Opioid Dose Reductions by Sex and Race in a Cohort of Patients in a Family Medicine Clinic.

BACKGROUND: The 2022 Centers for Disease Control's "Clinical Practice Guidelines for Prescribing Opioids for Pain in United States" called for attention and action toward reducing disparities in untreated and undertreated pain among Black and Latino patients. There is growing evidence for controlled substance safety committees (CSSC) to change prescribing culture, but few have been examined through the lens of health equity. We examined the impact of a primary care CSSC on opioid prescribing, including by patients' race and sex. METHODS: We conducted a retrospective cohort study. Our primary outcome was a change in prescribed morphine milligram equivalents (MME) at baseline (2017) and follow-up (2021). We compared the differences in MME by race and sex. We also examined potential intersectional disparities. We used paired t test to compare changes in mean MME's and logistic regression to determine associations between patient characteristics and MME changes. RESULTS: Our cohort included 93 patients. The mean opioid dose decreased from nearly 200 MME to 136.1 MME, P < .0001. Thirty percent of patients had their dose reduced to under 90 MME by follow-up. The reduction rates by race or sex alone were not statistically significant. There was evidence of intersectional disparities at baseline. Black women were prescribed 88.5 fewer MME's at baseline compared with their White men counterparts, P = .04. DISCUSSION: Our findings add to the previously documented success of CSSCs in reducing opioid doses for chronic nonmalignant pain to safer levels. We highlight an opportunity for primary care based CSSCs to lead the efforts to identify and address chronic pain management inequities.

Fitting in? Physician practice style after forced relocation.

OBJECTIVE: This study aims to examine how variation in physicians' treatment decisions for newborn deliveries responds to changes in the hospital-level norms for obstetric clinical decision-making. DATA SOURCES: All hospital-based births in Florida from 2003 through 2017. STUDY DESIGN: Difference-in-differences approach is adopted that leverages obstetric unit closures as the source of identifying variation to exogenously shift obstetricians to a new, nearby hospital with different propensities to approach newborn deliveries less intensively. DATA EXTRACTION: Births attributed to physicians continuously observed 2 years before the closure event and 2 years after the closure event (treatment group physicians) or for identical time periods around a randomly assigned placebo closure date (control group physicians). PRINCIPAL FINDINGS: All of the physicians meeting our inclusion criteria shifted their births to a new hospital less than 20 miles from the hospital shuttering its obstetric unit. The new hospitals approached newborn births more conservatively, and treatment group physicians sharply became less aggressive in their newborn birth clinical management (e.g., use of C-section). The immediate 11-percentage point (33%) increase in delivering newborns without any procedure behavior change is statistically significant (p value <0.01) and persistent after the closure event; however, the physicians' payer and patient mix are unchanged. CONCLUSIONS: Obstetric physician behavior change appears highly malleable and sensitive to the practice patterns of other physicians delivering newborns at the same hospital. Incentives and policies that encourage more appropriate clinical care norms hospital-wide could sharply improve physician treatment decisions, with benefits for maternal and infant outcomes.

Understanding provider use of a new clinical decision support tool aimed at reducing excess telemetry in an academic health system: A retrospective study.

RATIONALE: Cardiac monitoring has often been identified as an area of overutilization and remains a limited resource in many hospitals. With the aim of reducing telemetry overuse, we added clinical decision support to our health system's telemetry order with guidance on appropriate indications for monitoring. The new order requires selection of an appropriate clinical indication. AIMS AND OBJECTIVES: In this study, we aimed to understand provider engagement with this tool by assessing concordance between selected indications within the order and the clinical presence of those conditions as documented within the patient chart. METHODS: We randomly selected 100 telemetry orders from July to October 2022 across four different hospitals at NYU Langone Health. Two independent, blinded reviewers used a structured protocol to identify documentation of actual indications for telemetry in each selected chart. We calculated the rate of concordance between indications selected in the order and indications that were determined to be clinically present on chart review. RESULTS: There were 30,839 telemetry orders placed during the study timeframe. Overall concordance between the selection within the order and the actual indication was 48% (95% confidence interval [CI], 38.21%-57.79%). We observed especially low concordance rates for vague indications, such as 'Other', and for 'Confirmed Stroke', which was the only indication allowing for indefinite telemetry. CONCLUSION: The overall low concordance suggests a disconnect between the support tool and clinical practice. Providers are more likely to select an indication that reduces downstream work regardless of a patient's true clinical indication.

