Closing the gap: improving the percentage of Annual Wellness Visits among Medicare patients.

BACKGROUND: The Medicare Annual Wellness Visit (AWV) allows providers to acquire critical information about patients' health through a review of vitals, environmental risks, and medical and family history. These visits are free to those enrolled in Medicare and prioritize patient-provider relationship building and preventative care. Despite this, AWV completion rates are suboptimal. METHODS: A quality improvement project was aimed to increase the percentage of AWVs among Medicare patients in a primary care internal medicine practice from a baseline of 1.7% completion to 2.7% in 3 months from January to April 2023. INTERVENTION: With eligible patients identified, a standardized approach was created where an AWV appointment was ordered, and a patient message explaining the benefit of the appointment was sent by the patient portal. RESULTS: Our AWV intervention resulted in 72 patients being seen for an AWV, which increased the percentage of completed AWVs in the division by 2.1% from 1.7% to 3.8% in 3 months. CONCLUSION: This intervention will continue to improve AWV rates and improve patient care for Medicare patients in internal medicine. It could be applied to other areas of primary care and within other health systems.

Utility of Dermoscopy Training in Improving Diagnostic Accuracy of Skin Lesions Among Physician Assistant Students.

INTRODUCTION: Patients often first present to their primary care provider for skin lesion concerns, and dermoscopy is a tool that enhances diagnostic acumen of both malignant and benign skin lesions. Physician assistants (PAs) frequently serve as primary care and dermatology providers, but to our knowledge, no current research on dermoscopy expertise with PAs exists. We hypothesize that PA students could be taught dermoscopy based on the triage amalgamated dermoscopic algorithm (TADA) to increase their diagnostic skill, as previously shown with medical students. METHODS: Dermoscopy was taught to first-year PA students at all 5 PA programs in the state of Minnesota. The training was 50 minutes in length and focused on the fundamentals of the TADA method. Physician assistant students participated in a pretraining and post-training test, consisting of 30 dermoscopic images. RESULTS: A total of 139/151 (92%) PA students completed both the pretraining and post-training tests. Overall, mean scores for all students increased significantly ( P < .0001) after dermoscopy training was given (18.5 ± 7.1 vs. 23.8 ± 6.7). CONCLUSION: Our study demonstrates that after TADA training, PA students improved their ability to assess dermoscopy images of both skin cancer and benign lesions accurately, suggesting that PAs can be trained as novice dermoscopists and provide better dermatologic care to patients. We strongly encourage integration of dermoscopy into didactic education across PA programs. Implementing a dermoscopy curriculum in established PA programs will enable future PAs to provide better clinical care when evaluating skin lesions.

Identifying Discrepancies in Gestational Diabetes Mellitus Postpartum Follow-Up During Care Transitions.

BACKGROUND: Gestational diabetes mellitus (GDM) is a common complication of pregnancy that carries lasting risks. For women who have a history of GDM, the risk of developing type 2 diabetes mellitus (T2DM) increases by 50 to 60%. To monitor and prevent the development of T2DM, guidelines suggest screening those with a history of GDM at 6-weeks and 3-years post-delivery. For patients with abnormal lab results at the 6-week mark, it is advised to complete lab work sooner, at the 1-year mark. Data suggests that these guidelines are not being followed globally, and most do not receive adequate screening for T2DM. METHODS: A retroactive chart review of 203 women between 18 and 55 years old with a past medical history significant for GDM was conducted to determine if patients with GDM completed screening for T2DM at 6-week, 1-year, and 3-year timestamps post-delivery. Patient demographics (age, race, ethnicity, language), clinical characteristics (body mass index), provider gender, and whether prediabetes or T2DM developed were recorded. Patients who did not complete the required follow-up received educational materials via the online portal system, and hemoglobin A1c (HbA1c) screening tests were ordered. RESULTS: Ninety days post-intervention, 38 patients (50%) completed the HbA1c screening test, which exceeded our goal of a 5% improvement. Age and BMI 1-year postpartum were found to be significant factors in whether a patient completed HbA1c screening, with 16/18 (89%) completing screening with a healthy BMI 1-year postpartum (18.5 ≤ BMI < 25.0) but only 11/41 (27%) completing screening for patients under 40 years with an unhealthy BMI 1-year postpartum. Of the 38 patients who completed HbA1c screening, 9 (23.7%) had abnormal screening results. CONCLUSION: Follow-up surveillance for T2DM among women with a history of GDM is poor. Electronic health records can be used to identify and rectify gaps in care. Dissemination of standardized educational materials and electronic order entry for patients improved screening between the handoff from obstetrics to primary care.

Saturday Pap Smear Clinic: addressing barriers to cervical cancer screening.

