Identifying barriers to shared decision-making about bariatric surgery in two large health systems.

OBJECTIVE: Prior research suggests shared decision-making (SDM) could improve patient and health care provider communication about bariatric surgery. The aim of this work was to identify and prioritize barriers to SDM around bariatric surgery to help guide implementation of SDM. METHODS: Two large US health care systems formed multidisciplinary teams to facilitate the implementation of SDM around bariatric surgery. The teams used a nominal group process approach involving (1) generation of multilevel barriers, (2) round-robin recording of barriers, (3) facilitated discussion, and (4) selection and ranking of barriers according to importance and feasibility to address. RESULTS: One health system identified 13 barriers and prioritized 5 as the most important and feasible to address. The second health system identified 14 barriers and prioritized 6. Both health systems commonly prioritized six barriers: lack of insurance coverage; lack of understanding of insurance coverage; lack of organizational prioritization of SDM; lack of knowledge about bariatric surgery; lack of interdepartmental clarity between primary and specialty care; and limited training on SDM conversations and tools. CONCLUSIONS: Health systems face numerous barriers to SDM around bariatric surgery, and these can be easily identified and prioritized by multistakeholder teams. Future research should seek to identify effective strategies to address these common barriers.

Primary care physician resource use changes associated with feedback reports.

OBJECTIVES: To measure changes in primary care physician (PCP) ordering rates for 4 global resource use measures before and after dissemination of physician feedback reports that provided peer-comparison resource use rates. We also explored whether physician practice characteristics (panel size, clinic size, and years of experience) were associated with resource use changes. STUDY DESIGN: Pre-post implementation study measuring physician resource use in an integrated healthcare system (2011-2014). METHODS: Kaiser Permanente Washington PCPs (N = 210) were provided annual feedback reports showing their personal ordering rates compared with those of their peers. Monthly physician ordering was measured from November 2011 to September 2014 (including prereport and postreport periods). We examined 4 physician ordering rates (specialty referrals, high-end imaging, laboratory tests, and 30-day prescriptions) per 1000 patients, adjusted for patient age, gender, and clinical complexity. RESULTS: After accounting for physician practice characteristics, monthly PCP ordering rates for high-end imaging significantly decreased by 0.8 images per 1000 patients (P <.01). In contrast, orders for laboratory tests and 30-day prescriptions significantly increased by 15.0 tests and 84.7 prescriptions per 1000 patients (both P <.01). We observed greater changes following feedback in physicians with fewer years of experience (≤10 years), who had 4.2 fewer specialty referrals (P = .01) and 101.3 more 30-day prescriptions (P <.01) compared with those with more experience (>20 years). CONCLUSIONS: Physician feedback reports may be associated with changes in physician resource use, and physicians with fewer years of experience may be more responsive to feedback reports. Better understanding of factors associated with changes in resource use is necessary for future targeted development of physician interventions.

Primary Care Clinicians' Perspectives on Reducing Low-Value Care in an Integrated Delivery System.

CONTEXT: Perceptions about low-value care (eg, medical tests and procedures that may be unnecessary and/or harmful) among clinicians with capitated salaries are unknown. OBJECTIVE: Explore clinicians' perceived use of and responsibility for reducing low-value care by focusing on barriers to use, awareness of the Choosing Wisely campaign, and response to reports of peer-comparison resource use and practice patterns. METHODS: Electronic, cross-sectional survey, distributed in 2013, to 304 salaried primary care physicians and physician assistants at Group Health Cooperative. MAIN OUTCOME MEASURES: Attitudes, awareness, and barriers of low-value care strategies and initiatives. RESULTS: A total of 189 clinicians responded (62% response rate). More than 90% believe cost is important to various stakeholders and believe it is fair to ask clinicians to be cost-conscious. Most found peer-comparison resource-use reports useful for understanding practice patterns and prompting peer discussions. Two-thirds of clinicians were aware of the Choosing Wisely campaign; among them, 97% considered it a legitimate information source. Although 88% reported being comfortable discussing low-value care with patients, 80% reported they would order tests or procedures when a patient insisted. As key barriers in reducing low-value care, clinicians identified time constraints (45%), overcoming patient preferences/values (44%), community standards (43%), fear of patients' dissatisfaction (41%), patients' knowledge about the harms of low-value care (38%), and availability of tools to support shared decision making (37%). CONCLUSIONS: Salaried clinicians are aware of rising health care costs and want to be stewards of limited health care resources. Evidence-based initiatives such as the Choosing Wisely campaign may help motivate clinicians to be conscientious stewards of limited health care resources.