Dutch, UK and US professionals' perceptions of screening for Barrett's esophagus and esophageal adenocarcinoma: a concept mapping study.

BACKGROUND: Novel, less-invasive technologies to screen for Barrett's esophagus (BE) may enable a paradigm shift in early detection strategies for esophageal adenocarcinoma (EAC). Understanding professionals' perspectives on screening is important to determine how to proceed. We aimed to explore and compare professionals' perceptions of screening for BE and EAC screening in three countries. METHODS: In this study, 29 Dutch, 20 British and 18 American health care professionals (clinicians, researchers and policy makers) participated in concept mapping: a mixed-methods consensus building methodology. Statements on perceived barriers, facilitators, advantages, disadvantages, implications or worries associated with screening for BE and EAC were collected in asynchronous digital brainstorm sessions. Subsequently, participants sorted the statements into groups according to thematic similarity and assessed the relevance of each statement in evaluating the acceptability of BE and EAC screening. Multidimensional scaling and cluster analysis were used to map the associations between generated statements. RESULTS: Professionals across three countries identified eight consistent themes that relate to their perceptions of screening for BE and EAC: (1) Benefits, (2) Harms, (3) Clinical effectiveness concerns, (4) Screening population, (5) Screening modality, (6) Resources, (7) Ownership, and (8) Public communication. Dutch and American professionals prioritized the potential health benefits of screening but also questioned clinical impact. In contrast, British participants prioritized identification of the screening population and suitable test. CONCLUSIONS: Most professionals see potential in less-invasive screening tests for BE and EAC but underline the need to define the target screening population and determine benefits and harms before widely employing them. Successful implementation will require thoughtful consideration of the involvement of general practitioners, readiness of endoscopy and pathology services, balanced public communication, and country-specific regulations.

Identification of over- and undertreatment in the Dutch national cervical cancer screening program: A data linkage study at the hospital level.

Research into the quality of cancer screening programs often lacks the perspective of clinicians, missing insights into the performance of individual hospitals. This retrospective cohort study aimed to identify guideline deviation (specifically, overtreatment and undertreatment) related to the cervical cancer screening program in Dutch hospitals by deterministically linking nationwide insurance data with pathology data for cervical intraepithelial neoplasia (CIN). We then constructed quality indicators using the Dutch CIN guideline and National Health Care Institute recommendations to assess compliance with CIN management, treatment outcomes, and follow-up, using an empirical Bayes shrinkage model to correct for case-mix variation and hospitals with few observations. Data were linked for 115,899 of 125,751 (92%) eligible women. Overtreatment was observed in the see-and-treat approach (immediate treatment) for women with low-grade referral cytology (4%; hospital range, 0%-25%), CIN ≤ 1 treatment specimens (26%; hospital range, 10%-55%), and follow-up cervix cytology ≥2 months before the guideline recommendation after treatment for CIN 2 (2%; hospital range, 0%-9%) or CIN 3 (5%; hospital range, 0%-19%). By contrast, undertreatment was observed for treatment within 3 months after a CIN 3 biopsy result (90%; hospital range 59%-100%) and follow-up ≥2 months beyond the guideline recommendation after treatments for CIN 2 (21%, hospital range 7%-48%) and CIN 3 (20%, hospital range 7%-90%). In conclusion, we found evidence of CIN overtreatment and undertreatment in all measured domains at the hospital level. Guideline adherence could be improved by implementing the developed indicators in an audit and feedback instrument for use by healthcare professionals in routine practice.

The impact of performance feedback reports on physician ordering behavior in the use of computed tomography pulmonary angiography (CTPA).