BACKGROUND: The incidence of cervical cancer has decreased by 70% since the 1950s. Preventative measures include vaccination against HPV strains and Papanicolaou tests. Early identification of cervical cancer through routine screening can significantly improve patient outcomes. MATERIALS AND METHODS: At our academic institution, Community Internal Medicine (CIM) Clinic, 63% of female patients aged 21-65 were compliant with cervical cancer screening. The opening of the 'Saturday Pap Smear Clinic' sought to address barriers by offering non-traditional appointment times on Saturday mornings with an all female staff. Our aim was to increase the cervical cancer screening rate by 1% within 12 weeks. Our team compared CIM (intervention) and family medicine (FM) (control) compliance rates from September 2021 to January 2022. Messages were sent to the patient indicating non-compliance and offering options to complete screening. RESULTS: At the start of this study, 5239 CIM patients were cervical cancer screening non-compliant. Postintervention, cervical screening rates among non-compliant women within CIM improved by 1.2%. The intervention cohort, CIM patients, had a significant improvement in compliance compared with the control group, FM patients. White women between the ages of 50 and 65 comprised the majority of patients who used the 'Saturday Pap Smear Clinic'. CONCLUSIONS: The availability of Saturday appointments for cervical cancer screening completion can enhance cervical cancer screening compliance among eligible women. Eliminating barriers for women can improve health outcomes.

Stats on the desats: alarm fatigue and the implications for patient safety.

BACKGROUND: Physiological monitoring systems, like Masimo, used during inpatient hospitalisation, offer a non-invasive approach to capture critical vital signs data. These systems trigger alarms when measurements deviate from preset parameters. However, often non-urgent or potentially false alarms contribute to 'alarm fatigue,' a form of sensory overload that can have adverse effects on both patients and healthcare staff. The Joint Commission, in 2021, announced a target to mitigate alarm fatigue-related fatalities through improved alarm management. Yet, no established guidelines are presently available. This study aims to address alarm fatigue at the Mayo Clinic to safeguard patient safety, curb staff burnout and improve the sensitivity of oxygen saturation monitoring to promptly detect emergencies. METHODS: A quality improvement project was conducted to combat minimise the false alarm burden, with data collected 2 months prior to intervention commencement. The project's goal was to decrease the total alarm value by 20% from 55%-85% to 35%-75% within 2 months, leveraging quality improvement methodologies. INTERVENTIONS: February to April 2021, we implemented a two-pronged intervention: (1) instituting a protocol to evaluate patients' continuous monitoring needs and discontinuing it when appropriate, and (2) introducing educational signage for patients and Mayo Clinic staff on monitoring best practices. RESULTS: Baseline averages of red alarms (158.6), manual snoozes (37.8) and self-resolves (120.7); the first postintervention phase showed reductions in red alarms (125.5), manual snoozes (17.8) and self-resolves (107.8). Second postintervention phase recorded 138 red alarms, 13 manual snoozes and 125 self-resolves. Baseline comparison demonstrated an average of 16.92% reduction of alarms among both interventions (p value: 0.25). CONCLUSION: Simple interventions like education and communication techniques proved instrumental in lessening the alarm burden for patients and staff. The findings underscore the practical use and efficacy of these methods in any healthcare setting, thus contributing to mitigating the prevalent issue of alarm fatigue.

Papanicolaou test collection with the Papette brush or the spatula with cytobrush: A pragmatic study.

BACKGROUND: Cotesting with the Papanicolaou (Pap) and human papillomavirus tests detects most precancerous and cancerous lesions and increases the sensitivity for detecting high-grade precancerous and invasive cervical cancers compared with human papillomavirus testing alone. OBJECTIVE: To compare the use of the Papette brush (hereafter Papette) to the traditional spatula with endocervical brush (cytobrush) for cervical cancer screening. DESIGN: Pragmatic observational study. METHODS: Adult women aged 21-64 years who were eligible for a Papanicolaou test at a Midwest Community Internal Medicine practice underwent cervical cancer screening using the Papette or spatula with cytobrush from 18 August 2021 through 1 February 2022. Cluster sampling was used across the practice. Pathology reports were then analyzed to compare the number of satisfactory versus unsatisfactory results between the two collection techniques. RESULTS: We collected results for 756 Pap tests. The test results were satisfactory with the Papette 93.8% of the time compared with 93.0% for the spatula with cytobrush. CONCLUSION: The Papette is not inferior to a spatula with cytobrush as a collection method for Pap tests.

Understanding attributes and characteristics of the PA leader-physician relationship.

