Rebooting the ambulatory enterprise in a community medical group in Kentucky following the initial surge of COVID-19.

ABSTRACT: The novel coronavirus disease 2019 (COVID-19) pandemic has intensified globally since its origin in Wuhan, China in December 2019. Many medical groups across the United States have experienced extraordinary clinical and financial pressures due to COVID-19 as a result of a decline in elective inpatient and outpatient surgical procedures and most nonurgent elective physician visits. The current study reports how our medical group in a metropolitan community in Kentucky rebooted our ambulatory and inpatient services following the guidance of our state's phased reopening. Particular attention focused on the transition between the initial COVID-19 surge and post-COVID-19 surge and how our medical group responded to meet community needs. Ten strategies were incorporated in our medical group, including heightened communication; ambulatory telehealth; safe and clean outpatient environment; marketing; physician, other medical provider, and staff compensation; high quality patient experience; schedule optimization; rescheduling tactics; data management; and primary care versus specialty approaches. These methods are applicable to both the current rebooting stage as well as to a potential resurgence of COVID-19 in the future.

Reduction in Schedule II opioid prescribing by primary care -providers, orthopedic and general surgeons, and pain -management specialists following the implementation of a State House Bill and an Institutional Controlled Substance Task Force.

OBJECTIVE: Prescription opioid misuse represents a social and economic challenge in the United States. We evaluated Schedule II opioid prescribing practices by primary care providers (PCPs), orthopedic and general surgeons, and pain management specialists. DESIGN: Prospective evaluation of prescribing practices of PCPs, orthopedic and general surgeons, and pain management specialists over 5 years (October 1, 2014-September 30, 2019) in an outpatient setting. METHODS: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards at our institution. RESULTS: There were significantly more PCPs, orthopedic and general surgeons, and pain management specialists with a significantly increased number who prescribed Schedule II opioids, whereas there was a simultaneous significant decline in the average number of Schedule II opioid prescriptions per provider, Schedule II opioid pills prescribed per provider, and Schedule II opioid pills prescribed per patient by providers. The average number of Schedule II opioid prescriptions with a quantity >90 and Opana/Oxycontin prescriptions per PCP, orthopedic surgeon, and pain management specialist significantly decreased. The total morphine milligram equivalent (MME)/day of Schedule II opioids ordered by PCPs, orthopedic and general surgeons, and pain management specialists significantly declined. The ages of the providers remained consistent throughout the study. CONCLUSIONS: This study reports the implementation of federal and state regulations and institutional evidence-based guidelines into primary care and medical specialty practices to reduce the number of Schedule II opioids prescribed. Further research is warranted to determine alternative therapies to Schedule II opioids that may alleviate a patient's pain without initiating or exacerbating a potentially lethal opioid addiction.

Multidisciplinary approach to enhancing provider well-being in a metropolitan medical group in the United States.

BACKGROUND: Physician burnout refers to depersonalization, emotional exhaustion, and a sense of lower personal accomplishment. Affecting approximately 50% of physicians in the United States, physician burnout negatively impacts both the physician and patient. Over a 3-year-period, this prospective study evaluated the multidisciplinary approach to decreasing provider burnout and improving provider well-being in our metropolitan community. METHODS: A multidisciplinary Well-Being Task Force was established at our Institution in 2017 to assess the myriad factors that may play a role in provider burnout and offer solutions to mitigate the stressors that may lead to decreased provider well-being. Four multifaceted strategies were implemented: (1) provider engagement & growth; (2) workflow/office efficiencies; (3) relationship building; and (4) communication. Providers at our Institution took the Mayo Clinic's well-being index survey on 3 occasions over 3 years. Their scores were compared to those of providers nationally at baseline and at 1 and 2 years after implementing organizational and individualized techniques to enhance provider well-being. Lower well-being index scores reflected better well-being. RESULTS: The average overall well-being index scores of our Institution's providers decreased from 1.76 at baseline to 1.32 2 years later compared to an increase in well-being index scores of physicians nationally (1.73 to 1.85). Both male and female providers' average well-being index scores at our Institution decreased over the 3 years of this study, from 1.72 to 1.58 for males and 1.78 to 1.21 for females, while physicians' scores nationally increased for both genders. The average well-being index scores were highest for providers at our Institution who graduated from medical school less than 5 years earlier (2.0) and who graduated 15-24 years earlier (2.3), whereas the average lowest scores were observed in providers who graduated ≥25 years earlier (1.37). Obstetricians/gynecologists and internal medicine physicians had the highest average well-being index scores (2.48 and 2.4, respectively) compared to other medical specialties. The turnover rate of our Institution's providers was 5.6% in 2017 and 3.9% in 2019, reflecting a 30% decrease. CONCLUSION: This study serves as a model to reduce provider burnout and enhance well-being through both organizational and individual interventions.

