Buy or Build: Challenges Developing Consumer Digital Health Interventions.

BACKGROUND: Digital health interventions offer opportunities to improve collaborative care between clinicians and patients. Designing and implementing digital health interventions requires decisions about buying or building each technology-related component, all of which can lead to unanticipated issues. OBJECTIVES: This study aimed to describe issues encountered from our "buy or build" decisions developing two digital health interventions over different timeframes, designed to use patient-generated health data to: (1) improve hypertension control and (2) measure and improve adherence to HIV-related medications. METHODS: CONDUIT-HID (CONtrolling Disease Using Information Technology-Hypertension In Diabetes) was developed during 2010 to 2015 to allow patients receiving care from a multispecialty group practice to easily upload home blood pressure readings into their electronic health record and trigger clinician action if mean blood pressure values indicated inadequate control. USE-MI (Unobtrusive SEnsing of Medication Intake) was developed from 2016 to 2022 to allow entry of patients' HIV-related medication regimens, send reminders if patients had not taken their medications by the scheduled time(s), attempt to detect medication ingestion through machine learning analysis of smartwatch motion data, and present graphical adherence summaries to patients and clinicians. RESULTS: Both projects required multiple "buy or build" decisions across all system components, including data collection, transfer, analysis, and display. We used commercial, off-the-shelf technology where possible, but virtually all of these components still required substantial custom development. We found that, even though our projects spanned years, issues related to our "buy or build" decisions stemmed from several common themes, including mismatches between existing and new technologies, our use case being new or unanticipated, technology stability, technology longevity, and resource limitations. CONCLUSION: Those designing and implementing digital health interventions need to make numerous "buy or build" decisions as they create the technologies that underpin their intervention. These "buy or build" decisions, and the ensuing issues that will arise because of them, require careful planning, particularly if they represent an "edge case" use of existing commercial systems.

Predictors of Art and PrEP Adherence and Medication-Taking Practices and Preferences to Inform Development of a Wrist-Worn Adherence System.

We examined adherence, medication-taking practices, and preferences to inform development of a wrist-worn adherence system. Two convenience samples of persons taking antiretroviral therapy and HIV pre-exposure prophylaxis completed a survey. Additional online questions asked about willingness to use a wrist-worn device and reminder and feedback preferences. Among 225 participants, 13% reported adherence < 90%; this was associated with younger age and clinic sample. Compared to pill bottle-using participants, mediset users less commonly reported adherence < 90% (aOR = 0.16, p = .02), and blister pack users (aOR = 6.3, p = .02) and pill roll users (aOR = 3.3, p = .04) more commonly reported adherence < 90%. Sixty-two percent of the online participants reporting adherence (< 100%) had some interest in receiving adherence reminders, including 42% with interest in receiving reminders by smartwatch notifications. Although confounders are likely, formative work identified potential users and interest in using a wrist-worn adherence system. Future work will determine its acceptability and efficacy.

Can scribes boost FPs' efficiency and job satisfaction?

PURPOSE: Research in other medical specialties has shown that the addition of medical scribes to the clinical team enhances physicians' practice experience and increases productivity. To date, literature on the implementation of scribes in primary care is limited. To determine the feasibility and benefits of implementing scribes in family medicine, we undertook a pilot mixed- method quality improvement (QI) study. METHODS: In 2014, we incorporated 4 parttime scribes into an academic family medicine practice consisting of 7 physicians. We then measured, via survey and time-tracking data, the impact the scribes had on physician office hours and productivity, time spent on documentation, perceptions of work-life balance, and physician and patient satisfaction. RESULTS: Six of the 7 faculty physicians participated. This study demonstrated that the use of scribes in a busy academic primary care practice substantially reduced the amount of time that family physicians spent on charting, improved work-life balance, and had good patient acceptance. Specifically, the physicians spent an average of 5.1 fewer hours/week (hrs/wk) on documentation, while various measures of productivity revealed increases ranging from 9.2% to 28.8%. Perhaps most important of all, when the results of the pilot study were annualized, they were projected to generate $168,600 per year--more than twice the $79,500 annual cost of 2 full-time equivalent scribes. Surveys assessing work-life balance demonstrated improvement in the physicians' perception of the administrative burden/paperwork related to practice and a decrease in their perception of the extent to which work encroached on their personal lives. In addition, survey data from 313 patients at the time of their ambulatory visit with a scribe present revealed a high level of comfort. Likewise, surveys completed by physicians after 55 clinical sessions (ie, blocks of consecutive, uninterrupted patient appointments; there are usually 2 sessions per day) revealed good to excellent ratings more than 90% of the time. CONCLUSION: In an outpatient family medicine clinic, the use of scribes substantially improved physicians' efficiency, job satisfaction, and productivity without negatively impacting the patient experience.