PURPOSE: This study sought to evaluate the attributes and characteristics of physician mentors, dual-roled physician assistant (PA) leaders, and how this relationship affects PA leaders and the PA leader-physician relationship. Dual-role PA leaders may possess additional formal job titles and duties as well as having direct reports. METHOD: We surveyed PA leaders at a single large academic medical center and its associated health system. The survey instrument evaluated perceptions, attitudes, and characteristics of the PA leader and influential physician and their relationship. RESULTS: Of the 56 PA leaders surveyed, 34 responded, for a 60.7% response rate. Effective communication was the most prevalent relational characteristic ranked as most important for both PA leaders (30%) and physician mentors (36%). Additional self-identified positive attributes of the team included collaborative mindset, reliability/trustworthiness, work ethic, and delivery of patient care. Influential physician mentors may have a significant effect on PA leader job satisfaction and career advancement. CONCLUSIONS: This is a novel study of PA leaders examining perceptions, beliefs, and characteristics of the PA leader-physician relationship. PAs are integral healthcare team members and medical providers. As PAs work closely in physician-led teams, further understanding the PA leader-physician relationship could influence PA and physician professional development, career trajectory, and healthcare team outcomes.

Bleeding Complications Associated With Intrauterine Contraception in Women Receiving Anticoagulation Therapy.

Objective: To determine whether anticoagulation therapy is associated with an increased risk of complications after initiation of intrauterine contraception (IUC). Patients and Methods: We retrospectively reviewed records of women receiving anticoagulation therapy at the time of IUC placement from 2000 to 2017 and records of controls (no anticoagulation), matched by race, age, and body mass index. The primary outcome was the cumulative incidence of bleeding (more than spotting [World Health Organization bleeding grades 2 to 4]), IUC expulsion, and IUC removal. Secondary outcomes included treatment for bleeding and bleeding patterns stratified by medication and IUC type. Outcomes were assessed at 24 hours, 30 days, and 6 months after IUC placement. Results: We matched 208 women taking anticoagulants with 421 controls. The most common anti-coagulant agents were aspirin (60.1%) and warfarin (36.1%). Most women received the levonorgestrel IUC. No complications occurred within 24 hours. Patients receiving anticoagulants had higher rates of the primary composite outcome at 30 days (odds ratio, 1.77 [95% CI, 1.04 to 3.04]; P=.04) and at 6 months (odds ratio, 2.05 [95% CI, 1.29 to 3.26]; P=.002). Primary complications did not differ by IUC type among control patients, but among women receiving anticoagulants, nonhormonal IUC was associated with an increased rate of complications (P=.04). Conclusion: Anticoagulation therapy was associated with higher rates of bleeding at 30 days and 6 months, and nonhormonal IUC plus anticoagulation therapy was associated with higher rates of primary complications. Our findings support current periprocedural anticoagulation guidelines, which state that anticoagulation and antiplatelet therapy can be continued at the time of IUC insertion.

Barriers to cervical cancer screening among immigrants.

ABSTRACT: For women ages 21 to 65 years who have not had a hysterectomy, the US Preventive Services Task Force (USPSTF) recommends cervical cancer screening with cytology (Pap smear) every 3 years or a combination of cytology and human papillomavirus (HPV) testing every 5 years. However, foreign-born women were less likely to have received a Pap smear compared with US-born women. This article reviews barriers to cervical cancer screening for foreign-born women.

Clicks away from reduced healthcare expenditures: leveraging the electronic health record to reinforce education efforts.

OBJECTIVES: Lupron 11.25 mg has both a narrow indication and a high cost compared to other Lupron presentations. Prior to our study initiation there was no clear distinction between presentations when ordering within the health-system's Electronic Health Record (EHR). This resulted in inappropriate product selection, payment and billing errors that negatively impact our healthcare system. To reinforce prior education efforts, a new approach was considered leveraging the EHR with information to steer prescribers to the proper Lupron presentation based on indication. This study aimed to reduce off-label prescribing for Lupron 11.25 mg (NDC 00074-3663-03) by 25% by 02/28/2022 without negatively impacting the insurance collection rate. METHODS: Baseline Lupron 11.25 mg adult kit administrations one year prior to intervention and off-label prescribing was found to account for 22.7% of administrations. In December 2021 intervention order questions were added to Lupron 11.25 mg in the EHR. One and two-month data was obtained after implementing order questions within the EHR. Lupron 11.25 mg administrations were classified into one of four categories to determine impact on off-label prescribing. RESULTS: In the one- and two-month post-implementation periods off-label prescribing was 0% and 15.3% respectively, a reduction of 22.7% to and 7.4% respectively from the baseline assessment. There were no clinical denials found in either post-implementation reporting period. CONCLUSION: This report adds to the body of evidence that leveraging the EHR can lead to healthcare savings and illustrates how patient and healthcare system burden can be reduced by prompting thought and direction when a medication has indication specific dose requirements.

PA job satisfaction and career plans.