Decision aids for benign prostatic hyperplasia and prostate cancer.

OBJECTIVES: To examine the relationships among implementing decision aids (DAs) for benign prostatic hyperplasia (BPH) and prostate cancer (PRCA), and treatment rates and costs. STUDY DESIGN: A pre-post observational evaluation of a quality improvement initiative in a healthcare system in Washington state. METHODS: Men with BPH seen in urology clinics and all men diagnosed with localized PRCA were identified for an intervention period, in which urologists were instructed to order a DA for every patient with those conditions, and a historical control period. Outcomes were 6-month rates of surgery for BPH, any active treatment (hormone therapy, radiation, or surgery) for PRCA, and total healthcare costs. Results During the intervention, DAs were delivered to 22% of men with recent BPH drug treatment, 24% of men with untreated BPH, and 56% of men with PRCA. DA implementation was associated with a 32% lower rate of surgery among men with treated BPH (rate ratio [RR], 0.68; 95% CI, 0.49-0.94) and a nonsignificant 22% lower rate of surgery among men with previously untreated BPH (RR, 0.78; 95% CI, 0.50-1.22). For PRCA, DA implementation was associated with a 27% lower rate of active treatment (RR, 0.73; 95% CI, 0.57-0.93). We found no significant associations between DA implementation and costs of care for either condition. CONCLUSIONS: Implementing patient DAs was associated with lower rates of elective surgery for previously treated BPH and active treatment for localized PRCA; however, implementation of these DAs was not associated with lower costs of care.

Successful practices in the use of secure e-mail.

Physician use of secure e-mail with patients is anticipated to increase under Stage 2 Meaningful Use requirements, but little is known about how physicians can successfully incorporate it into daily work. We interviewed 27 "super user" physicians at Kaiser Permanente and Group Health who were identified by leaders as being technologically, operationally, and clinically adept and as having high levels of secure e-mail use with patients. They highly valued the use of secure e-mail with patients, despite concerns about a lack of adequate time to respond, and provided tips for using it successfully. They identified benefits that included better care and improved relationships with their patients.

Coordinate regulation of TPL-2 and NF-κB signaling in macrophages by NF-κB1 p105.

The role of IκB kinase (IKK)-induced proteolysis of NF-κB1 p105 in innate immune signaling was investigated using macrophages from Nfkb1(SSAA/SSAA) mice, in which the IKK target serines on p105 are mutated to alanines. We found that the IKK/p105 signaling pathway was essential for TPL-2 kinase activation of extracellular signal-regulated kinase (ERK) mitogen-activate protein (MAP) kinase and modulated the activation of NF-κB. The Nfkb1(SSAA) mutation prevented the agonist-induced release of TPL-2 from its inhibitor p105, which blocked activation of ERK by lipopolysaccharide (LPS), tumor necrosis factor (TNF), CpG, tripalmitoyl-Cys-Ser-Lys (Pam(3)CSK), poly(I · C), flagellin, and R848. The Nfkb1(SSAA) mutation also prevented LPS-induced processing of p105 to p50 and reduced p50 levels, in addition to decreasing the nuclear translocation of RelA and cRel. Reduced p50 in Nfkb1(SSAA/SSAA) macrophages significantly decreased LPS induction of the IκBζ-regulated Il6 and Csf2 genes. LPS upregulation of Il12a and Il12b mRNAs was also impaired although specific blockade of TPL-2 signaling increased expression of these genes at late time points. Activation of TPL-2/ERK signaling by IKK-induced p105 proteolysis, therefore, induced a negative feedback loop to downregulate NF-κB-dependent expression of the proinflammatory cytokine interleukin-12 (IL-12). Unexpectedly, TPL-2 promoted soluble TNF production independently of IKK-induced p105 phosphorylation and its ability to activate ERK, which has important implications for the development of anti-inflammatory drugs targeting TPL-2.