Implementing an osteoarthritis management program to deliver guideline-driven care for knee and hip osteoarthritis in a U.S. academic health system.

Objective: Assess implementation feasibility and outcomes for an Osteoarthritis Management Program (OAMP) at an academic center. Design: This open study assessed an OAMP designed to deliver care in 1-5 individual or group visits across ≤12 months. Eligibility included adults with knee or hip osteoarthritis with ≥1 visit from 7/1/2017-1/15/2021. A multidisciplinary care team provided: education on osteoarthritis, self-management, exercise, weight loss; pharmacologic management; assessments of mood, sleep, quality of life, and diet. Clinic utilization and growth are reported through 2022. Patient outcomes of body mass index (BMI), pain, and function were analyzed using multivariable general linear models. OAMP outcomes were feasibility and sustainability. Results: Most patients were locally referred by primary care. 953 patients attended 2531 visits (average visits 2.16, treatment duration 187.9 days). Most were female (72.6%), older (62.1), white (91.1%), and had medical insurance (95.4%). Obesity was prevalent (84.7% BMI ≥30, average BMI 40.9), mean Charlson Comorbidity Index was 1.89, and functional testing was below average. Longitudinal modeling revealed statistically but not clinically significant pain reduction (4.4-3.9 on 0-10 scale, p â€‹= â€‹0.002). BMI did not significantly change (p â€‹= â€‹0.87). Higher baseline pain and BMI correlated with greater reductions in each posttreatment. Uninsured patients had shorter treatment duration. Increasing clinic hours (4-24 â€‹h weekly) and serving 953 patients over four years demonstrated OAMP sustainability. Conclusions: OAMP implementation was feasible and sustainable. Patients with high baseline pain and BMI were more likely to improve. Noninsurance was a barrier. These results contribute to understanding OAMP outcomes in U.S. healthcare.

Feasibility Study of a Low-Carbohydrate/Time-Restricted Eating Protocol for Insulin-Using Type 2 Diabetic Patients.

INTRODUCTION: Low-carbohydrate diets and time-restricted eating are methods to improve hemoglobin A1C in patients with type 2 diabetes. However, insulin-using patients are often counseled against these practices due to hypoglycemia concerns. This observational study evaluated a protocol utilizing both methods coupled with proactive insulin titration. OBJECTIVES: To evaluate the safety and feasibility of a timed eating protocol for insulin-using patients and to assess its impact on outcomes, including insulin use and hemoglobin A1C. METHODS: Participants included insulin-using adults ages 49 to 77 years with type 2 diabetes. They were counseled to eat 2 meals per day in a 6- to 8-hour window of their choosing, with a goal intake of ≤ 30 grams of carbohydrates per day. Glucose was closely monitored, and insulin was adjusted per study protocol. Primary outcomes included hypoglycemic events and compliance with timed eating. Insulin use, hemoglobin A1C, body mass index, blood pressure, and quality of life also were measured. RESULTS: Nineteen of the 20 participants completed the 6-month study. No hypoglycemic events requiring urgent medical care occurred. Symptomatic episodes with glucose between 47 and 80 mg/dl were reported by 37% (7/19) of participants. Average daily insulin use decreased by 62.2 U (P < 0.001) and insulin was discontinued for 14 participants. Average hemoglobin A1C remained unchanged. Average body mass index decreased by 4.0 (P = 0.01), systolic blood pressure decreased by 9.9 mm Hg (P = 0.02), and diabetes-related quality-of-life metrics improved significantly. CONCLUSIONS: These results demonstrate that a time-restricted eating protocol is feasible and safe for insulin-using patients with type 2 diabetes when paired with a proactive insulin titration.

Mini-Residencies to Improve Care for Women Veterans: A Decade of Re-Educating Veterans Health Administration Primary Care Providers.

Background: Many primary care providers (PCPs) in the Veterans Health Administration need updated clinical training in women's health. The objective was to design, implement, and evaluate a training program to increase participants' comfort with and provision of care to women Veterans, and foster practice changes in women's health care at their local institutions. Methods: The Women's Health Mini-Residency was developed as a multi-day training program, based on principles of adult learning, wherein knowledge gleaned through didactic presentations was solidified during small-group case study discussions and further enhanced by hands-on training and creation of a facility-specific action plan to improve women Veterans' care. Pre, post, and 6-month surveys assessed attendees' comfort with and provision of care to women. The 6-month survey also queried changes in practice, promulgation of program content, and action plan progress. Results: From 2008 to 2019, 2912 PCPs attended 26 programs. A total of 2423 (83.2%) completed pretraining and 2324 (79.3%) completed post-training surveys. The 6-month survey was sent to the 645 attendees from the first 14 programs; 297 (46.1%) responded. Comparison of pre-post responses indicated significant gains in comfort managing all 19 content areas. Six-month data showed some degradation, but comfort remained significantly improved from baseline. At 6 months, participants also reported increases in providing care to women, including performing more breast and pelvic examinations, dissemination of program content to colleagues, and progress on action plans. Conclusions: This interactive program appears to have been successful in improving PCPs' comfort in providing care for women Veterans and empowering them to implement institutional change.

