Improve Advance Care Planning: A Brief Report Discussing Goals of Care Interventions to Improve Communication Among Health Care Teams and Patients Maximizing the Use of the Electronic Health Record Tools.

Introduction: A key element of advance care planning (ACP) is the goals of care (GOC) conversation between the provider and the patient. The value of meaningful GOC conversations for the patient, provider, and health care institution is well documented. However, if the GOC documentation is buried in the medical record, not well defined, or poorly documented, that value is squandered. The Improvement Process: Interventions were implemented with oncology physicians and nurse practitioners (NPs). These included education, system reform including improving the ease and consistency of documentation of ACP, and regular feedback. Results: Participants reported increased confidence in communication skills about GOC conversations postworkshops. Data results for the tracked metrics, health care power of attorney, code status, and GOC, all showed improvement. Conclusion: Physicians and NPs recognized the importance of GOC conversations as part of ACP. Considerable progress was made by focusing on GOC conversations, maximizing information technology, participating in coaching, and ongoing data monitoring.

Giving Patients the Focused Attention They Deserve.

This viewpoint discusses the need for physicians to give focused attention to patients and the challenges that prevent them from doing so and suggests goals to create conditions that ensure that physicians are fully present during patient visits.

Making sense of diabetes medication decisions: a mixed methods cluster randomized trial using a conversation aid intervention.

PURPOSE: To determine the effectiveness of a shared decision-making (SDM) tool versus guideline-informed usual care in translating evidence into primary care, and to explore how use of the tool changed patient perspectives about diabetes medication decision making. METHODS: In this mixed methods multicenter cluster randomized trial, we included patients with type 2 diabetes mellitus and their primary care clinicians. We compared usual care with or without a within-encounter SDM conversation aid. We assessed participant-reported decisions made and quality of SDM (knowledge, satisfaction, and decisional conflict), clinical outcomes, adherence, and observer-based patient involvement in decision-making (OPTION12-scale). We used semi-structured interviews with patients to understand their perspectives. RESULTS: We enrolled 350 patients and 99 clinicians from 20 practices and interviewed 26 patients. Use of the conversation aid increased post-encounter patient knowledge (correct answers, 52% vs. 45%, p = 0.02) and clinician involvement of patients (Mean between-arm difference in OPTION12, 7.3 (95% CI 3, 12); p = 0.003). There were no between-arm differences in treatment choice, patient or clinician satisfaction, encounter length, medication adherence, or glycemic control. Qualitative analyses highlighted differences in how clinicians involved patients in decision making, with intervention patients noting how clinicians guided them through conversations using factors important to them. CONCLUSIONS: Using an SDM conversation aid improved patient knowledge and involvement in SDM without impacting treatment choice, encounter length, medication adherence or improved diabetes control in patients with type 2 diabetes. Future interventions may need to focus specifically on patients with signs of poor treatment fit. CLINICAL TRIAL REGISTRATION: ClinicalTrial.gov: NCT01502891.

A Model for Improving Adherence to Prescribing Guidelines for Chronic Opioid Therapy in Rural Primary Care.

OBJECTIVE: To describe the steps taken and results obtained by a rural primary care practice to effectively implement opioid prescribing guidelines. PATIENTS AND METHODS: Between December 1, 2014, and May 30, 2017, a quality improvement project was undertaken. Elements included prescribing registries, a nurse coordinator, and an Opioid Use Review Panel. Clinic workflow was redesigned to more consistently incorporate these and other guideline recommendations into practice. The effect on opioid prescribing was measured as well as patient outcomes. RESULTS: There were 462 patients meeting inclusion criteria before implementation. At the conclusion, 16 patients (3%) had died, 9 patients (2%) were no longer seeing clinicians participating in the project, and 2 patients (0.4%) had transitioned to hospice or long-term care facilities. Of the remaining 435 patients, 96 (22.1%; 95% CI, 18.4-26.2) had decreased prescribing below the threshold for inclusion or were no longer receiving opioid prescriptions. Originally, 64 patients (13.9%; 95% CI, 11.0-17.3) were using average daily doses equal to or greater than 90 morphine milligram equivalents. After implementation, 54 of 435 patients (12.4%; 95% CI, 9.6-15.8) were still using equal to or greater than 90 morphine milligram equivalents per day after accounting for death or loss to follow-up. CONCLUSION: A change in clinic process to implement guidelines for prescribing of chronic opioid therapy was completed. It was associated with a decrease in the number of patients using chronic opioid therapy, primarily at lower doses. This was accomplished in a rural practice with very limited resources in pain medicine, psychiatry, and addiction medicine.