OBJECTIVE: To understand the relationships between burnout, job satisfaction, and career plans among physician assistants in the United States. METHODS: The authors surveyed PAs in 2016. The survey included the Maslach Burnout Inventory and items on job satisfaction and career plans. RESULTS: Overall 82.7% of PAs were satisfied with their job, 32.2% indicated intent to leave their current position, and 19.5% reported intent to reduce work hours. On multivariate analysis, burnout increased the odds of job dissatisfaction, intent to reduce work hours within the next year, and intent to leave the current practice in the next 2 years. CONCLUSIONS: About a third of PAs indicated intent to leave their current practice and one in five indicated intent to reduce their clinical hours. Burnout was an independent predictor of job satisfaction and career plans.

Addressing Anxiety and Fear during the Female Pelvic Examination.

METHODS: We reviewed the literature pertaining to anxiety and fear surrounding the pelvic examination to help guide health care providers' on available screening options and to review options for individualized patient management. RESULTS: Anxiety and fear are common before and during the pelvic examination. In fact, the pelvic exam is one of the most common anxiety-provoking medical procedures. This exam can provoke negative physical and emotional symptoms such as pain, discomfort, anxiety, fear, embarrassment, and irritability. These negative symptoms can interfere with preventative health screening compliance resulting in delayed or avoided care and significant health consequences. CONCLUSION: Assessing women for anxiety related to pelvic examinations may help decrease a delay or avoidance of examinations. Risk factor and symptom identification is also a key component in this. General anxiety questionnaires can help identify women with anxiety related to pelvic examinations. Strategies to reduce anxiety, fear and pain during a pelvic examination should routinely be implemented, particularly in women with high-risk factors or those identified with screening techniques as having anxiety, fear or pain with examinations. Treatment options should be targeted at understanding the patient's concerns, starting conversations about pelvic examinations early, educating patient's about the examination and offering the presence of a chaperone or support person. During an examination providers should ensure the patient is comfortable, negative phrases are avoided, the correct speculum size is utilized and proper lubrication, draping, dressing and positioning are performed. Treating underlying gynecologic or mental health conditions, consideration of cognitive behavioral therapy and complementary techniques such as lavender aromatherapy and music therapy should also be considered when appropriate.

Pregnancy Reasonably Excluded Guide (PREG) Evaluation of Pregnancy Status Before Contraceptive Procedures: Improved Availability of Same-Day Insertion.

OBJECTIVE: To determine whether implementation of the Pregnancy Reasonably Excluded Guide (PREG) in a primary care gynecology clinic improves access to contraceptive procedures and affects the number of urine human chorionic gonadotropin (hCG) tests. PATIENTS AND METHODS: PREG was administered to 981 women aged 18 to 50 years (1012 visits) who were seen in a primary care gynecology clinic for contraceptive procedures from September 30, 2015, through April 30, 2018. Contraceptive procedures included insertion of an intrauterine contraceptive (IUC) or subdermal contraceptive implant. After PREG review and patient discussion, health care professional decided to perform the procedure with or without hCG measurement or to reschedule if the patient's pregnancy status was uncertain. We collected data on the rate of same-day contraceptive procedures and the rate of hCG testing. Data from the PREG implementation period were compared with historical data from 185 women undergoing contraceptive procedures before PREG implementation. RESULTS: Measurement of hCG was performed in 53% of women before and 24.1% (224 of 1,012 visits) after PREG implementation in the primary care setting. After PREG implementation, 974 0f 1012 patients (96.2%) were eligible for a same-day contraceptive procedure. If traditional criteria, current menses, or a preexisting IUC or implant in place were required for IUC or implant insertion, only 594 patients (58.7%) would have qualified for a same-day procedure. No contraceptive procedures occurred in pregnant women. CONCLUSION: PREG implementation allowed for same-day IUC or implant insertion in 974 women (96.2%) seen for a contraceptive procedure. Most of the women (75.9%) did not require preprocedure hCG measurement.

Burnout and satisfaction with work-life integration among PAs relative to other workers.

OBJECTIVE: To evaluate burnout and satisfaction with work-life integration among physician assistants (PAs) compared with other US workers. METHODS: We surveyed PAs and a probability-based sample of US workers. The survey included the Maslach Burnout Inventory and an item on satisfaction with work-life integration. RESULTS: Overall, 41.4% of PAs had burnout symptoms and 65.3% were satisfied with their work-life integration. In multivariable analysis, working in emergency medicine and dissatisfaction with control of workload and work-life integration were independently associated with having higher odds of burnout. PAs were more likely to have burnout than other workers but did not have greater struggles with work-life integration. CONCLUSION: Findings from this study suggest burnout and dissatisfaction with work-life integration are common. PAs appear at higher risk for burnout than workers in other fields.