PURPOSE: The increased utilization, and potential overutilization, of computed tomography pulmonary angiography (CTPA) is a well-recognized issue within emergency departments (EDs). The objective of this study is to determine the impact of performance feedback reports on CTPA ordering behavior among ED physicians. METHODS: We conducted a prospective study of the impact of individualized performance feedback reports on the ordering behavior of physicians working at two high-volume community EDs in Ontario, Canada. We generated individualized reports (or "Dashboards") for each ED physician containing detailed feedback and peer comparison for each physician's CTPA ordering. Our baseline pre-intervention period was January 1 to December 31, 2018, and our intervention period was January 1, 2019, to December 31, 2021. We tracked individual and group ordering behavior through the study period. Our primary outcomes are impact of feedback on (1) overall group ordering rate and (2) overall diagnostic yield. Secondary analysis was done to determine the impact of the intervention on those physicians with the highest CTPA utilization rate. RESULTS: There was no statistically significant difference in the diagnostic yield of the included physicians in either of the years of the intervention period. There was a statically significant increase in the utilization rate for CTPA from 2018 to 2020 and 2021 from 5.9 to 7.9 and 11.4 CTPAs per 1000 ED visits respectively (p < 0.5). CONCLUSION: Our study found no consistent significant impact of individualized feedback and peer comparison on physician ordering of CTPAs. This points to a potentially greater impact of environmental and institutional factors, as opposed to physician-targeted quality improvement measures, on physician ordering behavior.

Parent and Provider Perspectives on Primary Continuity Intensivists and Nurses for Long-Stay Pediatric Intensive Care Unit Patients.

Rationale: Primary continuity intensivists and nurses for long-stay patients (LSPs) in pediatric intensive care units (PICUs) are understudied strategies used to mitigate the fragmented care of typical rotating care models. Objectives: To investigate the advantages and disadvantages of primary continuity intensivists and nurses for LSPs as perceived by their parents and PICU providers. Methods: We conducted a prospective cross-sectional mixed-methods study of the perspectives of parents whose children were admitted to a PICU for >10 days and had one or more complex chronic conditions regarding the care provided by their PICU intensivists and nurses. As part of a trial, patients had been randomized to care provided by a rotating on-service intensivist who changed weekly and by PICU nurses who changed every 12 hours (usual care group) or to care provided by the same on-service intensivist plus a primary continuity intensivist and primary nurses (primary group). In addition, PICU providers (intensivists, fellows, and nurses) were queried for their perspectives on primary intensivists and nurses. Novel questionnaires, assessed for content and face validity and for readability, were used. The parental questionnaire involved indicating their degree of agreement with 16 statements about their children's care. The provider questionnaire involved rating potential advantages of primary continuity intensivists and nurses and estimating the frequency of disadvantages. Descriptive statistics and divergent stack bar charts were used; parents' and providers' responses were compared, stratified by their children's group (usual care or primary) and provider role, respectively. Results: The parental response rate was 71% (120 completed questionnaires). For 10 of 16 statements, parents whose children had primary continuity intensivists and nurses indicated significantly more positive perceptions of care (e.g., communication, listening, decision making, problems due to changing providers). The provider response rate was 61% (117 completed questionnaires); more than 80% believed that primary intensivists and nurses were highly or very highly beneficial for LSPs. Providers perceived more benefits for patients/families (e.g., informational continuity, facilitating and expediting decision making) than for staff/institutions (e.g., staff satisfaction). Providers reported associated stress, expenditure of time and effort, and decreased staffing flexibility with primary practices. Conclusions: Perceived benefits of primary continuity intensivists and nurses by both parents and providers support more widespread adoption and study of these continuity strategies.

One-stop intravitreal injection model: expert consensus on establishment and management / 中华眼底病杂志

Intravitreal drug injection is a treatment for common chronic fundus diseases such as age-related macular degeneration and diabetic retinopathy. The "14th Five-Year" National Eye Health Plan (2021-2025) recommends focusing on fundus diseases and improve the management mode of patients with chronic eye diseases. Therefore, it is imperative to explore how to further optimize the service process of intravitreal injection under the premise of guaranteeing patients' medical safety, to promote medical service efficiency and standardized management level and improve the medical experience of patients. Based on the quality control standard of vitreous cavity injection for retinopathy in China, Chinese fundus disease and related field experts developed the present expert consensus on the establishment of a one-stop intravitreal injection model and the management of its organization after a serious, comprehensive, and complete discussion, focusing on a standardized operation process, quality control, and safety management, providing more references for establishing a suitable intravitreal injection management model for ophthalmology and promoting the development of diagnostic and treatment models for fundus disease in China.