Evaluating the structure of the Patient Assessment of Chronic Illness Care (PACIC) survey from the patient's perspective.

BACKGROUND: The Patient Assessment of Chronic Illness Care (PACIC) survey is a widely used instrument to assess the patient experience with healthcare delivery. PURPOSE: This study aims to evaluate the factorial structure of PACIC from the patient perspective. METHODS: A postal survey was mailed to 4,796 randomly selected adults with diabetes from 34 primary care clinics. Internal consistencies of PACIC subscales were assessed by Cronhach's α. Factorial structure was evaluated by confirmatory and exploratory factor analyses. RESULTS: Based on responses of 2,055 patients (43% response rate), exploratory factor analysis discerned a 4-factor, not 5-factor, model dominated by patient evaluation of healthcare services (explaining 74% of the variance). The other 3 factors addressed patient involvement (goal setting, participating in the healthcare team) and social support for self-management. CONCLUSIONS: The underlying factorial structure of PACIC, which reflects the patient perspective, is dynamic, patient-centered, and differs from the original 5-factor model that was more aligned with views of healthcare delivery stakeholders.

Improving hypertension control in diabetes: a multisite quality improvement project that applies a 3-step care bundle to a chronic disease care model for diabetes with hypertension.

Hypertension in diabetes patients leads to significant morbidity and mortality. Nonetheless blood pressure (BP) control in patients with diabetes remains disappointing. The authors applied a care bundle to decrease the proportion of patients with BP exceeding 130/80. Teams from 4 sites in 3 states (Minnesota, Florida, and Arizona) developed a bundle consisting of a standardized BP process, an order set, and a patient goal. Baseline data were collected in the first 12 weeks, followed by 6 weeks of implementing changes. The final 16 weeks represented the intervention. There was a statistically significant decrease in the proportion of patients with uncontrolled BP in 3 of 4 sites (P < .0001 in all 3 sites demonstrating improvement). There was a statistically significant improvement in the satisfaction survey (P = .0011). Implementing an evidence-based care bundle for hypertension in diabetes mellitus can improve BP outcomes.

Does the "office nurse" level of training matter in the family medicine office?

BACKGROUND: The "office nurse" or clinical associate (registered nurse [RN], licensed practical nurse[LPN], or medical assistant [MA]) is a key member of the family medicine care team, but little is known about the influence of their level of training on team performance. METHODS: The performance of the clinical dyad (clinician and associate) was studied in relation to the level of training of the nurse. The dyad's performance was measured by the performance indicators of diabetes scores, patient satisfaction, and productivity. RESULTS: Dyads with a RN scored higher in meeting all 5 of the diabetes quality indicators (27.8%) than those with a LPN (19.3%) or an MA (14.7%). For patient satisfaction, the RN dyads also scored higher than the other dyad groups (positive responses: RN, 96.8%; LPN, 95.5%; MA, 94.6%). Productivity was the same in all groups. Better diabetes performance was seen in those practices with fewer competing demands: nonrural versus rural (22.2% vs 15.1%, respectively), and those not doing obstetrics versus those doing obstetrics (20.3% vs 15.1%, respectively), and for physicians versus associate providers (18.8% vs 15.1%, respectively). Higher patient satisfaction was observed in those dyads who were nonrural verus rural (96.6 vs 94.1%), among those doing obstetrics (96.0% vs 94.9%), and in physicians verus associate providers (95.7% vs 93.2%). The number of years working with the same clinician was twice as high for RNs (6.63) and LPNs (6.57) than for MAs (3.29). CONCLUSIONS: A higher level of education of the clinical associate seems to confer skills that enhance the care team's management of chronic illness such as diabetes. This could potentially decrease the practice burden on other team members while facilitating the team's objectives in meeting quality indicators.

Patient characteristics of provider survey respondents: no evidence of nonresponse bias.