Persuasive Interventions for Controversial Cancer Screening Recommendations: Testing a Novel Approach to Help Patients Make Evidence-Based Decisions.

PURPOSE: We wanted to evaluate novel decision aids designed to help patients trust and accept the controversial, evidence-based, US Preventive Services Task Force recommendations about prostate cancer screening (from 2012) and mammography screening for women aged 40 to 49 years (from 2009). METHODS: We created recorded vignettes of physician-patient discussions about prostate cancer screening and mammography, accompanied by illustrative slides, based on principles derived from preceding qualitative work and behavioral science literature. We conducted a randomized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years. All participants saw a video intervention and a more traditional, paper-based decision aid intervention in random order. At entry and after seeing each intervention, they were surveyed about screening intentions, perceptions of benefits and harm, and decisional conflict. RESULTS: Changes in screening intentions were analyzed without regard to order of intervention after an initial analyses showed no evidence of an order effect. At baseline, 69% of men and 86% of women reported wanting screening, with 31% and 6%, respectively, unsure. Mean change on a 3-point, yes, unsure, no scale was -0.93 (P = <.001) for men and -0.50 (P = <.001) for women after seeing the video interventions vs 0.0 and -0.06 (P = .75) after seeing the print interventions. At the study end, 33% of men and 49% of women wanted screening, and 11% and 20%, respectively, were unsure. CONCLUSIONS: Our novel, persuasive video interventions significantly changed the screening intentions of substantial proportions of viewers. Our approach needs further testing but may provide a model for helping patients to consider and accept evidence-based, counterintuitive recommendations.

Inaccurate risk perceptions and individualized risk estimates by patients with type 2 diabetes.

BACKGROUND: We evaluated how diabetic patients understand and respond to the presentation of personalized risk information. METHODS: This was a mixed methods study involving 56 patients with type 2 diabetes and at least 1 additional cardiovascular risk factor. We assessed participants' perceptions of diabetes-related risks; asked them to rank order 6 events (death, heart attack, stroke, blindness, amputation, and kidney failure) by likelihood of occurrence in a specified time frame; presented them with personalized risk estimates; and asked them to re-rank the risks. The final 18 participants were tested to verify understanding before re-ranking risks. Qualitative analysis of interview transcripts identified themes and concepts underlying participants' ways of perceiving and reacting to risk. RESULTS: While mortality was the most likely outcome for almost all participants, nearly all estimated it to be least likely; only 28% adjusted their mortality rankings to match model predictions. Some did not understand the risk information: only two thirds of those asked could rank risks according to the information presented. Risk perceptions were influenced by factors including "knowing myself," powerful anecdotes, and belief that a "warning shot" would occur before death. CONCLUSIONS: Personalized risk estimates, particularly about mortality, had limited salience. Some participants could not understand the information, despite presentation in ways suggested by previous research.

The central role of comorbidity in predicting ambulatory care sensitive hospitalizations.

