Mitigating the Burden of Medication Costs.

This essay discusses medication cost−lowering strategies that clinicians can use in routine clinical and inpatient care to assist patients in affording and adhering to expensive therapy regimens.

Testing interventions to reduce clinical inertia in the treatment of hypertension: rationale and design of a pragmatic randomized controlled trial.

BACKGROUND: Clinical inertia, or failure to intensify treatment when indicated, leads to suboptimal blood pressure control. Interventions to overcome inertia and increase antihypertensive prescribing have been modestly successful in part because their effectiveness varies based on characteristics of the provider, the patient, or the provider-patient interaction. Understanding for whom each intervention is most effective could help target interventions and thus increase their impact. METHODS: This three-arm, randomized trial tests the effectiveness of 2 interventions to reduce clinical inertia in hypertension prescribing compared to usual care. Forty five primary care providers (PCPs) caring for patients with hypertension in need of treatment intensification completed baseline surveys that assessed behavioral traits and were randomized to one of three arms: 1) Pharmacist e-consult, in which a clinical pharmacist provided patient-specific recommendations for hypertension medication management to PCPs in advance of upcoming visits, 2) Social norming dashboards that displayed PCP's hypertension control rates compared to those of their peers, or 3) Usual care (no intervention). The primary outcome was the rate of intensification of hypertension treatment. We will compare this outcome between study arms and then evaluate the association between characteristics of providers, patients, their clinical interactions, and intervention responsiveness. RESULTS: Forty-five primary care providers were enrolled and randomized: 16 providers and 173 patients in the social norming dashboards arm, 15 providers and 143 patients in the pharmacist e-consult arm, and 14 providers and 150 patients in the usual care arm. On average, the mean patient age was 64 years, 47% were female, and 73% were white. Baseline demographic and clinical characteristics of patients were similar across arms, with the exception of more Hispanic patients in the usual care arm and fewest in the pharmacist e-consult arm. CONCLUSIONS: This study can help identify interventions to reduce inertia in hypertension care and potentially identify the characteristics of patients, providers, or patient-provider interactions to understand for whom each intervention would be most beneficial. TRIAL REGISTRATION: Clinicaltrials.gov (NCT, Registered: NCT04603560).

"How" Versus "Why" Messaging to Increase Uptake of Booster Vaccination Against COVID-19: Results of a Pragmatic Randomized Trial.

BACKGROUND: Messages aimed at increasing uptake of vaccines have been modestly successful, perhaps in part because they often focus on why individuals should receive a vaccine. Construal Level Theory posits that messages emphasizing "how" to get a vaccine may be more effective at encouraging vaccination than emphasizing "why." This message framing may be particularly important for COVID-19 booster acceptance. OBJECTIVE: To determine if pre-visit patient portal messages designed using Construal Level Theory increase rates of COVID-19 booster vaccination. DESIGN AND INTERVENTIONS: This 3-arm randomized trial was conducted across three large, diverse primary care clinics in Massachusetts between February and May 2022, testing the impact of "how" versus "why" framed pre-visit messages versus no messages ("usual care"). Messages were sent by patient portal two business days before a visit. PARTICIPANTS: Adults with upcoming primary care visits who had electronic health record evidence of receiving their initial COVID-19 vaccination series but not a booster dose. MAIN MEASURES: Receipt of a COVID-19 booster vaccination after the message was sent through the visit date (primary outcome) or 6 weeks (secondary outcome). KEY RESULTS: A total of 3665 patients were randomized (mean age: 53.5 years (SD: 17.3), 59% female, 65.2% White, 26.6% Hispanic), with 1249 to "how" 1199 to "why," and 1217 to usual care arms. Except for clinic and preferred language, characteristics were well balanced across arms. Rates of COVID-19 booster were 13.6% (usual care), 11.7% ("how") (odds ratio (OR) "how" vs usual care: 0.87, 95%CI: 0.67-1.14), and 13.7% ("why") ("why" vs usual care: OR: 1.01, 95%CI: 0.81-1.28). At 6 weeks, "why" outperformed "how" for vaccination (OR: 1.26, 95%CI: 1.06-1.49), with no difference versus usual care. CONCLUSIONS: We found no differences on visit booster receipt after single pre-visit portal messages designed using Construal Level Theory. Further studies to identify effective messaging interventions are needed, especially as additional doses are recommended. CLINICAL TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov, ID: NCT04871776 . Initial release occurred 04/30/2021.