Healthcare system approach to managing COVID-19 in a metropolitan community in Kentucky.

The novel coronavirus disease 2019 (COVID-19) pandemic emerged in Wuhan, China in December 2019 and has subsequently escalated exponentially worldwide. As this virus has never been experienced previously, it poses a significant challenge to healthcare systems who are poorly equipped to handle the large number of gravely ill patients who seek medical attention. Additionally, treating providers are placing their own lives at risk due to the lack of adequate personal protective equipment. We are reporting the proactive measures that were implemented at our healthcare system in a metropolitan community in Kentucky to address COVID-19. The primary goal was to maintain a safe environment for providers, staff, and patients. Three key strategies were incorporated at our healthcare system, including.

Multidisciplinary approach to low-dose CT screening for lung cancer in a metropolitan community.

BACKGROUND: Lung cancer is the primary cause of cancer death in men and women in the USA, led by Kentucky. In 2015, the Centers for Medicare and Medicaid Services initiated annual lung cancer screening with a low-dose computed tomography (LDCT) scan. This observational cohort study evaluated the multidisciplinary approach to this screening in our metropolitan community. METHODS: We present the prospective findings of patients who underwent a screening lung LDCT scan over a 2-year period at our institution in Kentucky. Patients who fulfilled the screening criteria were identified during an office visit with their primary care provider. RESULTS: Of the 4170 patients who underwent a screening lung LDCT scan, a total of 838 (20.9%) patients had nodules >4 mm. Of the 70 patients diagnosed with lung cancer, Stage 1 non-small cell lung cancer was most commonly detected [38 cases (54.3%)]. A follow-up lung LDCT scan (n = 897), pulmonary function test (n = 157), positron emission tomography scan (n = 12) and a lung biopsy (n = 53) were performed for certain individuals who had anomalies observed on the screening lung LDCT scan. A total of 42% of patients enrolled in group tobacco cessation classes quit smoking. CONCLUSIONS: This study provides a unique perspective of a lung LDCT scan screening program driven by primary care providers in a state plagued by cigarette smoking and lung cancer deaths and offers a valuable message into the prevention, high-risk screening and diagnosis of lung cancer.

Standardized warfarin monitoring decreases adverse drug reactions.

BACKGROUND: While warfarin is the most commonly prescribed medication to prevent thromboembolic disorders, the risk of adverse drug reactions (ADR) poses a serious concern. This prospective study evaluated how primary care providers (PCP) and cardiologists at our Institution managed patients treated with warfarin with the goal of decreasing the number of warfarin ADRs. METHODS: A multidisciplinary anticoagulation task force was established at our Institution in 2014 to standardize warfarin monitoring and management. Between 2013 and 2017, we analyzed patients who were prescribed warfarin by their PCP or cardiologist upon hospital discharge and in the ambulatory setting to determine the international normalized ratio (INR) within 5, 10, and 30 days after discharge, time in therapeutic range (TTR), number of severe warfarin ADRs, and total and average cost reduction of all severe warfarin ADRs to determine whether there was an organizational cost savings following the implementation of standardized warfarin care. RESULTS: The warfarin ADR rate significantly decreased over the 5-year period, from 3.8 to 0.98% (p < 0.0001). The proportion of warfarin prescriptions out of all anticoagulants significantly decreased, from 72.2 to 42.1% (p < 0.001). The proportion of individuals who received an INR at 5, 10, and 30 days after hospital discharge compared to the total number of patients prescribed warfarin significantly increased (p < 0.001). The total cost of severe warfarin ADRs decreased by 57.6% between 2013 and 2017. CONCLUSIONS: This study serves as a model to reduce the number of severe warfarin ADRs by the following tactics: (1) educating PCPs and cardiologists about evidence-based guidelines for warfarin management, (2) increasing the use of our Institution's electronic warfarin module, and (3) enhancing patient compliance with obtaining INR.

Decline in primary care providers' prescribing of Schedule II opioids following the implementation of federal and state guidelines.