Surveys of physicians are an important tool to assess opinions and self-reported behaviors of this policy-relevant population. However, this population is notoriously difficult to survey and plagued with low and falling response rates. In order to evaluate the potential import of response rate, we examine the presence of nonresponse bias in a survey of physicians providing diabetes care that achieved a 36% response rate. Unlike other studies examining differences in individual characteristics for responding and nonresponding physicians, we also assess differences with respect to aggregate patient demographic, clinical, and behavioral characteristics. We are unable to demonstrate nonresponse bias, even with what could be construed as a relative low response rate. Nonetheless as the threat of nonresponse bias can never be completely assuaged, we believe that it should be monitored as a matter of course in physician surveys and offer a new dimension by which it can be evaluated.

Offering results to participants in a diabetes survey: effects on survey response rates.

BACKGROUND: There are many reasons why an investigator may choose to share results with survey respondents; however, the practice is not universal. Moreover, while there is some evidence that the practice increases response rates, it is of limited generalizability. OBJECTIVE: The aim of this study was to determine both the impact on survey response rates of offering study results to participants, and the extent to which surveyed individuals with diabetes mellitus want results reported back from a postal questionnaire. METHODS: In November-December 2009, we surveyed 4796 randomly selected individuals from a US Midwestern health system diabetes registry. Half of the sample was randomized to receive an offer of survey results as an incentive. Response rates were compared across the two groups. Within the group offered results, we compared those that requested them with those that declined with respect to demographic characteristics, self-reported diabetes severity, and characterization of care received for diabetes. RESULTS: The overall response rate was 42.8% (n = 2055). Offering survey results did not impact response rates overall or within specific subpopulations. Of those randomized to the offer of results, 62.1% requested the results (n = 618). Requests for results differed by educational attainment and the rating of diabetes care as poor, although only education remained a significant predictor in multivariate analysis. There were no differences in rates of requests by disease severity or overall health status. CONCLUSION: Offering survey results to potential respondents did not increase the likelihood of response among a patient population with diabetes. Of those that were offered results and returned the survey, 62.1% requested that they receive study results, indicating a potentially important educational opportunity. However, as result requests were driven more by educational attainment than by health status, investigators may want to send results to everyone, not just those that request them.

How should clinicians and patients choose antihyperglycemic agents?: an evidence-based approach.

The choice of antihyperglycemic agents has become more complex as new drug classes have appeared and evidence about their efficacy and safety accumulates. Unfortunately, direct and fair comparisons are lacking and the clinician and patient are left to decide among agents with different safety and burden profiles. Furthermore, the relative efficacy of these agents beyond their ability to lower hemoglobin A1c - that is, in their ability to reduce the risk of diabetes complications - remains uncertain. In this sea of uncertainty, interests other than those of the patient actively shape choices. It is our expectation that better evidence, better policy and better decisions will eventually become routine in the care of patients with diabetes.

Individuals with diabetes preferred that future trials use patient-important outcomes and provide pragmatic inferences.

OBJECTIVE: We sought to examine patients' preferences regarding the design of diabetes trials. Specifically, do patients prefer trials to focus on patient-important outcomes (vs. surrogate outcomes) and provide practical/pragmatic answers (vs. mechanistic/explanatory answers)? STUDY DESIGN AND SETTING: We mailed a questionnaire to a stratified random sample of 4,796 patients with diabetes receiving care from 371 primary care clinicians in the US Midwest. Medical record review provided data on hemoglobin A1c (HbA1c). Descriptive statistics, logistic regression, and multiple regression techniques were used for analysis. RESULTS: We received completed surveys from 2,036 patients (response rate of 42.5%). On average, respondents were 65 years old, had 11 years of diabetes, and had excellent glycemic control (HbA1c=7%). Most patients (>75%) chose patient-important outcomes rather than HbA1c as their first choice for a trial primary outcome and preferred a practical trial design. Patients with poor glycemic control (HbA1c>8.0%) were more likely to prefer HbA1c as a primary end point (odds ratio: 1.5; 95% confidence interval: 1.1, 2.1). CONCLUSION: Individuals with diabetes report a strong preference for practical trials measuring the effect of treatments on patient-important outcomes. To our knowledge, this is the first report of patients endorsing key elements of the comparative effectiveness agenda.