Advancing pediatric primary care practice: Preparing youth for transition from pediatric to adult medical care, a quality improvement initiative.

BACKGROUND: Despite well-known guidelines to prepare adolescents to transition to adult care, research has shown that this is done less than 25% of time in pediatric practice. This quality improvement (QI) project aimed to improve the transition readiness process for all adolescents aged 14-18 at health care maintenance visits. METHODS: A multidisciplinary team conducted a quality improvement initiative in a large, urban pediatric academic teaching practice serving a low-income, multi-ethnic population. The team developed transition interventions through successive Plan-Do-Study-Act cycles. They included a formal transition readiness assessment tool, provider-delivered education related to transition readiness, and delivery of a transition brochure for all adolescents. The team used run charts to follow the rate of formal transitions discussions documented in the electronic medical record. RESULTS: Over the course of 36 months the outcome measure of provider documented transition readiness discussions increased from 19 to 64% of the time. Over the same course of time, the process measures of transition brochure distribution and completion of the readiness assessment tool increased from 0 to 94% and 0 to 84% respectively. CONCLUSIONS: QI methodology and multidisciplinary coordinating to streamline workflow, distribution of transition information, readiness assessment and provider discussion and documentation can be successfully incorporated into a busy primary care setting. By formalizing and standardizing the transition readiness process, pediatric providers can improve young adults' readiness to transition to adult medical care.

Reduction of Long-Term Opioid Prescribing for Back Pain in Community Health Centers After a Medicaid Policy Change.

INTRODUCTION: Beginning around 2011, innumerable policies have aimed to improve pain treatment while minimizing harms from excessive use of opioids. It is not known whether changing insurance coverage for specific conditions is an effective strategy. We describe and assess the effect of an innovative Oregon Medicaid back/neck pain coverage policy on opioid prescribing patterns. METHODS: This retrospective cohort study uses electronic health record data from a network of community health centers (CHCs) in Oregon to analyze prescription opioid dose changes among patients on long-term opioid treatment (LOT) affected by the policy. RESULTS: Of the 1,789 patients on LOT at baseline, 41.6% had an average daily dose of <20 morphine milligram equivalents (MME), 32.3% had ≥20 to <50 MME, 14.5% had ≥50 to <90 MME, and 11.6% ≥90 MME. Around half of each group discontinued opioids within the 18-month policy period. Those who discontinued did so gradually (average of 11 months) regardless of starting dosage. Predictors of discontinuation included: diagnosis of opioid use disorder, older, non-Hispanic white, and less medical complexity. CONCLUSIONS: Regardless of starting opioid dose, nearly half of patients affected by the 2016 Oregon Medicaid back/neck pain treatment policy no longer received opioid prescriptions by the end of the 18-month study period; another 30% decreased their dose. Gradual dose reduction was typical. These outcomes suggest that the policy impacted opioid prescribing. Understanding patient experiences resulting from such policies could help clinicians and policy makers navigate the complex balance between potential harms and benefits of LOT.

Consensus Approach to a Treat-to-target Strategy in Juvenile Idiopathic Arthritis Care: Report From the 2020 PR-COIN Consensus Conference.

OBJECTIVE: Treat to target (T2T) is a strategy of adjusting treatment until a target is reached. An international task force recommended T2T for juvenile idiopathic arthritis (JIA) treatment. Implementing T2T in a standard and reliable way in clinical practice requires agreement on critical elements of (1) target setting, (2) T2T strategy, (3) identifying barriers to implementation, and (4) patient eligibility. A consensus conference was held among Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) stakeholders to inform a statement of understanding regarding the PR-COIN approach to T2T. METHODS: PR-COIN stakeholders including 16 healthcare providers and 4 parents were invited to form a voting panel. Using the nominal group technique, 2 rounds of voting were held to address the above 4 areas to select the top 10 responses by rank order. RESULTS: Incorporation of patient goals ranked most important when setting a treatment target. Shared decision making (SDM), tracking measurable outcomes, and adjusting treatment to achieve goals were voted as the top elements of a T2T strategy. Workflow considerations, and provider buy-in were identified as key barriers to T2T implementation. Patients with JIA who had poor prognostic factors and were at risk for high disease burden were leading candidates for a T2T approach. CONCLUSION: This consensus conference identified the importance of incorporating patient goals as part of target setting and of the influence of patient stakeholder involvement in drafting treatment recommendations. The network approach to T2T will be modified to address the above findings, including solicitation of patient goals, optimizing SDM, and better workflow integration.