BACKGROUND: Ambulatory care sensitive hospitalizations (ACSHs) are commonly used as measures of access to and quality of care. They are defined as hospitalizations for certain acute and chronic conditions; yet, they are most commonly used in analyses comparing different groups without adjustment for individual-level comorbidity. We present an exploration of their roles in predicting ACSHs for acute and chronic conditions. METHODS: Using 1998-99 US Medicare claims for 1 06 930 SEER-Medicare control subjects and 1999 Area Resource File data, we modelled occurrence of acute and chronic ACSHs with logistic regression, examining effects of different predictors on model discriminatory power. RESULTS: Flags for the presence of a few comorbid conditions-congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and, for acute ACSHs, dementia-contributed virtually all of the discriminative ability for predicting ACSHs. C-statistics were up to 0.96 for models predicting chronic ACSHs and up to 0.87 for predicting acute ACSHs. C-statistics for models lacking comorbidity flags were lower, at best 0.73, for both acute and chronic ACSHs. CONCLUSION: Comorbidity is far more important in predicting ACSH risk than any other factor, both for acute and chronic ACSHs. Imputations about quality and access should not be made from analyses that do not control for presence of important comorbid conditions. Acute and chronic ACSHs differ enough that they should be modelled separately. Unaggregated models restricted to persons with the relevant diagnoses are most appropriate for chronic ACSHs.

Provision of contraceptive services to homeless women: results of a survey of health care for the homeless providers.

Homeless women have both a higher rate of pregnancy and a higher proportion of unintended pregnancies than other American women. The authors sought to learn about contraception services offered by providers of health care to homeless women and barriers to provision of long-acting, reversible contraception in these settings. A survey of the 31 member organizations in the national Health Care for the Homeless Practice-Based Research Network was conducted, inquiring about services provided and barriers to service provision. Among the 20 responding organizations (65% response rate), 17 directly provided contraceptive services; two referred patients elsewhere, and one provided no contraceptive services. All 17 that provided such services provided condoms; 15 provided oral contraceptives; 14 provided injectable contraception; 6 provided intrauterine devices, and 2 provided contraceptive implants. Barriers to providing the last two methods included lack of provider training, lack of resources for placement, costs, and concerns about complications. The present survey results suggested very limited access for homeless women across the country to the two most effective means of long-acting, reversible contraception. Modest investments of resources could reduce a number of barriers to providing these services.

Do primary care physicians lose contact with their colorectal cancer patients?

BACKGROUND: Primary care physicians and patients perceive that they lose contact with each other after a cancer diagnosis. The objective of this study was to determine whether colorectal cancer (CRC) patients are less likely to see their primary care physicians after cancer diagnosis. METHODS: This was a longitudinal cohort study using 1993 to 2001 Surveillance Epidemiology and End Results (SEER)-Medicare claims data. Eligible patients were those with stage 0 to 1 and 2 to 3 CRC aged 67 to 89 years at diagnosis. Main measures included the proportion of individuals with a face-to-face primary care visit and mean annual primary care visits per patient at baseline and during 5 years after treatment. RESULTS: Fewer than half of the cancer patients visited with a primary care physician at baseline. In the first year after treatment, patients with stage 0 to 1 CRC (48.9% vs 53.3%; P ≤ .001) and stage 2 to 3 CRC (43.6% vs 53.4%; P ≤ .001) significantly increased their likelihood of visiting a primary care physician from baseline. The proportion of patients with stage 0 to 1 CRC with a primary care visit remained relatively stable, and the proportion of patients with stage 2 to 3 CRC decreased somewhat between the first and fifth year after treatment. The findings for mean annual primary care visits per patient roughly paralleled those for the proportion of individuals with a primary care visit. CONCLUSIONS: Elderly patients with CRC, especially stage 2 to 3 CRC, increase rather than decrease contact with primary care providers after diagnosis. More work is needed to understand the care that different physician specialties provide cancer patients and to support their collaboration.

Are population-based diabetes models useful for individual risk estimation?