System-Level Factors and Time Spent on Electronic Health Records by Primary Care Physicians.

Importance: Primary care physicians (PCPs) spend the most time on the electronic health record (EHR) of any specialty. Thus, it is critical to understand what factors contribute to varying levels of PCP time spent on EHRs. Objective: To characterize variation in EHR time across PCPs and primary care clinics, and to describe how specific PCP, patient panel, clinic, and team collaboration factors are associated with PCPs' time spent on EHRs. Design, Setting, and Participants: This cross-sectional study included 307 PCPs practicing across 31 primary care clinics at Massachusetts General Hospital and Brigham and Women's Hospital during 2021. Data were analyzed from October 2022 to October 2023. Main Outcomes and Measures: Total per-visit EHR time, total per-visit pajama time (ie, time spent on the EHR between 5:30 pm to 7:00 am and on weekends), and total per-visit time on the electronic inbox as measured by activity log data derived from an EHR database. Results: The sample included 307 PCPs (183 [59.6%] female). On a per-visit basis, PCPs spent a median (IQR) of 36.2 (28.9-45.7) total minutes on the EHR, 6.2 (3.1-11.5) minutes of pajama time, and 7.8 (5.5-10.7) minutes on the electronic inbox. When comparing PCP time expenditure by clinic, median (IQR) total EHR time, median (IQR) pajama time, and median (IQR) electronic inbox time ranged from 23.5 (20.7-53.1) to 47.9 (30.6-70.7) minutes per visit, 1.7 (0.7-10.5) to 13.1 (7.7-28.2) minutes per visit, and 4.7 (4.1-5.2) to 10.8 (8.9-15.2) minutes per visit, respectively. In a multivariable model with an outcome of total per-visit EHR time per visit, an above median percentage of teamwork on orders was associated with 3.81 (95% CI, 0.49-7.13) minutes per visit fewer and having a clinic pharmacy technician was associated with 7.87 (95% CI, 2.03-13.72) minutes per visit fewer. Practicing in a community health center was associated with fewer minutes of total EHR time per visit (5.40 [95% CI, 0.06-10.74] minutes). Conclusions and Relevance: There is substantial variation in EHR time among individual PCPs and PCPs within clinics. Organization-level factors, such as team collaboration on orders, support for medication refill functions, and practicing in a community health center, are associated with lower EHR time for PCPs. These findings highlight the importance of addressing EHR burden at a systems level.

Principles to Inform Risk Adjustment Policy: Reflection From the Front Lines.

This Viewpoint discusses the benefits and drawbacks of current risk adjustment tools, outlines the pressures clinicians may face to use these tools, and proposes principles and policy solutions to ensure that risk adjustment is clinically meaningful and to minimize gaming and waste.

Shell-sheddable dendritic polyglycerol sulfates loaded with sunitinib for inhibition of tumor angiogenesis.

Induced angiogenesis, a specific hallmark of cancer, plays a vital role in tumor progression and can be targeted by inhibitors like sunitinib. Sunitinib is a small hydrophobic molecule suffering from low bioavailability and a short half-life in the bloodstream. To overcome these drawbacks, suitable drug delivery systems need to be developed. In this work dendritic polyglycerol (dPG), a well-known polymer, was functionalized with a sheddable shell. Therefore, aliphatic chains of different lengths (C5, C9, C11) were coupled to dPG through a cleavable ester bond. To restore water solubility and improve tumor targeting, the surface was decorated with sulfate groups. The resulting shell-sheddable dPG sulfates were characterized and evaluated regarding their loading capacity and biocompatibility in cell culture. The nine-carbon chain derivative (dPG-TNS) was selected as the best candidate for further experiments due to its high drug loading capacity (20 wt%), and a sustained release in vitro. The cellular biocompatibility of the blank carrier up to 1 mg/mL was confirmed after 24 h incubation on HeLa cells. Furthermore, the shell-cleavability of dPG-TNS under different physiological conditions was shown in a degradation study over four weeks. The activity of sunitinib-loaded dPG-TNS was demonstrated in a tube formation assay on Human umbilical vein endothelial cells (HUVECs). Our results suggest that the drug-loaded nanocarrier is a promising candidate to be further investigated in tumor treatments, as it shows similar efficacy to free sunitinib while overcoming its limitations.