Screening and management of subclinical interstitial lung disease in systemic sclerosis: an international survey.

OBJECTIVE: Interstitial lung disease (ILD) is the leading cause of mortality in SSc. Experts now recommend high-resolution CT (HRCT) screening in all SSc patients and treatment of subclinical ILD in SSc patients with high-risk phenotypes. We undertook an international survey to understand current screening and treatment practices in subclinical SSc-ILD. METHODS: An electronic REDCap survey was distributed to 611 general rheumatologists, 348 national and international SSc experts, 285 general respirologists and 57 ILD experts. RESULTS: One hundred and ninety-eight participants responded to the survey, including 135 (68%) rheumatologists and 54 (27%) respirologists. Over half (59%) of respondents routinely ordered HRCTs in all newly diagnosed SSc patients, although this practice was more common in Europe (83%), the USA (68%), Asia (73%) and Latin America (100%) compared with Canada (40%) and Australia (40%). Nearly half (48%) of respondents would not treat subclinical SSc-ILD, whereas 52% would treat or consider treatment. At least 70% would likely treat subclinical ILD in the setting of diffuse SSc, anti-topoisomerase-I autoantibodies, disease duration below 18 months, ground-glass opacities, oxygen desaturation, or significant ILD progression on imaging or pulmonary function tests. The majority (67%) of respirologists would not treat subclinical ILD. MMF was the preferred first-line drug for the treatment of subclinical SSc-ILD. CONCLUSION: This international survey highlights important regional variations in SSc-ILD screening and significant heterogeneity among rheumatologists and respirologists in the treatment of subclinical SSc-ILD. High-quality research addressing these questions is needed to produce evidence-based guidelines and harmonize the approach to identification and treatment of subclinical SSc-ILD.

Some thoughts on hereditary dermatoses / 中华皮肤科杂志

Genodermatology is an important branch of dermatology. The Chinese dermatological community has made many achievements in the field of hereditary skin diseases, and a number of professional research institutions and teams have been internationally known. Under the social and technological background of the new era, the diagnosis and treatment patterns for hereditary dermatoses are expected to be developed according to national regulations and social needs. The author shares some thoughts on this field, in order to facilitate the research in, as well as diagnosis and treatment of hereditary skin diseases.

Evaluation of choosing wisely recommendations on preprocedural cardiovascular testing.

Study objective: The Choosing Wisely (CW) initiative currently has multiple recommendations focused on avoiding preprocedural testing in asymptomatic patients prior to low-risk surgery. The purpose of this study was to measure the potential impact of the CW recommendations as they relate to preprocedural testing prior to cataract surgery. Design: Retrospective cohort study. Setting: Single academic medical center. Participants: Patients undergoing cataract surgery from 01/02/2018 to 12/31/2018. Interventions: N/A. Main outcome measures: Prevalence of preprocedural testing in elevated versus low cardiac risk patients as defined by the Revised Cardiac Risk Index (RCRI). Results: Of a total 909 patients, 90 (9.9%) had some form of preprocedural testing ordered; testing was more common among elevated risk (n = 50/315, 15.9%) compared to low-risk patients (n = 40/594, 6.7%; p < 0.0001). Of the tests ordered, 9 were abnormal (4 in the low-risk cohort, 5 in the elevated risk cohort). ECGs were the vast majority of tests ordered (n = 88/90). No stress test orders or periprocedural adverse cardiovascular (CV) events were observed. Anesthesiology clinicians ordered 95.6% of preprocedural testing. "Routine" was the justification given for the substantial majority of tests ordered in both cohorts (90% low-risk, 86% elevated risk). Conclusion: Our investigation confirms that cataract surgery has exceptionally low rates of postprocedural CV events. In contemporary practice, preprocedural CV testing for cataract surgery is not highly prevalent, rarely abnormal, and also not well justified by ordering clinicians. Our results may be considered as justification for revisions of some CW recommendations to potentially target higher prevalence areas of low-value care.

Physician Referrals During Prenatal Care.

