Practice Facilitation to Address Unhealthy Alcohol Use in Primary Care: A Cluster Randomized Clinical Trial.

Importance: Unhealthy alcohol use (UAU) is the fourth most preventable cause of death in the US. The US Preventive Services Task Force recommends that primary care clinicians routinely screen all adults 18 years and older for UAU; however, this preventive service is poorly implemented. Objective: To determine if practice facilitation improved delivery of the recommended care for UAU compared to usual care. Design, Setting, and Participants: This practice-level cluster randomized clinical trial was conducted across diverse and representative primary care practices throughout Virginia. A total of 76 primary care practices enrolled between October 2019 and January 2023. Intervention: Practices received immediate (intervention) or 6-month delayed (control) practice facilitation, which included tailored educational sessions, workflow management, and tools for addressing UAU. Main Outcomes and Measures: Outcomes included the increase in recommended screening for UAU, brief interventions, referral for counseling, and medication treatment. Data were collected via medical record review (structured and free text data) and transcripts of practice facilitator sessions and exits interviews. Results: Of the 76 primary care practices enrolled, 32 were randomized to intervention and 35 to control; 11 789 patients (mean [SD] age, 50.1 [16.3] years; 61.1% women) were randomly selected for analysis, with patient demographics similar to Virginia at large. From baseline to 6 months after intervention, screening with a validated instrument increased from 2.1% (95% CI, 0.5%-8.4%) to 35.5% (95% CI, 11.5%-69.9%) in the intervention group compared to 0.4% (95% CI, 0.1%-1.8%) to 1.4% (95% CI, 0.3%-5.8%) in the control group (P < .001). Brief office-based interventions for the intervention group increased from 26.2% (95% CI, 14.2%-45.8%) to 62.6% (95% CI, 43.6%-78.3%) vs 45.5% (95% CI, 28.0%-64.1%) to 55.1% (95% CI, 36.5%-72.3%) in the control group (P = .008). Identification of UAU, referral for counseling, and medication treatment had similar changes for both groups. Qualitative analyses of transcripts revealed that few clinicians understood the preventive service prior to practice facilitation, but at the end most felt much more competent and confident with screening and brief intervention for UAU. Conclusions and Relevance: This cluster randomized clinical trial demonstrated that practice facilitation can help primary care practices to better implement screening and counseling for UAU into their routine workflow. Effective primary care practice implementation interventions such as this can have a profound effect on the health of communities. Given the number of people that the participating practices care for, this intervention resulted in an additional 114 604 patients being screened annually for UAU who would not have been otherwise. Trial Registration: ClinicalTrials.gov Identifier: NCT04248023.

Evidence-Based Medicine Culture, Curriculum, and Program Outcomes: A CERA Study.

BACKGROUND: Limited faculty development is a barrier to advancing evidence-based medicine (EBM) education. This study sought to describe program director perception of EBM culture in family medicine residency training and to assess the association among structured faculty roles, EBM curricula, and specific resident outcomes including publications in EBM. METHODS: Members of the Society of Teachers of Family Medicine EBM collaborative drafted survey questions based on a literature review. The questions were electronically distributed in May 2023 to all US family medicine residency program directors who had not previously opted out by the Council of Academic Family Medicine Educational Research Alliance within its study of family medicine program directors. We analyzed results using descriptive and comparative statistics. RESULTS: The overall response rate was 44.7% (309/691). We found that 260/281 (92%) of program directors reported an EBM curriculum of some kind, and 253/281 (90%) of program directors agreed/strongly agreed that EBM was accepted by residents. Of the respondents, 72/281 (25.6%) reported that no specific faculty member was responsible for their EBM curriculum. Most program directors reported that less than 50% of residents will leave their programs with the ability to detect an error in original research (23.8%; 67/281), detect an important omission in an UpToDate article (16%; 45/281), or author a narrative review for American Family Physician (10%; 28/281). CONCLUSIONS: Program directors reported strong acceptance of EBM among residents and a high prevalence of a formal curriculum. However, many lacked a specific faculty lead, and few reported that residents had strong EBM skills. This study identified gaps in residency training to support future EBM-skilled family physicians as well as concerns about pathways for the development of future EBM faculty.

Screening for Unhealthy Alcohol Use Among Patients With Multiple Chronic Conditions in Primary Care.