Association Between Electronic Health Record Time and Quality of Care Metrics in Primary Care.

Importance: Physicians across the US spend substantial time working in the electronic health record (EHR), with primary care physicians (PCPs) spending the most time. The association between EHR time and ambulatory care quality outcomes is unclear. Objective: To characterize measures of EHR use and ambulatory care quality performance among PCPs. Design, Setting, and Participants: A cross-sectional study of PCPs with longitudinal patient panels using a single EHR vendor was conducted at Brigham and Women's Hospital and Massachusetts General Hospital during calendar year 2021. Exposures: Independent variables included PCPs demographic and practice characteristics and EHR time measures (PCP-level mean of daily total EHR time, after-hours time, time from 5:30 pm to 7:00 am and time on weekends, and daily EHR time on notes, sending and receiving patient, staff, results, prescription, or system messages [in-basket], and clinical review). Main Outcomes and Measures: Outcome variables were ambulatory quality measures (year-end, PCP panel-level achievement of targets for hemoglobin A1c level control, lipid management, hypertension control, diabetes screening, and breast cancer screening). Results: The sample included 291 physicians (174 [59.8%] women). Median panel size was 829 (IQR, 476-1157) patients and mean (SD) clinical full-time equivalent was 0.54 (0.27). The PCPs spent a mean (SD) of 145.9 (64.6) daily minutes on the EHR. There were significant associations between EHR time and panel-level achievement of hemoglobin A1c control, hypertension control, and breast cancer screening targets. In adjusted analyses, each additional 15 minutes of total daily EHR time was associated with 0.58 (95% CI, 0.32-0.84) percentage point greater panel-level hemoglobin A1c control, 0.52 (95% CI, 0.33-0.71) percentage point greater hypertension control, and 0.28 (95% CI, 0.05-0.52) higher breast cancer screening rates. Each daily additional 15 minutes of in-basket time was associated with 2.26 (95% CI, 1.05-3.48) greater panel-wide hemoglobin A1c control, 1.65 (95% CI, 0.83-2.47) percentage point greater hypertension control, and 1.26 (95% CI, 0.51-2.02) percentage point higher breast cancer screening rates. Associations were largely concentrated among PCPs with 0.5 clinical full-time equivalent or less. There were no associations between EHR use metrics and diabetes screening or lipid management in patients with cardiovascular disease. Conclusions and Relevance: This cross-sectional study found an association between EHR time and some measures of ambulatory care quality. Although increased EHR time is associated with burnout, it may represent a level of thoroughness or communication that enhances certain outcomes. It may be useful for future studies to characterize payment models, workflows, and technologies that enable high-quality ambulatory care delivery while minimizing EHR burden.

Preferences of adolescents - A dataset containing linked experimental task measures and register data.

Between March 2019 and March 2020, we visited 53 school groups (classes) in 9 Hungarian schools to measure time, risk, social and competitive preferences of 1108 secondary school students using incentivized laboratory experimental tasks. We applied the unfolding brackets method to measure time preferences [1], and the bomb-risk elicitation task [2] to test risk preferences. For assessing competitive preferences, we utilized a real effort task (counting zeros) and used the three-round measure of competition [3]. We applied three different games to test social preferences: the dictator game, the trust game, and a simple public good game. We gave out vouchers for the school buffet to incentivize the experiments. We then took these anonymously measured preferences and connected them to the administrative panel of the National Assessment of Basic Competencies (NABC) using the hash codes provided by the Education Authority. We gain all additional information on gender, parental background, standardized test scores and school performance (grades) from the NABC data. The dataset provides detailed insights into how preferences of upper secondary school students associate with educational outcomes, social background and gender. The database contains rich background data on the individual level. We observe students nested in classes (groups of students having most of their courses together) nested in schools which allows the analyst to see how the background variables relate to preferences not only on the individual level, but also within schools and within classes. Moreover, as we measure nine aspects of the four most widely used preferences at once, we can assess these relationships more precisely, conditional on correlated preferences. In an accompanying paper we study gender differences in preferences of adolescents using this dataset [4].

