Use of a PHQ-9 Heat Map to Facilitate Management Decisions in Patients With Depression.

BACKGROUND: Depression is a common concern for patients seeking medical care. The Patient Health Questionnaire-9 (PHQ-9) is a tool used to diagnose and manage depression. Tracking individual symptom scores rather than the sum of multiple symptom scores has been found to be more predictive of depression treatment response. METHODS: The records of 30 patients who had a follow-up visit in primary care were reviewed. We discuss 3 patient scenarios and present their PHQ-9 data as individual symptom scores, in the form of a color-coded heat map. RESULTS: In the cases presented, medication side effects, anxiety, a thyroid disorder, and fibromyalgia were identified as possible influencers of the PHQ-9 survey scores. DSICUSSION: A heat map helped clinicians understand the patient's clinical status in an efficient manner. We encourage the development of a PHQ-9 heat map in electronic medical record systems.

Measuring Workload Among Family Medicine Health Professionals During the COVID-19 Pandemic.

The global COVID-19 pandemic presented a period of considerable stress for healthcare professionals on a global scale. The strain on healthcare facilities nationwide has resulted in profound implications for the well-being of numerous healthcare practitioners. A heightened demand for extended working hours emerged, potentially amplifying the workload for these professionals. This study aims to scrutinize the workload levels experienced by healthcare professionals specializing in family medicine at a tertiary medical center. Our findings reveal a persistent escalation in workload over the course of the study. Notably, the overall mean workload index score exhibited a substantial increase from phase one to phase two (48.07 compared to 66.36). Recognizing the impact of workload variations according to professional roles is crucial for devising effective solutions. Consequently, comprehending the nuances of workload distribution among healthcare professionals is imperative for the successful implementation of targeted interventions.

A Rare Case of Losartan-Induced Visceral Angioedema.

The following describes a case of isolated visceral angioedema related to an angiotensin II receptor blocker (ARB) medication. Additionally, we discuss the pathophysiology of drug-induced angioedema, various presentations that can be encountered, and the leading theorized mechanisms of how renin-angiotensin-aldosterone system (RAAS) blocking medications lead to angioedema. The goal of sharing this case is to help increase awareness of the possibility of ARB-induced angioedema and to recommend keeping visceral angioedema as part of the differential diagnosis when presented with a patient who is taking an angiotensin converting enzyme inhibitor (ACEI) or ARB medication that is experiencing gastrointestinal symptoms of unclear etiology.

Clinician Adoption of an Artificial Intelligence Algorithm to Detect Left Ventricular Systolic Dysfunction in Primary Care.

OBJECTIVE: To compare the clinicians' characteristics of "high adopters" and "low adopters" of an artificial intelligence (AI)-enabled electrocardiogram (ECG) algorithm that alerted for possible low left ventricular ejection fraction (EF) and the subsequent effectiveness of detecting patients with low EF. METHODS: Clinicians in 48 practice sites of a US Midwest health system were cluster-randomized by the care team to usual care or to receive a notification that suggested ordering an echocardiogram in patients flagged as potentially having low EF based on an AI-ECG algorithm. Enrollment was between June 26, 2019, and July 30, 2019; participation concluded on March 31, 2020. This report is focused on those clinicians randomized to receive the notification of the AI-ECG algorithm. At the patient level, data were analyzed for the proportion of patients with positive AI-ECG results. Adoption was defined as the clinician order of an echocardiogram after prompted by the alert. RESULTS: A total of 165 clinicians and 11,573 patients were included in this analysis. Among patients with positive AI-ECG, high adopters (n=41) were twice as likely to diagnose patients with low EF (33.9%) vs low adopters, n=124, (16.9%); odds ratio, 1.62; 95% CI, 1.21 to 2.17). High adopters were more often advanced practice providers (eg, nurse practitioners and physician assistants) vs physicians, Family Medicine vs Internal Medicine specialty, and tended to have less complex patients. CONCLUSION: Clinicians who most frequently followed the recommendations of an AI tool were twice as likely to diagnose low EF. Those clinicians with less complex patients were more likely to be high adopters. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT04000087.