Patient and physician perceptions of knee and hip osteoarthritis care: A qualitative study.

BACKGROUND: Knee and hip osteoarthritis (KHOA) are common, chronic conditions affecting function, morbidity and mortality. Although the societal burden is high and guidelines are available to guide management, many patients do not receive recommended care. We investigated patient and physician perspectives on barriers and facilitators to KHOA guideline-based treatment and patient experiences in living with KHOA and navigating care. METHODS: Thirty-minute face-to-face interviews were conducted with primary care physicians and up to 4 patients of each physician at a US academic medical center. Physicians were recruited from 1 general internal medicine clinic and 1 family medicine clinic. All of their patients diagnosed with knee or hip osteoarthritis from 2008 to 2011 and under their care during the study period (2008-2015) were mailed study recruitment materials. Interviews were audio-recorded and transcribed. Content analysis was performed using QSR NVivo. RESULTS: Six of 19 physicians (31.6%) responded to the recruitment email and completed the interview. Seventy-three patients were sent recruitment letters; 18 (24.7%) expressed interest and 11 were scheduled for and completed the interview. Many patients reported a poor understanding of osteoarthritis and available treatment options and obtained most of their information from sources other than their medical team. They expressed fear of joint pain and often modified activities to avoid all pain. Many developed complex, time intensive treatment regimens that were not always evidence-based. Physicians expressed difficulties in managing osteoarthritis given time constraints and competing agenda items at appointments. Many felt that asking patients to make lifestyle changes for weight loss and exercise was daunting and unachievable. Both physicians and patients expressed interest in obtaining osteoarthritis education. CONCLUSIONS: Although evidence-based treatments for KHOA exist, our study highlights patient and physician barriers to receipt of this care. Better educational resources and new models of care to address these barriers may contribute to improved osteoarthritis management.

Multimodal Care for Knee and Hip Osteoarthritis: A Pilot Feasibility Study of a Novel Approach to a Common Problem.

BACKGROUND: Osteoarthritis is common and debilitating. Evidence-based care exists; there is a gap between recommended and received are. Multimodal treatment is recommended, with unknown effectiveness. We report pilot feasibility data for a new university-based clinic providing multimodal care for knee and hip osteoarthritis (KHOA). METHODS: Quality-improvement case series with the first 50 patients. A multidisciplinary team provided care. Feasibility outcomes included treatment duration, patient adherence, provision of guideline-recommended care, and satisfaction. Secondary outcomes included self-reported and objectively assessed patient measures. RESULTS: Fifty patients (59±10.5 years, 32 female) received guideline-recommended care; 40 adhered to 3.83±2.21 follow-up visits over 12.24±7.79 months; satisfaction was high. Objectively assessed outcomes improved, but self-reported outcomes did not. DISCUSSION: Early data suggest multimodal care for knee and hip osteoarthritis is feasible and may be associated with improved outcomes.

Chaos in the Clinic: Characteristics and Consequences of Practices Perceived as Chaotic.

The Minimizing Error, Maximizing Outcome (MEMO) study of clinics in New York City, Chicago, and Wisconsin linked primary care work experiences to physician stress. We analyzed MEMO data to determine how chaos in the clinic was associated with work conditions and quality of care measures. Surveys and medical record audits determined practice characteristics and medical errors, respectively. Physicians rated clinic atmosphere on a scale of 1 (calm) to 5 (chaotic). Chaotic clinics were defined as practices rated either 4 or 5 by greater than 50% of clinic physicians. Forty of 112 MEMO clinics (36%) were chaotic. Compared with nonchaotic practices, these clinics served more minority and Medicaid patients and had a greater likelihood of clinic bottlenecks such as phone access (both p < .01). Physicians in chaotic clinics reported lower work control and job satisfaction, less emphasis on teamwork and professionalism, more stress and burnout, and a higher likelihood of leaving the practice within 2 years (all p < .05). Chaotic clinics had higher rates of medical errors and more missed opportunities to provide preventative services (both p < .05). More research should examine the effectiveness of organizational interventions to decrease chaos in the clinic and to mitigate its effects on patient safety.

Predictors and Outcomes of Burnout in Primary Care Physicians.