Introduction: Unhealthy alcohol use increases the risk for and exacerbation of chronic health conditions. As such, screening, prevention, and management of unhealthy alcohol use is especially critical to improving health outcomes for patients with multiple chronic health conditions. It is unclear to what extent multiple chronic condition status is a barrier to screening for unhealthy alcohol use in the primary care setting. The authors hypothesized that patients with multiple chronic conditions would be at lower odds of being screened for unhealthy alcohol use than patients without multiple chronic conditions. Methods: The authors performed a secondary analysis of electronic health record data for patients from 67 primary care practices in Virginia (2020-2023). Using the Center for Medicare and Medicaid Services' chronic disease framework, they classified patients by multiple chronic condition status: no multiple chronic conditions, physical multiple chronic conditions, mental health multiple chronic conditions, and physical and mental health multiple chronic conditions. They used multiple logistic regressions with an added practice-level random effect to analyze the relationship between multiple chronic condition status and the odds of receiving an alcohol-related assessment, of being screened for unhealthy alcohol use with a U.S. Preventive Services Task Force-recommended instrument, and of screening positive for unhealthy alcohol use within the past 2 years. Results: Within a final cohort of n=11,789, a total of 6,796 patients (58%) had multiple chronic conditions (29% physical multiple chronic conditions, 4% mental health multiple chronic conditions, and 25% physical and mental health multiple chronic conditions). In all, 69% of patients were screened for unhealthy alcohol use, whereas 16% were screened with a U.S. Preventive Services Task Force-recommended instrument, and 7% screened positive for unhealthy alcohol use. Patients with physical and mental health multiple chronic conditions had 0.9 times lower odds of receiving any screening for unhealthy alcohol use than those with no multiple chronic conditions (95% CI=0.8, 1.0; p=0.0240), whereas patients with only physical multiple chronic conditions or only mental health multiple chronic conditions had similar odds. There was no difference in the odds of being screened with a U.S. Preventive Services Task Force-recommended instrument on the basis of multiple chronic condition status. Patients with mental health multiple chronic conditions and physical and mental health multiple chronic conditions had 1.8 and 1.5 times greater odds of screening positive for unhealthy alcohol use, respectively (95% CI=1.3, 2.7; p=0.0014 and 95% CI=1.2, 1.8; p=0.0003). Conclusions: Although patients with chronic mental health conditions were more likely to screen positive for unhealthy alcohol use than patients without multiple chronic conditions, Virginia primary care patients with physical and mental health multiple chronic conditions were less likely to receive an alcohol-related assessment during the past 2 years. Given the overall modest rate of screening with a U.S. Preventive Services Task Force-recommended instrument, further efforts are needed to create the conditions for high-quality alcohol-related preventive service delivery in primary care, particularly for patients with high complexity and/or mental health conditions.

Scoping review of interventions to de-implement potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) in healthcare settings.

OBJECTIVES: Potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) utilisation persists at undesirable rates worldwide. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research. DESIGN: Scoping review. DATA SOURCES: PubMed, CINAHL, Embase, Cochrane Central and Google Scholar (1 January 2000 to 31 May 2022). STUDY SELECTION: Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilisation in healthcare settings. DATA EXTRACTION: Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilisation. RESULTS: From 7818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the USA (35.3%), with randomised controlled trial as the most common design (55.9%). Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%) but were rarely (14.9%) guided by an implementation model, framework or theory. Academic detailing, clinical decision support or electronic medical record interventions, performance reports and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients' age (55.8%), history of gastrointestinal disorders (47.1%), or history of kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter (OTC) NSAIDs in addition to prescription. The majority of studies (76.2%) reported a reduction in the utilisation of potentially harmful NSAIDs. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation. CONCLUSION: Many varied interventions to de-implement potentially harmful NSAIDs have been applied in healthcare settings worldwide. Based on these findings and identified knowledge gaps, further efforts to comprehensively evaluate the effectiveness of interventions and the combination of intervention characteristics associated with effective de-implementation are needed. In addition, future work should be guided by de-implementation theory, focus on OTC NSAIDs and incorporate patient-focused strategies and outcomes, including the evaluation of unintended consequences of the intervention.

Maternal Mortality: A National Institutes of Health Pathways to Prevention Panel Report.

The National Institutes of Health's (NIH) Pathways to Prevention panel on postpartum health provides a consensus statement on the evidence, research gaps, and future priorities to prevent maternal morbidity and mortality. The panel reviewed an NIH-commissioned evidence review and workshop that included epidemiologic studies, demonstration interventions, and other maternal morbidity and mortality research to create these national recommendations. The panel concludes that a maternal morbidity and mortality crisis reflects a systemic failure of current U.S. health care, research efforts, and social policies. The panel recommends improving maternal health through a "maternal morbidity and mortality prevention moonshot" that adopts a comprehensive, multilevel life course conceptual framework; strengthens the research methods used within the science of maternal health; establishes and conducts national prevention, treatment, and policy interventions; and reimburses evidence-informed clinical approaches to improve maternal health across the life course. Without a national focus on fundamentally transformative interventions and other initiatives aimed at redressing structural racism and inequities in health care, current interventions and clinical advances in maternal morbidity and mortality prevention will remain tragically insufficient.

