Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study.

OBJECTIVES: The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care. MATERIALS AND METHODS: Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics. We examined differences in timely completion ("loop closure") of tests/referrals for (1) patients who used the portal and read ≥1 note (Portal + Notes); (2) those with a portal account but who did not read notes (Portal Account Only); and (3) those who did not register for the portal (No Portal). We estimated the predictive probability of loop closure in each group after adjusting for socio-demographic and clinical factors using multivariable logistic regression. RESULTS: Among 12 849 tests/referrals, loop closure was more common among Portal+Note-readers compared to their counterparts for all tests/referrals (54.2% No Portal, 57.4% Portal Account Only, 61.6% Portal+Notes, P < .001). In adjusted analysis, compared to the No Portal group, the odds of loop closure were significantly higher for Portal Account Only (OR 1.2; 95% CI, 1.1-1.4), and Portal+Notes (OR 1.4; 95% CI, 1.3-1.6) groups. Beyond portal registration, note reading was independently associated with loop closure (P = .002). DISCUSSION AND CONCLUSION: Compared to no portal registration, the odds of loop closure were 20% higher in tests/referrals for patients with a portal account, and 40% higher in tests/referrals for note readers, after controlling for sociodemographic and clinical factors. However, important safety gaps from unclosed loops remain, requiring additional engagement strategies.

Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees.

BACKGROUND: A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure. METHODS: This retrospective cohort study included all patient visits from January 1, 2018, to December 31, 2021, at two academic medical center-based primary care practices where residents and faculty practice in the same setting. The primary outcome was prevalence of failure to close the loop for (1) dermatology referrals, (2) colonoscopy, and (3) cardiac stress testing. The primary predictor was resident vs. faculty status of the ordering provider. The authors present an unadjusted analysis and the results of a multivariable logistic regression analysis incorporating all patient factors to determine their association with loop closure. RESULTS: Of 12,282 orders for referrals and tests for the three studied areas, 1,929 (15.7%) were ordered by a resident physician. Of resident orders for all three tests, 52.9% were completed within the designated time vs. 58.4% for orders placed by attending physicians (p < 0.01). In an unadjusted analysis by test type, a similar trend was seen for colonoscopy (51.4% completion rate for residents vs. 57.5% for attending physicians, p < 0.01) and for cardiac stress testing (55.7% completion rate for residents vs. 61.2% for attending physicians), though a difference was not seen for dermatology referrals (64.2% completion rate for residents vs. 63.7% for attending physicians). In an adjusted analysis, patients with resident orders were less likely than attendings to close the loop for all test types combined (odds ratio 0.88, 95% confidence interval 0.79-0.98), with low rates of test completion for both physician groups. CONCLUSION: Loop closure for three diagnostic interventions was low for patients in both faculty and resident primary care clinics, with lower loop closure rates in resident clinics. Failure to close diagnostic loops presents a safety challenge in primary care and is of particular concern for training programs.

Completion Rates and Timeliness of Diagnostic Colonoscopies for Rectal Bleeding in Primary Care.

BACKGROUND: Rectal bleeding is the most common presenting symptom of colorectal cancer, and guidelines recommend timely follow-up, usually with colonoscopy to ensure timely diagnoses of colorectal cancer. OBJECTIVE: Identify loop closure rates and vulnerable process points for patients with rectal bleeding. DESIGN: Retrospective cohort study, using medical record review of patients aged ≥ 40 with index diagnosis of rectal bleeding at 2 primary practices-an urban academic practice and affiliated community health center, between January 1, 2018, and December 31, 2020. Patients were classified as having completed recommended follow-up workup ("closed loop") vs. not ("open loop"). Open loop patient cases were categorized into six types of process failures. PARTICIPANTS: A total of 837 patients had coded diagnoses of rectal bleeding within study window. Sixty-seven were excluded based on prior colectomy, clinical presentation more consistent with upper GI bleed, no rectal bleeding documented on chart review, or expired during the follow-up period, leaving 770 patients included. MAIN MEASURES: Primary outcomes were percentages of patient cases classified as "open loops" and distribution of these cases into six categories of process failure that were identified. KEY RESULTS: 22.3% of patients (N = 172) failed to undergo timely recommended workup for rectal bleeding. Largest failure categories were patients for whom no procedure was ordered (N = 62, 36%), followed by patients with procedures ordered but never scheduled (N = 44, 26%) or scheduled but subsequently cancelled or not kept (N = 31, 18%). While open loops increased after the onset of the COVID-19 pandemic, this difference was not significant within our study period. CONCLUSIONS: Significant numbers of patients presenting to primary care with rectal bleeding fail to undergo recommended workup. The majority either have no procedure ordered, or procedure ordered but never scheduled or cancelled and not kept, suggesting these are important failure modes to target in future interventions. Ensuring reliable ordering and processes for timely scheduling and completion of procedures represent critical areas for improving the diagnostic process for patients with rectal bleeding in primary care.

Completion of Recommended Tests and Referrals in Telehealth vs In-Person Visits.