Development and Early Experience of a Primary Care Learning Collaborative in a Large Health Care System.

INTRODUCTION: Primary care clinicians are presented with hundreds of new clinical recommendations and guidelines. To consider practice change clinicians must identify relevant information and develop a contextual framework. Too much attention to information irrelevant to one's practice results in wasted resources. Too little results in care gaps. A small group of primary care clinicians in a large health system sought to address the problem of vetting new information and providing peer reviewed context. This was done by engaging colleagues across the system though a primary care learning collaborative. METHODS: The collaborative was a grass roots initiative between community and academic-based clinicians. They invited all the system's primary care clinicians to participate. They selected new recommendations or guidelines and used surveys as the principal communication instrument. Surveys shared practice experience and also invited members to give narrative feedback regarding their acceptance of variation in care relate to the topic. A description of the collaborative along with its development, processes, and evolution are discussed. Process changes to address needs during the COVID-19 pandemic including expanded information sharing was necessary. RESULTS: Collaborative membership reached across 5 states and included family medicine, internal medicine, and pediatrics. Members found involvement with the collaborative useful. Less variation in care was thought important for public health crises: the COVID pandemic and opioid epidemic. Greater practice variation was thought acceptable for adherence to multispecialty guidelines, such as diabetes, lipid management, and adult ADHD care. Process changes during the pandemic resulted in more communications between members to avoid practice gaps. CONCLUSION: An internet-based learning collaborative in a health system had good engagement from its members. Using novel methods, it was able to provide members with feedback related to the importance of new practice recommendations as perceived by their peers. Greater standardization was thought necessary when adopting measures to address public health crisis, and less necessary when addressing multispecialty guidelines. By employing a learning collaborative, this group was able to keep members interested and engaged. During the first year of the COVID pandemic the collaborative also served as a vehicle to share timely information.

Improving Immunization Rates During the 2019 Measles Outbreak.

In 2019, there were multiple outbreaks of measles in the United States. In the context of the public awareness of these outbreaks, we performed an intervention with the intent to improve the rate of measles immunization in our pediatric population. Pediatric patients that were lacking adequate measles immunization were identified by electronic medical record (EMR) survey. Charts were reviewed and updated if records were found to be incomplete. Parents of the remaining children were sent a letter, personally signed by the child's primary care provider, encouraging measles immunization. A measles fact sheet, produced by the United States Center for Disease Control, was also included with the letter. There were 44 patients in the study group whose parents received a letter and measles fact sheet. As a result, 5 of these children were brought in for a measles, mumps, and rubella (MMR) immunization. The 44 patients whose parents received a letter included 20 patients whose parents had previously expressed intent to not vaccinate their children as documented in the EMR. None of these children received an MMR immunization. Although small in scope, this project provides a glimpse into the importance of personal provider guidance to parents who are inclined to immunize their children. Unfortunately, it also demonstrated that provider advice did not change the opinions of parents who had already taken a stance against vaccination, even in the context of an urgent public health situation that had garnered widespread coverage in the lay press and social media.

Clinician Care Team Composition and Health Care Utilization.

OBJECTIVE: To test the hypothesis that a greater proportion of physician time on primary care teams are associated with decreased emergency department (ED) visits, hospital admissions, and readmissions, and to determine clinician and care team characteristics associated with greater utilization. PATIENTS AND METHODS: We retrospectively analyzed administrative data collected from January 1 to December 31, 2017, of 420 family medicine clinicians (253 physicians, 167 nurse practitioners/physician assistants [NP/PAs]) with patient panels in an integrated health system in 59 Midwestern communities serving rural and urban areas in Minnesota, Wisconsin, and Iowa. These clinicians cared for 419,581 patients through 110 care teams, with varying numbers of physicians and NP/PAs. Primary outcome measures were rates of ED visits, hospitalizations, and readmissions. RESULTS: The proportion of physician full-time equivalents on the team was unrelated to rates of ED visits (rate ratio [RR] = 0.826; 95% confidence interval [CI], 0.624 to 1.063), hospitalizations (RR = 0.894; 95% CI, 0.746 to 1.072), or readmissions (RR = -0.026; 95% CI, 0.364 to 0.312). In separate multivariable models adjusted for clinician and practice-level characteristics, the rate of ED visits was positively associated with mean panel hierarchical condition category (HCC) score, urban vs rural setting, NP/PA vs physician, and lower years in practice. The rate of inpatient admissions was associated with HCC score, and 30-day hospital readmissions were positively associated with HCC score, lower years in practice, and male clinicians. CONCLUSION: Care team physician and NP/PA composition was not independently related to utilization. More complex panels had higher rates of ED visits, hospitalization, and readmissions. Statistically significant differences between physician and NP/PA panels were only evident for ED visits.