OBJECTIVE: Referrals are an important component of patient care, and have been increasing over time. During pregnancy, people have intensive contact with the healthcare system, but little is known about the involvement of different physicians for pregnant patients during this period. This study examines referral patterns during prenatal care visits. METHODS: Using the 2006-2015 National Ambulatory Medical Care Survey and national birth certificate data, we estimate the number of referrals per pregnancy from prenatal care visits with OB/GYN and family medicine physicians. We use multivariable regression analysis to compare the probability of receiving a referral during a prenatal visit for visits with family medicine and OB/GYN physicians, controlling for visit, patient, and physician characteristics. Analyses are weighted to make results nationally representative. RESULTS: 224,335,436 prenatal visits over 19,893,015 pregnancies were included; 60% of these visits were covered by private insurance. On average, 0.3 referrals are made per pregnancy (95% confidence interval [CI] 0.22, 0.38). A prenatal visit with an OB was 5.5% points less likely to result in a referral than a visit with a family medicine physician, controlling for other characteristics. CONCLUSIONS: Referrals are relatively common in prenatal care, and are more commonly initiated by family medicine physicians than by OB/GYNs. Understanding the contribution of multiple clinicians to a pregnant person's health during the prenatal period and how coordination among clinicians impacts care receipt is an important next step. As healthcare becomes more specialized, better understanding care teams of individuals during the perinatal period is important for improving prenatal care.

Indications and diagnostic outcome of antineutrophil cytoplasmic antibody testing in hospital medicine: a pattern of over-screening.

INTRODUCTION/OBJECTIVE: Antineutrophil cytoplasmic antibodies (ANCA) serology can aid in the diagnosis and classification of ANCA-associated vasculitides (AAV). However, it is often ordered in patients without clinical manifestations of vasculitis. In this retrospective chart review, we aim to better understand the clinical practices on ANCA testing. METHODS: We retrospectively reviewed patients' charts for the indications and diagnostic outcomes of ANCA tests. All ANCA tests ordered at two Canadian hospitals (a community hospital and an academic tertiary hospital) between January and December 2016 were included in the study. Descriptive statistics are used. RESULTS: A total of 302 ANCA tests were included. The majority (n = 198, 65.6%) were ordered without an indication for testing. For those patients with at least 1 clinical manifestation of AAV (n = 104), 25% were ANCA positive and 18.3% resulted in a diagnosis of AAV. In comparison, among those without a clinical manifestation of AAV (n = 198), only 1.5% were ANCA positive and none was diagnosed with AAV. All patients diagnosed with AAV had at least 1 indication for ANCA testing. The three most common clinical presentations in patients with a final diagnosis of AAV were glomerulonephritis (81.8%), pulmonary hemorrhage (45.5%), and multiple lung nodules (31.8%). CONCLUSION: To our knowledge, this is the first study that evaluates patients with both positive and negative ANCA test results in an inpatient setting. We demonstrated a low rate of ANCA positivity and AAV diagnosis in patients without clinical manifestations of AAV. Overall, there is a high rate of ANCA testing without an indication at our academic institution. This over-testing may be curbed by strategies such as a gating policy, culture changes, and clinician education. Key Points • AAV is a clinical-pathological diagnosis, and despite the usefulness of ANCA testing, it does not confirm nor rule out AAV. • ANCA testing for the diagnosis of AAV is generally only indicated when there is a clear manifestation of AAV. • Although patients with AAV may occasionally present without classic signs and symptoms, the diagnostic utility of ANCA serology in this setting is low, and testing is more likely to result in a false-positive or false-negative test. • If clinical suspicion remains high despite negative ANCA testing, clinicians should seek consultation with a rheumatologist.

A proposed taxonomy for population-level prescription use patterns.

Recent and increasing discussion of prescription price transparency highlights the importance of defining, measuring and communicating prescription drug value. To help advance these goals, the authors propose a taxonomy of population-level prescription drug use patterns. The taxonomy assigns prescription use to one of five categories according to likely population-level health impact. The categories include effective, potentially discretionary, potentially harmful, wasteful, and lifestyle. The authors hope the proposed taxonomy will inform discussion of prescription drug value by providing estimates of population impact, especially the balance of anticipated benefit and harm.