Primary care physician's (PCP) perceived value of patient-reported outcomes (PROs) in clinical practice: a mixed methods study.

BACKGROUND: Patient-reported outcomes (PROs) can promote patient engagement, shared-decision making and improve the overall experience of care. However, PRO integration in the primary care clinical setting is limited. Exploring the perspectives of primary care physicians (PCPs) on PROs is key to understanding how they are being used in the clinical setting. We sought to elucidate this clinical perspective at one of the largest US health systems that has integrated a wide range of PROs into routine primary care. METHODS: Mixed methods study with both anonymous online surveys and in-person qualitative semistructured interviews conducted with PCPs to understand their clinical perspectives on the applications of the existing PROs. PCPs from the 19 affiliated clinics were prompted to complete the survey. Interviewed PCPs were selected via a combination of random and purposive selection from the PCP directory. RESULTS: Of 172 PCPs, 117 (68%) completed the online survey and 28 completed semistructured interviews. Most PCPs (77%) reviewed PRO responses with their patients. PCPs endorsed that PROs improve clinic efficiency and clinical management. However, PCPs have heterogeneous perspectives on the relevance of PROs in clinical practice, likely due to variations in clinic practice. For specific PRO instruments, PCPs reported anxiety and depression screening PROs to be most helpful. PCPs felt that PROs assisted with completing screening questions that are required by regulatory bodies. Barriers to using PROs include poor user-interface for both clinicians and patients and inadequate training. CONCLUSIONS: Most PCPs regularly use PRO data though there are mixed opinions about their clinical relevance. An adaptable, user-friendly PRO system has the potential to have meaningful clinical applications in primary care.

HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes Management.

BACKGROUND: Electronic consultation (eConsultation) offers a potential mechanism to increase access to specialty care, address knowledge gaps, and overcome therapeutic inertia in patients with type 2 diabetes (T2DM) being managed by primary care physicians (PCPs). OBJECTIVE: To develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5-10.5% managed by PCPs. DESIGN: Cluster-randomized matched cohort study with implementation evaluation. PARTICIPANTS: PCPs affiliated with Massachusetts General Hospital (MGH). INTERVENTIONS: Unsolicited endocrinology eConsultation. MAIN MEASURES: The primary clinical outcome was mean change in HbA1c at 6 months. Secondary process outcomes included referral completion rate, prescription rates of glucose-lowering medications, differences in rate of other management recommendations, change in all glucose-lowering medications, and number of face-to-face endocrinology visits. KEY RESULTS: 161 PCPs were randomly assigned to intervention (n=81) and control (n=80) arms. eConsultations were triggered on 130 patients from intervention arm PCPs. Intervention arm patients had a 0.89 (SD 1.45) decrease in HbA1c compared to 0.69 (SD 1.32) decrease in the control arm (p=0.28). There were significant differences in prescribing of glucose-lowering medications between arms. There was a 19.3% increase in patients prescribed GLP-1 RA or SGLT2i in the intervention arm compared to a 6.9% increase in control (p=0.003). There were also significant increases in prescription rates of metformin (3.1% vs -3.1%, p=0.03) and sulfonylureas (1.5% vs -6.9%, p=0.03). At 6-month follow-up, the intervention arm had 13 in-person endocrinology visits compared to 29 (p=0.012) in the control arm. PCPs were more likely to accept recommendations regarding adherence to or dose adjustment of current medications than initiation of new medications. CONCLUSIONS: The implementation of an unsolicited endocrinology eConsult system for patients with poorly controlled T2DM is feasible. Unsolicited eConsultation was associated with increased prescribing of glucose-lowering medications without significant difference in HbA1c. TRIAL REGISTRATION: Clinicaltrials.gov registration: NCT03542084.

Prevalence of Angina Among Primary Care Patients With Coronary Artery Disease.