Artificial intelligence-enabled electrocardiograms for identification of patients with low ejection fraction: a pragmatic, randomized clinical trial.

We have conducted a pragmatic clinical trial aimed to assess whether an electrocardiogram (ECG)-based, artificial intelligence (AI)-powered clinical decision support tool enables early diagnosis of low ejection fraction (EF), a condition that is underdiagnosed but treatable. In this trial ( NCT04000087 ), 120 primary care teams from 45 clinics or hospitals were cluster-randomized to either the intervention arm (access to AI results; 181 clinicians) or the control arm (usual care; 177 clinicians). ECGs were obtained as part of routine care from a total of 22,641 adults (N = 11,573 intervention; N = 11,068 control) without prior heart failure. The primary outcome was a new diagnosis of low EF (≤50%) within 90 days of the ECG. The trial met the prespecified primary endpoint, demonstrating that the intervention increased the diagnosis of low EF in the overall cohort (1.6% in the control arm versus 2.1% in the intervention arm, odds ratio (OR) 1.32 (1.01-1.61), P = 0.007) and among those who were identified as having a high likelihood of low EF (that is, positive AI-ECG, 6% of the overall cohort) (14.5% in the control arm versus 19.5% in the intervention arm, OR 1.43 (1.08-1.91), P = 0.01). In the overall cohort, echocardiogram utilization was similar between the two arms (18.2% control versus 19.2% intervention, P = 0.17); for patients with positive AI-ECGs, more echocardiograms were obtained in the intervention compared to the control arm (38.1% control versus 49.6% intervention, P < 0.001). These results indicate that use of an AI algorithm based on ECGs can enable the early diagnosis of low EF in patients in the setting of routine primary care.

Relationship of Clinician Care Team Composition and Diabetes Quality Outcomes.

The objective was to determine if a greater proportion of physician full-time equivalent (FTE%) relative to nurse practitioners/physician assistants (NPs/PAs) on care teams was associated with improved individual clinician diabetes quality outcomes. The authors conducted a retrospective cross-sectional study of 420 family medicine clinicians in 110 care teams in a Midwest health system, using administrative data from January 1, 2017 to December 31, 2017. Poisson regression was used to examine the relationship between physician FTE% and the number of patients meeting 5 criteria included in a composite metric for diabetes management (D5). Covariates included panel size, clinician type, sex, years in practice, region, patient satisfaction, care team size, rural location, and panel complexity. Of the 420 clinicians, 167 (40%) were NP/PA staff and 253 (60%) were physicians. D5 criteria were achieved in 37.9% of NP/PA panels compared with 44.5% of physician panels (P < .001). In adjusted analysis, rate of patients achieving D5 was unrelated to physician FTE% on the care team (P = .78). Physicians had a 1.082 (95% confidence interval 1.007-1.164) times greater rate of patients with diabetes achieving D5 than NPs/PAs. Clinicians at rural locations had a .904 (.852-.959) times lower rate of achieving D5 than those at urban locations. Physicians had a greater rate of patients achieving D5 compared with NPs/PAs, but physician FTE% on the care team was unrelated to D5 outcomes. This suggests that clinician team composition matters less than team roles and the dynamics of collaborative care between members.

Gynecomastia in a Patient Taking Meloxicam-A Case Report.