Opioid Education and Prescribing Practices.

BACKGROUND: Lack of training among health care providers (HCPs) to safely prescribe opioids is a contributing factor to the opioid crisis. Training and other resources have been developed to educate providers about safe and appropriate opioid prescribing practices. METHOD: The national survey was conducted with 2000 HCPs representing primary care physicians (PCPs), including family practice, general practice, and internal medicine; specialists (SPs); physician assistants (PAs); and nurse practitioners (NPs), a mix of primary care and specialists. This survey examined exposure to opioid educational information and opioid prescribing. RESULTS: PCPs reported prescribing opioids for chronic pain to significantly more patients compared with other HCP groups. PCPs (89.8%) and NPs (85.5%) reported significantly greater exposure to opioid educational information compared with both SPs (71.9%) and PAs (78.8%). Overall, HCPs had limited knowledge about abuse-deterrent formulations, but PCPs had greater knowledge than other groups. HCPs had an increased likelihood of prescribing opioids to fewer patients in the last 3 months relative to the prior 12 months if they worked in a state or county clinic vs a solo or group practice type (adjusted odds ratio [AOR] = 1.97; 95% confidence interval [CI], 1.12-3.49) and were exposed to more opioid educational information during the last 12 months (AOR = 1.19; 95% CI, 1.06-1.32). DISCUSSION: HCPs' exposure to opioid educational information was associated with less opioid prescribing for chronic pain. Findings indicated a difference in exposure and knowledge gaps across provider groups. More information is needed on the content of opioid educational information provided to HCPs.

Neonatal Intensive Care Utilization and Postdischarge Newborn Outcomes: A Population-based Study of Texas Medicaid Insured Infants.

OBJECTIVE: To test the hypothesis that newborn infants cared for in hospitals with greater utilization of neonatal intensive care experienced fewer postdischarge adverse events. STUDY DESIGN: We developed 3 retrospective population-based cohorts of Texas Medicaid insured singletons born in 2010-2014 (very low birth weight [VLBW n = 11 139], late preterm [n = 57 509], and non-preterm [n = 664 447]) who received care in higher volume hospitals with level III/IV neonatal intensive care units (NICUs). Measures of NICU care were hospital-level risk adjusted NICU admission rates, special care days (days of nonroutine care) per infant, and the percent of intensive (highest billable care code) special care days. The units of analysis were hospitals (n = 80) and the primary outcome was an adverse event, (defined as admission, emergency department visit, or death) within 30 days postdischarge. RESULTS: Higher use of NICU care at a hospital level was not associated with lower postdischarge 30-day adverse event. Infants cared for in hospitals with above vs below median special care day rates experienced slightly higher postdischarge adverse event per 100 infants (VLBW: 14.01 [95% CI 12.74-15.27] vs 11.84 [10.52-13.16], P < .05; late preterm: 7.33 [6.68-7.97] vs 6.28 [5.87-6.69], P < .01; non-preterm: 4.47 [4.17-4.76] vs 3.97 [3.75-4.18], P < .01). Weak positive associations (Pearson correlations of 0.31-0.37, P < .01) were observed for adverse event with special care days; in no instance was a negative association observed between NICU utilization and adverse event. CONCLUSION: Higher utilization of NICU care was not associated with lower rates of short-term events suggesting that there may be opportunities to safely decrease admission rates and length of NICU stays.

"Alexa, Can You Be My Family Medicine Doctor?" The Future of Family Medicine in the Coming Techno-World.

Even before social distancing disrupted normative expectations and prompted an immediate shift to remote doctor/patient interactions, technology companies-Amazon, Apple, and Google-were preparing to disrupt medical care through the innovative use of technology. This article presents a possible scenario for how technology, in the near future, will completely up-end primary care practice. What does face-to-face interaction accomplish that cannot be done remotely? What do family physicians offer that cannot be accomplished by technology? More than just relationship, family medicine brings the therapeutic use of the self to engage with people, an ability to advocate for patients, and the ability to step back and reflect on the power of relationships. In addition, family physicians bring wisdom, making decisions in the liminal state between patient and physician, the resulting product of the human connection but also the ability to manage complexity using the best evidence. The ability to do both gives family medicine physician the skills to leverage but also control the coming big data.