Importance: Angina pectoris is associated with morbidity and mortality. Angina prevalence and frequency among contemporary US populations with coronary artery disease (CAD) remain incompletely defined. Objective: To ascertain the angina prevalence and frequency among stable outpatients with CAD. Design, Setting, and Participants: This cross-sectional survey study involved telephone-based administration of the Seattle Angina Questionnaire-7 (SAQ-7) between February 1, 2017, and July 31, 2017, to a nonconvenience sample of adults with established CAD who receive primary care through a large US integrated primary care network. Data analysis was performed from August 2017 to August 2019. Exposure: SAQ-7 administration. Main Outcomes and Measures: Angina prevalence and frequency were assessed using SAQ-7 question 2. Covariates associated with angina were assessed in univariable and multivariable regression. Results: Of 4139 eligible patients, 1612 responded to the survey (response rate, 38.9%). The mean (SD) age of the respondents was 71.8 (11.0) years, 577 (35.8%) were women, 1447 (89.8%) spoke English, 147 (9.1%) spoke Spanish, 1336 (82.8%) were White, 76 (4.7%) were Black, 92 (5.7%) were Hispanic, 974 (60.4%) had Medicare, and 83 (5.2%) had Medicaid. Among respondents, 342 (21.2%) reported experiencing angina at least once monthly; among those, 201 (12.5%) reported daily or weekly angina, and 141 respondents (8.7%) reported monthly angina. The mean (SD) SAQ-7 score was 93.7 (13.7). After multivariable adjustment, speaking a language other than Spanish or English (odds ratio [OR], 5.07; 95% CI, 1.39-18.50), Black race (OR, 2.01; 95% CI, 1.08-3.75), current smoking (OR, 1.88; 95% CI, 1.27-2.78), former smoking (OR, 1.69; 95% CI, 1.13-2.51), atrial fibrillation (OR, 1.52; 95% CI, 1.02-2.26), and chronic obstructive pulmonary disease (OR, 1.61; 95% CI, 1.18-2.18) were associated with more frequent angina. Male sex (OR, 0.63; 95% CI, 0.47-0.86), peripheral artery disease (OR, 0.63; 95% CI, 0.44-0.90), and novel oral anticoagulant use (OR, 0.19; 95% CI, 0.08-0.48) were associated with less frequent angina. Conclusions and Relevance: Among stable outpatients with CAD receiving primary care through an integrated primary care network, 21.2% of surveyed patients reported experiencing angina at least once monthly. Several objective demographic and clinical characteristics were associated with angina frequency. Proactive assessment of angina symptoms using validated assessment tools and estimation of patients at higher risk of suboptimally controlled angina may be associated with reduced morbidity.

Chronic disease management in the COVID-19 era.

In the coronavirus disease 2019 (COVID-19) era, clinical registries and innovative virtual care delivery tools should be leveraged to engage populations in effective chronic disease management.

Time preferences and their life outcome correlates: Evidence from a representative survey.

We collect data on time preferences of a representative sample of the Hungarian adult population in a non-incentivized way and investigate how patience and present bias associate with important life outcomes in five domains: i) educational attainment, ii) unemployment, iii) income and wealth, iv) financial decisions and difficulties, and v) health. Based on the literature, we formulate the broad hypotheses that patience relates positively, while present bias associates negatively with positive outcomes in the domains under study. With the exception of unemployment, we document a consistent and often significant positive relationship between patience and the corresponding domain, with the strongest associations in educational attainment, wealth and financial decisions. We find that present bias associates significantly with saving decisions and financial difficulties.

An Audit and Feedback Intervention to Improve Internal Medicine Residents' Performance on Ambulatory Quality Measures: A Randomized Controlled Trial.

Audit and feedback is an effective method to improve attending physician performance. However, there are limited data on how audit and feedback impacts care provided by resident physicians. The authors conducted a 3-arm randomized clinical trial among internal medicine resident physicians to examine the impact of an audit and feedback intervention on ambulatory quality measures (AQMs). Residents in all 3 groups received an email containing the contact information of a population health coordinator and a list of AQMs (control). In addition, the Practice Target group received individual AQM data compared to the target AQM goals for all primary care practices. The Peer Comparison group received information on individual AQM data compared to the average performance of residents in the same postgraduate year. Residents in each intervention group received updated information 6 months later. Ten AQMs related to diabetes care, hypertension management, lipid control, and cancer screening, as well as a composite quality score, were examined at baseline, 6 months, and 13 months. At 13 months follow-up, the Practice Target group had statistically significant improvement in cervical cancer screening rate (77% vs. 65.3%), colorectal cancer screening rate (72.5% vs. 64.6%), and composite quality score (71.7% vs 65.4%) compared to baseline. Providing internal medicine residents with individual AQMs data compared to target goal for the practice led to statistically significant improvement in cancer screening rates and the composite quality score. Audit and feedback may be a relatively simple yet effective tool to improve population health in the resident clinic setting.