A Scoping Review of Interventions to De-implement Potentially Harmful Nonsteroidal Anti-inflammatory Drugs (NSAIDs) in Healthcare Settings.

Objectives: Potentially harmful nonsteroidal anti-inflammatory drugs (NSAIDs) utilization persists at undesirable rates throughout the world. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research. Design: Scoping review. Data Sources: PubMed, CINAHL, Embase, Cochrane Central, and Google Scholar (2000-2022). Study Selection: Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilization in healthcare settings. Data Extraction: Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilization. Results: From 7,818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the U.S. (35.3%), with randomized controlled trial as the most common design (55.9%). The majority of studies (76.2%) reported a reduction in the utilization of potentially harmful NSAIDs. Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%). Academic detailing, clinical decision support or electronic medical record interventions, performance reports, and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients' age (55.8%) or history of gastrointestinal disorders (47.1%) or kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter NSAIDs in addition to prescription. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation. Conclusion: Many varied interventions are effective in de-implementing potentially harmful NSAIDs in healthcare settings. Efforts to adapt, scale, and disseminate these interventions are needed. In addition, future interventions should address over-the-counter NSAIDs, which are broadly available and widely used. Evaluating unintended consequences of interventions, including patient-focused outcomes, is another important priority.

A "sludge audit" for health system colorectal cancer screening services.

OBJECTIVES: "Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services. STUDY DESIGN: Mixed methods sludge audit. METHODS: We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes. RESULTS: Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients. CONCLUSIONS: Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.

Implementation of a Multimodal Heart Failure Management Protocol in a Skilled Nursing Facility.

Hospitals and skilled nursing facilities (SNFs) are incentivized to reduce hospital readmissions among patients with heart failure (HF). We used the RE-AIM framework and mixed quantitative and qualitative data to evaluate the implementation of a multimodal HF management protocol (HFMP) administered in a SNF in 2021. Over 90% of eligible patients were enrolled in the HFMP (REACH). Of the 42 enrolled patients (61.9% female, aged 81.9 ± 8.9 years, 9.5% Medicaid), 2 (4.8%) were readmitted within 30 days of hospital discharge and 4 (9.5%) were readmitted within 30 days of SNF discharge compared with historical (2020) rates of 16.7% and 22.2%, respectively (a potential savings of $132,418-$176,573 in hospital costs) (EFFECTIVENESS). Although stakeholder feedback about ADOPTION and IMPLEMENTATION was largely positive, challenges associated with clinical data collection, documentation, and staff turnover were described. Findings will inform refinement of the HFMP to facilitate further testing and sustainability (MAINTENANCE).

The Current State of Alcohol Screening and Management in Virginia Primary Care Practices: An Evaluation of Preventive Service Use.

The US Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling for adults over 18 years for unhealthy alcohol use. Recommended screening instruments include the Alcohol Use Disorders Identification Test-Concise and or Single Alcohol Screening Question. Behavioral counseling is feasible in primary care, taking on average 30 minutes. Baseline data for a practice facilitation trial demonstrated clinicians appropriately screened only 10.8% of patients and only identified 9.6% as having risky drinking. Yet, 24% of patients reported risky drinking on a survey, demonstrating the implementation gap of the USPSTF recommendation and opportunity to improve health.

Screening for Primary Open-Angle Glaucoma: US Preventive Services Task Force Recommendation Statement.

Importance: Glaucoma affects an estimated 2.7 million people in the US. It is the second-leading cause of irreversible blindness in the US and the leading cause of blindness in Black and Hispanic/Latino persons. Objective: To update its 2013 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for glaucoma in adults. Population: Adults 40 years or older who present in primary care and do not have signs or symptoms of open-angle glaucoma. Evidence Assessment: The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for glaucoma in adults. The benefits and harms of screening for glaucoma in adults are uncertain. More research is needed. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary open-angle glaucoma in adults. (I statement).

Screening for Impaired Visual Acuity in Older Adults: US Preventive Services Task Force Recommendation Statement.