Gynecomastia is benign enlargement of glandular tissue in the male breast. It occurs due to an imbalance of estrogen and testosterone. It may be unilateral or bilateral. Physiologic gynecomastia commonly occurs in infants and during puberty and is self-limited. Gynecomastia may affect up to 50% of adult men over age 50 years old and can be related to underlying medical illness or caused by certain medications. Known causative agents include anti-androgenic and estrogenic drugs. Probable agents include alcohol and anti-ulcer, psychoactive, and antiretroviral medications. Non-steroidal anti-inflammatory drugs (NSAIDs) are not commonly associated with the development of gynecomastia. This case presents an instance in which the NSAID, meloxicam, was the only identified variable in a patient who developed unilateral gynecomastia. His breast tenderness and abnormal exam resolved spontaneously within 4 weeks of cessation of meloxicam therapy.

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.

Análisis retrospectivo de las enfermedades parasitarias del mono ardilla (Saimiri sciureus) en dos condiciones ex situ en el noroccidente de los Andes suramericanos / Retrospective analysis of the squirrel monkey’s (saimiri sciureus) parasitic diseases in two ex situ conditions in the northwestern Andes in South America / Análise retrospectiva das doenças parasitárias do macaco-de-cheiro (Saimiri sciureus) em duas condições ex situ no noroeste dos Andes sul-americanos

El mono ardilla (Cebidae: Saimiri sciureus) es una especie de primate neotropical. La mayor susceptibilidad a la presencia de parásitos en estos primates se puede deber a las condiciones ex situ a las que se encuentran sometidos, en donde se exponen a diferentes factores ambientales y de manejo. A partir de las historias clínicas de una población de 94 Saimiri sciureusdel Parque Zoológico Jaime Duque (PZJD) y de la Unidad de Rescate y Rehabilitación de Animales Silvestres (Urras), instituciones ubicadas al noroccidente de los Andes suramericanos, se determinó la presencia de los parásitos diagnosticados en estas dos condiciones (exhibición y rehabilitación, respectivamente), estableciendo la posible asociación con la edad, el sexo, la sintomatología y los medicamentos. Se utilizaron histogramas y prueba de chi cuadrado para definir las diferencias de parásitos en estos dos lugares y poder determinar la mayor frecuencia presente en Saimiri sciureus. Por otro lado, el limitado conocimiento y los estudios parasitológicos de estos primates delimitan la gestión pública y dificultan el establecimiento de posibles zoonosis.

The squirrel monkey (Cebidae: Saimiri sciureus) is a species of Neotropical primate. The increased susceptibility to the presence of parasites in these primates may be due to the ex situ conditions to which they are subjected, and where they are exposed to different environmental and managerial factors. The presence of the parasites diagnosed in these two conditions (exhibition and rehabilitation, respectively) was determined based on the medical records of a population of 94 Saimiri sciureus from the Jaime Duque Zoo (PZJD) and the Wild Animal Rescue and Rehabilitation Unit (Urras), both institutions located at the northwestern part of the Andes in South America, thus establishing the possible association with age, gender, symptomatology and medicine. Histograms and chi-squared tests were used to define the parasite differences in these two places and to determine the most frequent ones in Saimiri sciureus. On the other hand, the limited knowledge and parasitological studies of these primates delimitate public management and hinder the establishment of possible zoonoses.

O macaco-de-cheiro (Cebidae: Saimiri sciureus) é uma espécie de primata neotropical. A maior suscetibilidade à presença de parasitas nestes primatas pode-se dever as condições ex situ às que se encontram submetidos, onde são expostos a diferentes fatores ambientais e de manejo. A partir das histórias clínicas de uma população de 94 Saimiri sciureus do Parque Zoológico Jaime Duque (PZJD) e da Unidade de Resgate e Reabilitação de Animais Silvestres (Urras), instituições localizadas ao noroeste dos Andes sul-americanos, determinou-se a presença dos parasitas diagnosticados nestas duas condições (exibição e reabilitação, respectivamente), estabelecendo a possível associação com a idade, o sexo, a sintomatologia e os medicamentos. Foram utilizados histogramas e prova de qui-quadrado para definir as diferenças de parasitas nestes dois lugares, e poder determinar a maior frequência presente em Saimiri sciureus. Por outro lado, o limitado conhecimento e os estudos parasitológicos destes primatas delimitam a gestão pública e dificultam o estabelecimento de possíveis zoonoses.