Which preferences associate with school performance?-Lessons from an exploratory study with university students.

Success in life is determined to a large extent by school performance so it is important to understand the effect of the factors that influence it. In this exploratory study, in addition to cognitive abilities, we attempt to link measures of preferences with outcomes of school performance. We measured in an incentivized way risk, time, social and competitive preferences and cognitive abilities of university students to look for associations between these measures and two important academic outcome measures: exam results and GPA. We find consistently that cognitive abilities (proxied by the Cognitive Reflection Test) are very well correlated with school performance. Regarding non-cognitive skills, we report suggestive evidence for many of our measured preferences. We used two alternative measures of time preference: patience and present bias. Present bias explains exam grades better, while patience explains GPA relatively better. Both measures of time preferences have a non-linear relation to school performance. Competitiveness matters, as students, who opt for a more competitive payment scheme in our experimental task have a higher average GPA. We observe also that risk-averse students perform a little better than more risk-tolerant students. That makes sense in case of multiple choice exams, because more risk-tolerant students may want to try to pass the exam less prepared, as the possibility of passing an exam just by chance is not zero. Finally, we have also detected that cooperative preferences-the amount of money offered in a public good game-associates strongly with GPA in a non-linear way. Students who offered around half of their possible amounts had significantly higher GPAs than those, who offered none or all their money.

Impact of a Population Health Management Intervention on Disparities in Cardiovascular Disease Control.

BACKGROUND: Healthcare systems use population health management programs to improve the quality of cardiovascular disease care. Adding a dedicated population health coordinator (PHC) who identifies and reaches out to patients not meeting cardiovascular care goals to these programs may help reduce disparities in cardiovascular care. OBJECTIVE: To determine whether a program that used PHCs decreased racial/ethnic disparities in LDL cholesterol and blood pressure (BP) control. DESIGN: Retrospective difference-in-difference analysis. PARTICIPANTS: Twelve thousdand five hundred fifty-five primary care patients with cardiovascular disease (cohort for LDL analysis) and 41,183 with hypertension (cohort for BP analysis). INTERVENTION: From July 1, 2014-December 31, 2014, 18 practices used an information technology (IT) system to identify patients not meeting LDL and BP goals; 8 practices also received a PHC. We examined whether having the PHC plus IT system, compared with having the IT system alone, decreased racial/ethnic disparities, using difference-in-difference analysis of data collected before and after program implementation. MAIN MEASURES: Meeting guideline concordant LDL and BP goals. KEY RESULTS: At baseline, there were racial/ethnic disparities in meeting LDL (p = 0.007) and BP (p = 0.0003) goals. Comparing practices with and without a PHC, and accounting for pre-intervention LDL control, non-Hispanic white patients in PHC practices had improved odds of LDL control (OR 1.20 95% CI 1.09-1.32) compared with those in non-PHC practices. Non-Hispanic black (OR 1.15 95% CI 0.80-1.65) and Hispanic (OR 1.29 95% CI 0.66-2.53) patients saw similar, but non-significant, improvements in LDL control. For BP control, non-Hispanic white patients in PHC practices (versus non-PHC) improved (OR 1.13 95% CI 1.05-1.22). Non-Hispanic black patients (OR 1.17 95% CI 0.94-1.45) saw similar, but non-statistically significant, improvements in BP control, but Hispanic (OR 0.90 95% CI 0.59-1.36) patients did not. Interaction testing confirmed that disparities did not decrease (p = 0.73 for LDL and p = 0.69 for BP). CONCLUSIONS: The population health management intervention did not decrease disparities. Further efforts should explicitly target improving both healthcare equity and quality. Clinical Trials #: NCT02812303 ( ClinicalTrials.gov ).