BACKGROUND: Predictive models are increasingly used in guidelines and informed decision-making interventions. We compared predictions from 2 prominent models for diabetes: the United Kingdom Prospective Diabetes Study (UKPDS) outcomes model and the Archimedes-based Diabetes Personal Health Decisions (PHD) model. METHODS: Ours was a simulation study comparing 10-year and 20-year model predictions for risks of myocardial infarction (MI), stroke, amputation, blindness, and renal failure for representative test cases. RESULTS: The Diabetes PHD model predicted substantially higher risks of MI and stroke in most cases, particularly for stroke and for 20-year outcomes. In contrast, the UKPDS model predicted risks of amputation and blindness ranging from 2-fold to infinitely higher than the Diabetes PHD model. Predictions for renal failure all differed by more than 2-fold but in a complicated pattern varying by time frame and specific risk factors. Relative to their predictions for white men, the UKPDS model predicted much lower MI and stroke risks for women and Afro-Caribbean men than the Diabetes PHD model did for women and black men. A substantial majority of the Diabetes PHD point estimates fell outside of the UKPDS outcomes model's 95% CIs. CONCLUSIONS: These models produced markedly different predictions. Patients and providers considering risk estimates from such models need to understand their substantial uncertainty and risk of misclassification.

Receipt of general medical care by colorectal cancer patients: a longitudinal study.

BACKGROUND: cancer diagnosis has the potential to overshadow patients' general medical care needs. This study examined changes in general medical care among elderly patients with colorectal cancer (CRC), from before diagnosis through long-term survival. METHODS: this longitudinal cohort study used 1993 to 1999 Surveillance, Epidemiology, and End Results and 1991 to 2001 Medicare claims data for 22,161 patients with stage 0 to 3 CRC and 81,669 controls aged 67 to 89 years. Outcomes were preventive services (influenza vaccination, mammography) and, among diabetics, HgbA1c and lipid testing in the phase before diagnosis, the phase after initial treatment, the surveillance phase, and the survival care phase. Logistic regression provided adjusted relative risks of care receipt for patients with stage 0 to 1 cancer, stage 2 to 3 cancer, and no cancer. RESULTS: in the phase before diagnosis through the surveillance phase, patients with stage 0 to 1 CRC had the highest annual preventive service rates. Patients with stage 2 to 3 CRC made substantial gains in preventive service use, especially mammography, after diagnosis (influenza vaccination, 46.4% before diagnosis to 50.2% after initial treatment; mammography, 31.4% before diagnosis to 40.2% after initial treatment) but not in diabetes care (eg, HgbA1c, 53.4% before diagnosis to 54.9% after initial treatment). CONCLUSIONS: CRC diagnosis seems to facilitate receipt of preventive services but not diabetes care for elderly, later-stage patients. Additional strategies such as strengthening partnerships between cancer patients, primary care physicians, and cancer care physicians are needed to improve care for a chronic disease like diabetes.

Effect of financial incentives on improvement in medical quality indicators for primary care.

PURPOSE: The efficacy of rewarding physicians financially for preventive services is unproven. The objective of this study was to evaluate the effect of a physician pay-for-performance program similar to the Medicare Physician Quality Reporting Initiative program on quality of preventive care in a network of community health centers. METHODS: A retrospective review of administrative data was done to evaluate a natural quasi-experiment in a network of publicly funded primary care clinics. Physicians in 6 of 11 clinics were given a financial incentive twice the size of the current Centers for Medicare and Medicaid Services' incentive for achieving group targets in preventive care that included cervical cancer screening, mammography, and pediatric immunization. They also received productivity incentives. Six years of performance indicators were compared between incentivized and nonincentivized clinics. We also surveyed the incentivized clinicians about their perception of the incentive program. RESULTS: Although some performance indicators improved for all measures and all clinics, there were no clinically significant differences between clinics that had incentives and those that did not. A linear trend test approached conventional significance levels for Papanicolaou smears (P = .08) but was of very modest magnitude compared with observed nonlinear variations; there was no suggestion of a linear trend for mammography or pediatric immunizations. The survey revealed that most physicians felt the incentives were not very effective in improving quality of care. CONCLUSION: We found no evidence for a clinically significant effect of financial incentives on performance of preventive care in these community health centers. Based on our findings and others, we believe there is great need for more research with strong research designs to determine the effects, both positive and negative, of financial incentives on clinical quality indicators in primary care.