Importance: Use of telehealth has increased substantially in recent years. However, little is known about whether the likelihood of completing recommended tests and specialty referrals-termed diagnostic loop closure-is associated with visit modality. Objectives: To examine the prevalence of diagnostic loop closure for tests and referrals ordered at telehealth visits vs in-person visits and identify associated factors. Design, Setting, and Participants: In a retrospective cohort study, all patient visits from March 1, 2020, to December 31, 2021, at 1 large urban hospital-based primary care practice and 1 affiliated community health center in Boston, Massachusetts, were evaluated. Main Measures: Prevalence of diagnostic loop closure for (1) colonoscopy referrals (screening and diagnostic), (2) dermatology referrals for suspicious skin lesions, and (3) cardiac stress tests. Results: The study included test and referral orders for 4133 patients (mean [SD] age, 59.3 [11.7] years; 2163 [52.3%] women; 203 [4.9%] Asian, 1146 [27.7%] Black, 2362 [57.1%] White, and 422 [10.2%] unknown or other race). A total of 1151 of the 4133 orders (27.8%) were placed during a telehealth visit. Of the telehealth orders, 42.6% were completed within the designated time frame vs 58.4% of those ordered during in-person visits and 57.4% of those ordered without a visit. In an adjusted analysis, patients with telehealth visits were less likely to close the loop for all test types compared with those with in-person visits (odds ratio, 0.55; 95% CI, 0.47-0.64). Conclusions: The findings of this study suggest that rates of loop closure were low for all test types across all visit modalities but worse for telehealth. Failure to close diagnostic loops presents a patient safety challenge in primary care that may be of particular concern during telehealth encounters.

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

Ideally, urgent dermatology referrals for evaluation of a lesion concerning for skin cancer should be triaged and processed with appropriate urgency by primary care and dermatology, respectively. We performed a retrospective single-institution study by conducting chart reviews of all dermatology referrals designated by primary care as urgent for evaluation of a lesion concerning for skin cancer. We identified 320 referrals placed between January 1 and December 31, 2018. Dermatology encounters for these patients occurred on or before 30 days for 50.6% of referrals and on or after 31 days for 38.4% of referrals, with 10.9% never completed. The percentage of all races excluding whites, non-Hispanic in the delayed appointment group (≥ 31 days) was 15.1% higher (95% CI 5.3-24.9) than in the timely appointment group (≤ 30 days). Similarly, the percentage of non-English languages in the delayed group was 7.1% higher (95% CI 0.5-13.7) than in the timely group. Overall, 15.8% of these referrals yielded diagnoses of malignancy, while 76.8% and 7.4% resulted in benign and pre-malignant diagnoses, respectively. The primary care team documented referral status (i.e., completed, incomplete, or pending) during their subsequent visits with the patients in only 37.5% of these referrals. Our findings demonstrate the need to improve the reliability of urgent referrals to ensure they occur in a timely manner with confirmation of "referral loop" closure at the referring clinician's end.

Systems engineering analysis of diagnostic referral closed-loop processes.

BACKGROUND: Closing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%-73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes. OBJECTIVE: Conduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case. METHODS: An interdisciplinary team of clinicians, systems engineers, quality improvement specialists, and patient representatives collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health centre and a teaching practice within a large academic medical centre. Results were used to conduct an engineering process analysis, assess variation within and between practices, and identify common failure modes and potential solutions. RESULTS: Processes to complete diagnostic referrals involve many sub-standard design constructs, with significant workflow variation between and within practices, statistical instability and special cause variation in completion rates and timeliness, and only 21% of all process activities estimated as value-add. Failure modes were similar between the two practices, with most process activities relying on low-reliability concepts (eg, reminders, workarounds, education and verification/inspection). Several opportunities were identified to incorporate higher reliability process constructs (eg, simplification, consolidation, standardisation, forcing functions, automation and opt-outs). CONCLUSION: From a systems science perspective, diagnostic referral processes perform poorly in part because their fundamental designs are fraught with low-reliability characteristics and mental models, including formalised workaround and rework activities, suggesting a need for different approaches versus incremental improvement of existing processes. SE perspectives and methods offer new ways of thinking about patient safety problems, failures and potential solutions.

Lessons in translation: insights from a collaboration integrating community health workers into diabetes care.

Beginning in 2007, a community health center and a community health worker organization collaborated on a community health worker initiative to improve diabetes outcomes among underserved communities. Despite a shared vision, the initiative ended prematurely because of a number of unexpected collaborative challenges. This article describes the results of a qualitative investigation into these challenges. Through examples, we show how our collaborative difficulties were due to 3 interacting influences: logistics, participation, and institutional culture. We argue for the importance of institutional cultural competency in health care collaborations and provide recommendations for future collaborations that takes into account these 3 overarching influences.

Collective memory, candidacy, and victimisation: community epidemiologies of breast cancer risk.