Importance: Impairment of visual acuity is a serious public health problem in older adults. The number of persons 60 years or older with impaired visual acuity (defined as best corrected visual acuity worse than 20/40 but better than 20/200) was estimated at 2.91 million in 2015, and the number who are blind (defined as best corrected visual acuity of 20/200 or worse) was estimated at 760 000. Impaired visual acuity is consistently associated with decreased quality of life in older persons, including reduced ability to perform activities of daily living, work, and drive safely, as well as increased risk of falls and other unintentional injuries. Objective: To update its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for impaired visual acuity in older adults. Population: Asymptomatic adults 65 years or older who present in primary care without known impaired visual acuity and are not seeking care for vision problems. Evidence Assessment: The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in asymptomatic older adults. The evidence is lacking, and the balance of benefits and harms cannot be determined. More research is needed. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults. (I statement).

Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study.

BACKGROUND: The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. METHODS: Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. RESULTS: Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician's guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05). CONCLUSIONS: In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings.

Screening for Atrial Fibrillation: US Preventive Services Task Force Recommendation Statement.

Importance: Atrial fibrillation (AF) is the most common cardiac arrhythmia. The prevalence of AF increases with age, from less than 0.2% in adults younger than 55 years to about 10% in those 85 years or older, with a higher prevalence in men than in women. It is uncertain whether the prevalence of AF differs by race and ethnicity. Atrial fibrillation is a major risk factor for ischemic stroke and is associated with a substantial increase in the risk of stroke. Approximately 20% of patients who have a stroke associated with AF are first diagnosed with AF at the time of the stroke or shortly thereafter. Objective: To update its 2018 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review on the benefits and harms of screening for AF in older adults, the accuracy of screening tests, the effectiveness of screening tests to detect previously undiagnosed AF compared with usual care, and the benefits and harms of anticoagulant therapy for the treatment of screen-detected AF in older adults. Population: Adults 50 years or older without a diagnosis or symptoms of AF and without a history of transient ischemic attack or stroke. Evidence Assessment: The USPSTF concludes that evidence is lacking, and the balance of benefits and harms of screening for AF in asymptomatic adults cannot be determined. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for AF. (I statement).

Diagnostic accuracy of a new COVID-19 antigen test obtained by mid-turbinate swab.

Context: At the mid-point of the COVID-19 pandemic, polymerase chain reaction (PCR) testing for SARS-CoV-2 was difficult to obtain and took several days to return a result. Our health system wished to explore the use of the Quidel Sofia™ antigen test to diagnose COVID-19 in our primary care clinics, but the test was approved for emergency use authorization by the US Food and Drug Administration with only 250 test subjects. In addition, because it was important to avoid aerosol generating procedures in primary care clinics, it was necessary to test the diagnostic performance of the antigen test using mid-turbinate (MT) swabs rather than the approved nasopharyngeal (NP) swab technique. Objective: To assess the diagnostic test characteristics of a SARS-CoV-2 antigen test performed using mid-turbinate nasal swabs compared with the presumed reference standard PCR test by NP swab. Study Design: Prospective cohort study. Setting or Dataset: Outpatient. Population studied: Adults with symptoms consistent with mild-moderate COVID-19. We attempted to recruit 800 subjects to provide statistical assurance that the test sensitivity was at least 90%. Intervention/Instrument: After informed consent, subjects underwent MT nasal swab for antigen testing followed by NP swabbing for PCR testing. Outcome Measures: Sensitivity, specificity, positive and negative predictive values, and likelihood ratios, all with associated 95% confidence intervals. Results: Due to recruitment difficulty (subject reluctance and staffing issues at the testing centers), we recruited only 117 subjects. Sensitivity was 0.750 (95% CI 0.566, 0.885), and specificity was 0.988 (95% CI 0.936, 1.000). Positive Predictive Value was 0.960 (95% CI 0.796, 0.999) and Negative Predictive Value was 0.913 (95% CI 0.836, 0.962). The likelihood ratio for a positive test was 63.75 (95% CI 8.99, 451.97) and the likelihood ratio for a negative test was 0.25 (95% CI 0.14, 0.46). Conclusions: This antigen test for SARS-CoV-2 was of reasonable clinical utility in a low prevalence environment but concerns about the actual prevalence of COVID-19 and the ramifications of false negatives limited its use. Difficulty recruiting subjects and the resultant delay in the results made it impossible to implement this antigen testing in primary care practices, but it is hoped that these data will contribute to the accumulation of evidence about diagnostic testing for COVID-19.

Socializing the evidence for diabetes control to develop "Mindlines": A qualitative pilot study.

