECTS: Patients who were evaluated in a VA primary care clinic on at least 1 occasion for CTS and received carpal tunnel release over a 7-year period. MEASURES: We modeled facility-level performance on 2 outcomes: surgical delay (marker of quality) and number of presurgical encounters (utilization) for CTS, and examined association between patient, facility, and care process variables and performance. RESULTS: Among 41,912 Veterans undergoing carpal tunnel release at 127 VA medical centers, the median facility-level predicted probability of surgical delay was 48%, with 16 (13%) facilities having significantly less delay than the median and 13 (10%) facilities having greater delay. The median facility-level predicted number of presurgical encounters was 8.8 visits, with 22 (17%) facilities having significantly fewer encounters and 22 (17%) facilities having more. Care processes had a stronger association with both outcomes than structural variables included in the models. Processes associated with the greatest deviations in predicted delay and utilization included receipt of repeat electrodiagnostic testing, use of 2 or more nonoperative treatments, and community referral outside of VA. CONCLUSIONS: Using CTS as a test case, this study demonstrates the potential to assess presurgical value and identify modifiable care processes associated with presurgical delay and utilization performance.
Asunto(s)
Síndrome del Túnel Carpiano , Humanos , Síndrome del Túnel Carpiano/diagnóstico , Síndrome del Túnel Carpiano/cirugía , Estudios RetrospectivosRESUMEN
INTRODUCTION: The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery. MATERIALS AND METHODS: A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization. RESULTS: 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities. CONCLUSIONS: Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.
Asunto(s)
Medicare , Anciano , Humanos , Estados Unidos , Estudios Retrospectivos , Reproducibilidad de los Resultados , Riesgo , MichiganRESUMEN
BACKGROUND: Low-value use of screening colonoscopy is wasteful and potentially harmful to patients. Decreasing low-value colonoscopy prevents procedural complications, saves patient time and reduces patient discomfort, and can improve access by reducing procedural demand. The objective of this study was to develop and validate an electronic measure of screening colonoscopy overuse using International Classification of Diseases, Tenth Edition codes and then apply this measure to estimate facility-level overuse to target quality improvement initiatives to reduce overuse in a large integrated healthcare system. METHODS: Retrospective national observational study of US Veterans undergoing screening colonoscopy at 119 Veterans Health Administration (VHA) endoscopy facilities in 2017. A measure of screening colonoscopy overuse was specified by an expert workgroup, and electronic approximation of the measure numerator and denominator was performed ('electronic measure'). The electronic measure was then validated via manual record review (n=511). Reliability statistics (n=100) were calculated along with diagnostic test characteristics of the electronic measure. The measure was then applied to estimate overall rates of overuse and facility-level variation in overuse among all eligible patients. RESULTS: The electronic measure had high specificity (99%) and moderate sensitivity (46%). Adjusted positive predictive value and negative predictive value were 33% and 95%, respectively. Inter-rater reliability testing revealed near perfect agreement between raters (k=0.81). 269 572 colonoscopies were performed in VHA in 2017 (88 143 classified as screening procedures). Applying the measure to these 88 143 screening colonoscopies, 24.5% were identified as potential overuse. Median facility-level overuse was 22.5%, with substantial variability across facilities (IQR 19.1%-27.0%). CONCLUSIONS: An International Classification of Diseases, Tenth Edition based electronic measure of screening colonoscopy overuse has high specificity and improved sensitivity compared with a previous International Classification of Diseases, Ninth Edition based measure. Despite increased focus on reducing low-value care and improving access, a quarter of VHA screening colonoscopies in 2017 were identified as potential low-value procedures, with substantial facility-level variability.
Asunto(s)
Prestación Integrada de Atención de Salud , Clasificación Internacional de Enfermedades , Estados Unidos , Humanos , Estudios Retrospectivos , United States Department of Veterans Affairs , Reproducibilidad de los Resultados , Colonoscopía/métodosRESUMEN
This Viewpoint discusses how to extend Choosing Wisely principles to identify clinical management practices that lead to unnecessary burdens, approaches to identify and prioritize those low-value practices, the partnerships needed to reduce burdens, and a research agenda for evaluating the consequences of change.