Collectively shared ideas of community may be equally relevant for the study of health disparities as quantifying the relationship between community structures and health. Data from focus groups (N = 18) that explored understandings of breast cancer and breast cancer risk in African American neighbourhoods revealed three conceptual domains where shared ideas of community informed responses: collective memory, community candidacy, and community victimisation by external aggressors. Reading the focus group responses in terms of these domains identified perceptions of risk and of candidacy that may be overlooked by individualised or quantitative approaches to studying breast cancer risk perceptions and related behaviours. These include novel perceived risks, such as the 'risk of knowing', as well as community-level constructions of breast cancer candidacy. 'Lay epidemiologies' of breast cancer within this population might therefore be better understood as 'community epidemiologies', where community is central to the interpretation and operationalisation of breast cancer risk. Paying attention to such community epidemiologies of breast cancer provides theoretical insights for studying breast cancer disparities and risk perceptions as well as useful guidance for designing interventions.

Impact of incidental bilateral salpingo-oophorectomy in a family member on breast cancer risk assessment: clinical considerations.

BACKGROUND: Hysterectomy (TAH/TVH) with bilateral salpingo-oophorectomy (BSO) remains prevalent in the general population; however, current risk tools do not account for the potential impact of BSO on breast cancer risk calculations in family members. METHODS: CancerGene software was used to estimate the effect of BSO in a family member on proband risk across a range of simulated family cancer histories. RESULTS: Impact of BSO on proband risk appears most salient when it occurs in a first-degree relative. Race appears to modify the attainment of clinically significant risk thresholds, suggesting possible systematic risk underestimations among black women. CONCLUSIONS: When clinicians calculate risk in families where a close relative had BSO, they may choose to supplement standard risk calculations with numerical ranges of risk that account for the risk-reducing effect of BSO. More consideration is needed of whether failing to account for BSO in risk models perpetuates race-based health disparities.

"Why take it if you don't have anything?" breast cancer risk perceptions and prevention choices at a public hospital.

BACKGROUND: Despite advances in breast cancer risk assessment and risk reduction technologies, little is still known about how high-risk women make sense of their risk and assess prevention options, particularly among minority and low-income women. Qualitative methods explore the complex meanings and logics of risk and prevention that quantitative approaches overlook. OBJECTIVE: This study examined how women attending a high risk breast cancer clinic at a public hospital conceptualize their breast cancer risk and think about the prevention options available to them. METHODS: Semi-structured interviews were used to gather data from 33 high-risk women (75% African American) between May and August 2004. Interview transcripts were analyzed for recurrent themes and patterns. RESULTS: Despite general awareness of their objective risk status, many women in this study reported they did not feel "high risk" because they lacked signs and symptoms of cancer. Risk was described as an experienced acute problem rather than a statistical possibility. Women also frequently stated that thinking about cancer might cause it to happen and so it is better not to "dwell on it." While screening was welcomed, women were generally skeptical about primary prevention. In particular, preventive therapies were perceived to cause problems and were only acceptable as treatment options for a disease. CONCLUSIONS: The body of ideas about risk and prevention expressed by this population differ from the medical model. These findings have implications for risk perception research as well as for the efficacy of risk communication and prevention counseling in clinical contexts.

Internet marketing of bariatric surgery: contemporary trends in the medicalization of obesity.

In the context of political, economic, and scientific anxiety around the 'epidemic' rise in obesity in the US, the social and historical forces engendering the medicalization of obesity have been widely discussed. However, the recent growth of bariatric-weight loss-surgery and the expanding presence of advertising for bariatric surgery on the Internet suggest the possible emergence of new loci and languages of medicalization. We sought to identify the nature and extent to which web advertising of bariatric surgery contributes to the medicalization of obesity by examining the design and textual content of 100 bariatric surgery center websites. We found that websites, through strategic use of text and images, consistently describe obesity as a serious disease that requires professional ascertainment and supervision, entails substantial individual suffering, and is remedied through the transformative yet low risk effects of bariatric surgery. In the process, social normalcy and risk reduction come to replace physical criteria as the basis for determining health. Further, websites draw upon contradictory discourses of medicalization; that is, they insist upon 'external' (e.g. genetics, environment) causes of obesity to legitimize surgical intervention while implicating individual behaviors in surgical failure. From this, we suggest that the economic and professional motivations underlying website advertisements for bariatric surgery may result in confusing messages being sent to prospective patients as well as the perpetuation of gendered notions of obesity and the entrenchment of health disparities.

Measuring culture: a critical review of acculturation and health in Asian immigrant populations.

The number of studies examining how acculturation affects the health of Asian immigrants has increased in recent years. The proliferation of studies reflects the growing size and heterogeneity of Asian immigrant populations in the United States, Canada, Australia, New Zealand, and the United Kingdom. This paper compares various approaches to acculturation within the health literature on Asian immigrants by reviewing the literature in three-health domains (1) mental health (2) physical health and (3) health services use. The review critically examines the conceptualizations and measures of acculturation in these three domains and presents major findings. We observe that measurement difficulties posed by the experiences of heterogeneous Asian groups compound theoretical and disciplinary disparities between acculturation instruments. The extent to which conceptual and methodological critiques of acculturation studies in Hispanic populations apply to studies of Asian populations is also discussed. The critical review thus provides insights into the diverse ways that the relationship between culture and health is measured in this complicated and growing literature.