OBJECTIVE: Prescription opioid misuse represents a social and economic dilemma in the United States. The authors evaluated primary care providers' (PCPs) prescribing of Schedule II opioids at our institution in Kentucky. DESIGN: Prospective evaluation of PCPs' prescribing practices over a 3-year period (October 1, 2014 to September 30, 2017) in an outpatient setting. METHODS: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards. Special attention focused on Schedule II opioid prescriptions with a quantity > 90, Opana/Oxycontin, and morphine equivalent daily dosage. RESULTS: A statistically significant increase in the total number of PCPs and PCPs who prescribed Schedule II opioids was observed, while there was a concurrent significant decrease in the average number of Schedule II opioid pills prescribed per PCP, Schedule II opioid prescriptions per PCP, Schedule II opioid pills prescribed per patient by PCPs, Schedule II opioid prescriptions with a quantity > 90 per PCP, and Opana/Oxycontin prescriptions per PCP. A statistically significant decline in the average morphine equivalent daily dosage of Schedule II opioids per PCP was noted. CONCLUSIONS: This study reports the benefit of incorporating federal and state regulations and institutional evidence-based guidelines into primary care practice to decrease the number of Schedule II opioids prescribed. Further preventive measures include selecting alternative treatments to opioids and reducing the rates of opioid nonmedical use and overdose while maintaining access to prescription opioids when indicated.

Impact of parenting on the development of chronic diseases in adulthood.

The life course theory refers to a method developed in the 1960s that utilizes a multifaceted approach to evaluate people's lives, structural contexts, and social change. Adversities in childhood are associated with a heightened risk of chronic illnesses in adulthood. Parents play an important role in developing self-esteem, self-confidence, and effective coping mechanisms in their children. We discuss the myriad adverse childhood experiences that may contribute to the development of chronic diseases in adulthood and offer several strategies aimed at mitigating the effects of adverse childhood experiences and educating parents about their responsibilities of nurturing and preparing a child for life.

The S-curve discontinuity theory predicts the path towards a "well" society and increased longevity.

The logistic function or logistic growth curve is an "S" shape (sigmoid curve) that has been applied to numerous fields, including geology, physics, biology, mathematics, chemistry, economics, sociology, oncology, and statistics. The S-curve initiates with exponential growth, followed by slowing of growth as saturation occurs, and completion of growth at maturity. The S-curve follows the law of natural growth with a limiting factor, whether it be a competition for resources, investigation and demand for new products, or an economic bubble. The concept of the S-curve has been utilized in medicine to describe the advancements in the 20th century based on the diagnosis and treatment of disease (the "illness" curve [first S-curve]) and predict the future focused on disease prevention and health promotion (the "wellness" curve [second S-curve]). Herein, we propose a third S-curve that we are labeling the "longevity" curve.

Primary care providers' prescribing practices of opioid controlled substances.

OBJECTIVE: Prescription opioid abuse poses a significant public health concern. House Bill 1 (HB1) was enacted in 2012 to address prescription drug abuse in Kentucky. The authors investigated the impact of HB1 on primary care providers' (PCPs) prescribing practices of Schedule II controlled substances. DESIGN: Retrospective evaluation of PCPs' prescribing practices in an adult outpatient setting. METHODS: A review of the prescribing practices for Schedule II controlled substances written by 149 PCPs. The number of prescriptions for Schedule II controlled substances written by 149 PCPs was compared to the top 10 PCP prescribers. Attention was focused on providers who wrote for oxycontin and/or opana and prescriptions with > 90 pills dispensed. RESULTS: The top 10 PCP prescribers accounted for 38.4 percent of the Schedule II controlled substances and 47.8 percent of the Schedule II controlled substances with > 90 pills dispensed. Of the 60 PCPs who prescribed opana and/or oxycontin, the average number of prescriptions was 14.7 compared to 51.0 for the top 10 PCP prescribers. The average percentage of Schedule II controlled substance prescriptions compared to the total number of prescriptions was 27.9 percent for the top 10 PCP prescribers and 7.05 percent of all PCPs. The average percentage of office visits with Schedule II controlled substance prescriptions compared to total office visits was 24.8 percent for the top 10 PCP prescribers versus 7.7 percent for all PCPs. CONCLUSIONS: Further scrutiny is warranted to more closely analyze provider opioid prescribing habits and ensure that the providers at our Institution are prescribing Schedule II controlled substances in compliance with HB1.