OBJECTIVE: To assess relationships between primary care work conditions, physician burnout, quality of care, and medical errors. METHODS: Cross-sectional and longitudinal analyses of data from the MEMO (Minimizing Error, Maximizing Outcome) Study. Two surveys of 422 family physicians and general internists, administered 1 year apart, queried physician job satisfaction, stress and burnout, organizational culture, and intent to leave within 2 years. A chart audit of 1795 of their adult patients with diabetes and/or hypertension assessed care quality and medical errors. KEY RESULTS: Women physicians were almost twice as likely as men to report burnout (36% vs 19%, P < .001). Burned out clinicians reported less satisfaction (P < .001), more job stress (P < .001), more time pressure during visits (P < .01), more chaotic work conditions (P < .001), and less work control (P < .001). Their workplaces were less likely to emphasize work-life balance (P < .001) and they noted more intent to leave the practice (56% vs 21%, P < .001). There were no consistent relationships between burnout, care quality, and medical errors. CONCLUSIONS: Burnout is highly associated with adverse work conditions and a greater intention to leave the practice, but not with adverse patient outcomes. Care quality thus appears to be preserved at great personal cost to primary care physicians. Efforts focused on workplace redesign and physician self-care are warranted to sustain the primary care workforce.

The effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial.

PURPOSE: Despite sincere commitment to egalitarian, meritocratic principles, subtle gender bias persists, constraining women's opportunities for academic advancement. The authors implemented a pair-matched, single-blind, cluster randomized, controlled study of a gender-bias-habit-changing intervention at a large public university. METHOD: Participants were faculty in 92 departments or divisions at the University of Wisconsin-Madison. Between September 2010 and March 2012, experimental departments were offered a gender-bias-habit-changing intervention as a 2.5-hour workshop. Surveys measured gender bias awareness; motivation, self-efficacy, and outcome expectations to reduce bias; and gender equity action. A timed word categorization task measured implicit gender/leadership bias. Faculty completed a work-life survey before and after all experimental departments received the intervention. Control departments were offered workshops after data were collected. RESULTS: Linear mixed-effects models showed significantly greater changes post intervention for faculty in experimental versus control departments on several outcome measures, including self-efficacy to engage in gender-equity-promoting behaviors (P = .013). When ≥ 25% of a department's faculty attended the workshop (26 of 46 departments), significant increases in self-reported action to promote gender equity occurred at three months (P = .007). Post intervention, faculty in experimental departments expressed greater perceptions of fit (P = .024), valuing of their research (P = .019), and comfort in raising personal and professional conflicts (P = .025). CONCLUSIONS: An intervention that facilitates intentional behavioral change can help faculty break the gender bias habit and change department climate in ways that should support the career advancement of women in academic medicine, science, and engineering.

Patient-physician racial/ethnic concordance and blood pressure control: the role of trust and medication adherence.

OBJECTIVES: To examine the associations between racial/ethnic concordance and blood pressure (BP) control, and to determine whether patient trust and medication adherence mediate these associations. DESIGN: Cross-sectional study of 723 hypertensive African-American and white patients receiving care from 205 white and African-American providers at 119 primary care clinics, from 2001 to 2005. Racial/ethnic concordance was characterized as dyads where both the patient and physician were of the same race/ethnicity; discordance occurred in dyads where the patient was African-American and the physician was white. Patient perceptions of trust and medication adherence were assessed with self-report measures. The BP readings were abstracted from patients' medical charts using standardized procedures. RESULTS: Six hundred thirty-seven patients were in race/ethnic-concordant relationships; 86 were in race/ethnic-discordant relationships. Concordance had no association with BP control. White patients in race/ethnic-concordant relationships were more likely to report better adherence than African-American patients in race/ethnic-discordant relationships (OR: 1.27, 95% CI: 1.01, 1.61, p = 0.04). Little difference in adherence was found for African-American patients in race/ethnic-concordant vs. discordant relationships. Increasing trust was associated with significantly better adherence (OR: 1.17, 95% CI: 1.04, 1.31, p < 0.01) and a trend toward better BP control among all patients (OR: 1.26, 95% CI: 0.97, 1.63, p = 0.07). CONCLUSIONS: Patient trust may influence medication adherence and BP control regardless of patient-physician racial/ethnic composition.

Patient reaction to traumatic injury and inpatient AODA consult: six-month follow-up.

This paper describes the effects of traumatic injury and an inpatient Alcohol and Other Drug Abuse consultation on patients admitted to a university hospital with a positive blood alcohol concentration. Forty-six subjects reported 6-month post-injury data on their alcohol use and treatment, referral compliance, injuries, health care utilization, motor vehicle events, and quality of life. Sixty-one percent reported abstinence in the previous 7 days and no binge consumption in the previous 30 days. Fifty percent met criteria for current depression. The sample accounted for significant post-discharge health care utilization including 206 outpatient visits and five additional hospitalizations. Thirteen percent were still receiving disability compensation and 44% missed at least 1 day of work in the last 30 days due to their injuries. The 46 subjects reported a lifetime incidence of 72 alcohol-related injuries, 74 motor vehicle crashes, and 88 other legal events.