Asunto(s)
Pautas de la Práctica en Medicina , Sociedades Médicas , Recursos HumanosRESUMEN
Importance: More than 75% of US adults with diabetes do not meet treatment goals. More effective support from family and friends ("supporters") may improve diabetes management and outcomes. Objective: To determine if the Caring Others Increasing Engagement in Patient Aligned Care Teams (CO-IMPACT) intervention improves patient activation, diabetes management, and outcomes compared with standard care. Design, Setting, and Participants: This randomized clinical trial was conducted from November 2016 to August 2019 among participants recruited from 2 Veterans Health Administration primary care sites. All patient participants were adults aged 30 to 70 years with diabetes who had hemoglobin A1c (HbA1c) levels greater than 8% of total hemoglobin (to convert to proportion of total hemoglobin, multiply by 0.01) or systolic blood pressure (SBP) higher than 150 mm Hg; each participating patient had an adult supporter. Of 1119 recruited, 239 patient-supporter dyads were enrolled between November 2016 and May 2018, randomized 1:1 to receive the CO-IMPACT intervention or standard care, and followed up for 12 to 15 months. Investigators and analysts were blinded to group assignment. Interventions: Patient-supporter dyads received a health coaching session focused on dyadic information sharing and positive support techniques, then 12 months of biweekly automated monitoring telephone calls to prompt dyadic actions to meet diabetes goals, coaching calls to help dyads prepare for primary care visits, and after-visit summaries. Standard-care dyads received general diabetes education materials only. Main Outcomes and Measures: Intent-to-treat analyses were conducted according to baseline dyad assignment. Primary prespecified outcomes were 12-month changes in Patient Activation Measure-13 (PAM-13) and UK Prospective Diabetes Study (UKPDS) 5-year diabetes-specific cardiac event risk scores. Secondary outcomes included 12-month changes in HbA1c levels, SBP, diabetes self-management behaviors, diabetes distress, diabetes management self-efficacy, and satisfaction with health system support for the involvement of family supporters. Changes in outcome measures between baseline and 12 months were analyzed using linear regression models. Results: A total of 239 dyads enrolled; among patient participants, the mean (SD) age was 60 (8.9) years, and 231 (96.7%) were male. The mean (SD) baseline HbA1c level was 8.5% (1.6%) and SBP was 140.2 mm Hg (18.4 mm Hg). A total of 168 patients (70.3%) lived with their enrolled supporter; 229 patients (95.8%) had complete 12-month outcome data. In intention-to-treat analyses vs standard care, CO-IMPACT patients had greater 12-month improvements in PAM-13 scores (intervention effect, 2.60 points; 95% CI, 0.02-5.18 points; P = .048) but nonsignificant differences in UKPDS 5-year cardiac risk (intervention effect, 1.01 points; 95% CI, -0.74 to 2.77 points; P = .26). Patients in the CO-IMPACT arm also had greater 12-month improvements in healthy eating (intervention effect, 0.71 d/wk; 95% CI, 0.20-1.22 d/wk; P = .007), diabetes self-efficacy (intervention effect, 0.40 points; 95% CI, 0.09-0.71 points; P = .01), and satisfaction with health system support for the family supporter participants' involvement (intervention effect, 0.28 points; 95% CI, 0.07-0.49 points; P = .009); however, the 2 arms had similar improvements in HbA1c levels and in other measures. Conclusions and Relevance: In this randomized clinical trial, the CO-IMPACT intervention successfully engaged patient-supporter dyads and led to improved patient activation and self-efficacy. Physiological outcomes improved similarly in both arms. More intensive direct coaching of supporters, or targeting patients with less preexisting support or fewer diabetes management resources, may have greater impact. Trial Registration: ClinicalTrials.gov Identifier: NCT02328326.