Context: Evidence on specific interventions to improve diabetes control in primary care is available, but this evidence is not always well-implemented. The concept of "mindlines" has been proposed to explain how clinicians integrate evidence using specifics of their practices and patients to produce knowledge-in-practice-in-context. Objective: We designed a pilot study to operationalize the "mindlines" concept by creating a venue for clinician-staff interaction concerning evidence. We attempted to hold "mindlines"-producing conversations in primary care practices about evidence to improve diabetes control. Study design and Analysis: Qualitative analysis of recordings of facilitated practice-wide conversations and field notes. Setting: 4 primary care practices in a health system in southwest Virginia. Population Studied: Clinicians, nurses, medical assistants, and clerical staff in primary care practices. Intervention: In each of four primary care practices in a single health system, we held a practice-wide conversation about a simple diabetes intervention model over a provided lunch. We attempted to keep the conversation relatively informal and encouraged participation from all. We recorded the conversations and took field notes. Outcome Measures: We analyzed the data using a framework adapted from the "mindlines" research and noted additional emerging themes. We also analyzed practice average proportions of controlled glycated hemoglobin levels in diabetic patients. Results: While most of the conversation concerned barriers to implementation of the simple diabetes intervention model, we noted examples of practices adopting and adapting the evidence to suit their own needs and context, consistent with the fundamentals of the "mindlines" model. Performance metrics regarding diabetes control for the four practices improved after the intervention. Conclusions: It appears that the type of conversations that "mindlines" research describes can be generated with facilitation around evidence, but further research is required to better understand the limitations and impact of this intervention.

Does de-implementation of low value care impact the patient-clinician relationship? A mixed methods study.

Context: In the U.S., provision of LVC is prevalent (up to 20% of total health services), costly ($350 billion annually), and associated with patient harm. Concern about a negative impact on the patient-clinician relationship has been cited by primary care clinicians as a barrier to reducing LVC. Study Design: Mixed-methods study. Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading one of three vignettes about a clinician declining to provide a requested LVC service (antibiotics for sinusitis, screening EKG, or screening vitamin D test) or a comparison vignette. A different sample of participants was asked to imagine that their own clinician did not order requested antibiotics or screening EKG and then to respond to structured interview questions about satisfaction and trust. Setting: Primary care patients of a southwest Virginia health system. Population: Adults (n= 232 questionnaire/n= 24 interview). Outcome Measures: Participant demographics data, PDRQ-9 score for each vignette (higher score = greater relationship integrity), and thematic analysis of interview responses. Results: Among questionnaire participants, a lower PDRQ-9 score was associated with the vignette about not providing LVC vitamin D screening (31.2) compared with antibiotics (38.9), EKG screening (37.5), and the comparison vignette (36.4) (p<0.05). There was a statistically significant, but weak, correlation between education and PDRQ-9 score (r=0.2, p<0.01). More than half of interviewees believed that their satisfaction and trust would not be negatively impacted by not receiving the LVC service, citing the strength of their relationship with their clinician and faith in their guidance. Some even felt that not providing the service would increase their satisfaction and trust. Participants who believed their satisfaction and trust may be impacted seemed to recognize the complexity of the scenario, discussing medical necessity, potential harm, insurance, and the option to go elsewhere (ex: urgent care or a new doctor). However, most emphasized that negative impacts could be mitigated if the clinician listened to them, spent time with them, and offered understandable advice. Conclusions: Findings emphasize prioritization of the patient-clinician relationship in LVC de-implementation interventions and suggest minimal impact of such interventions on the patient-clinician relationship. Evidence of service-specific differences was observed.

Socializing the evidence for diabetes control to develop "mindlines": a qualitative pilot study.

BACKGROUND: Evidence on specific interventions to improve diabetes control in primary care is available, but this evidence is not always well-implemented. The concept of "mindlines" has been proposed to explain how clinicians integrate evidence using specifics of their practices and patients to produce knowledge-in-practice-in-context. The goal of this pilot study was to operationalize this concept by creating a venue for clinician-staff interaction concerning evidence. The research team attempted to hold "mindlines"-producing conversations in primary care practices about evidence to improve diabetes control. METHODS: Each of four primary care practices in a single health system held practice-wide conversations about a simple diabetes intervention model over a provided lunch. The conversations were relatively informal and encouraged participation from all. The research team recorded the conversations and took field notes. The team analyzed the data using a framework adapted from the "mindlines" research and noted additional emergent themes. RESULTS: While most of the conversation concerned barriers to implementation of the simple diabetes intervention model, there were examples of practices adopting and adapting the evidence to suit their own needs and context. Performance metrics regarding diabetes control for the four practices improved after the intervention. CONCLUSION: It appears that the type of conversations that "mindlines" research describes can be generated with facilitation around evidence, but further research is required to better understand the limitations and impact of this intervention.