No pain, but no gain? The disappearance of angina hospitalizations, 1992-1999.

BACKGROUND: Hospitalization for angina is commonly considered an ambulatory care sensitive hospitalization and used as a measure of access to primary care. OBJECTIVE: To analyze time trends in angina-related hospitalizations and seek possible explanations for an observed, marked decline during 1992 to 1999. RESEARCH DESIGN: We analyzed Medicare claims of SEER-Medicare control subjects for occurrence of angina hospital discharges, using the Agency for Healthcare Research and Quality Prevention Quality Indicator (PQI) definition, along with occurrence of related events including angina admissions with revascularization, angina admissions discharged as coronary artery disease (CAD) or myocardial infarction, and overall ischemic heart disease discharges. SUBJECTS: Approximately 124,000 cancer-free Medicare beneficiary/ies, with subjects contributing data for 1 to 8 years. RESULTS: Angina PQI hospital discharges declined 75% between 1992 and 1999. CAD hospital discharges rose in a reciprocal pattern, while angina discharges with revascularization declined and discharges for myocardial infarction and ischemic heart disease were relatively constant during this time period. CONCLUSIONS: The marked decline in angina PQI hospital discharges during 1992-1999 does not appear to represent improvements in access to care or prevention of heart disease, but rather increased coding of more specific discharge diagnoses for CAD. Our findings suggest that angina hospitalization is not a valid measure for monitoring access to care and, more generally, demonstrate the need for careful, periodic re-evaluation of quality measures.

The contribution of longitudinal comorbidity measurements to survival analysis.

BACKGROUND: Many clinical and health services research studies are longitudinal, raising questions about how best to use an individual's comorbidity measurements over time to predict survival. OBJECTIVES: To evaluate the performance of different approaches to longitudinal comorbidity measurement in predicting survival, and to examine strategies for addressing the inevitable issue of missing data. RESEARCH DESIGN: Retrospective cohort study using Cox regression analysis to examine the association between various Romano-Charlson comorbidity measures and survival. SUBJECTS: Fifty thousand cancer-free individuals aged 66 or older enrolled in Medicare between 1991 and 1999 for at least 1 year. RESULTS: The best fitting model combined both time independent baseline comorbidity and the time dependent prior year comorbidity measure. The worst fitting model included baseline comorbidity only. Overall, the models fit best when using the "rolling" comorbidity measures that assumed chronic conditions persisted rather than measures using only prior year's recorded diagnoses. CONCLUSIONS: Longitudinal comorbidity is an important predictor of survival, and investigators should make use of individuals' longitudinal comorbidity data in their regression modeling.

A tale of two studies: the importance of setting, subjects and context in two randomized, controlled trials of a web-based decision support for perimenopausal and postmenopausal health decisions.

OBJECTIVE: Knowledge relevant to women's peri- and postmenopausal health decisions has been evolving rapidly. Web-based decision supports can be rapidly updated and have the potential to improve the quality of patients' decisions. We developed and tested a web-based decision support for peri- and postmenopausal health decisionmaking. METHODS: We recruited 409 women aged 45-75 for one randomized, controlled trial and 54 women with an upcoming clinic appointment for a subsequent trial. Women were randomized to use the web-based decision support versus a printed brochure (first trial) and usual care (second trial). Outcomes were changes in decisional satisfaction, decisional conflict, and knowledge, both within each trial and compared across the trials. RESULTS: Intervention subjects had greater increases in decisional satisfaction in the second trial and knowledge in both trials. A high dropout rate among women randomized to the website in the first trial effectively negated benefits in that trial, but not in the second. CONCLUSIONS: The utility of this web-based decision support in two trials depended on a number of factors that appear related to the urgency of making a decision. PRACTICE IMPLICATIONS: Decision aids should be targeted to patients actively trying to make a decision.

Are statins associated with decreased tooth loss in chronic periodontitis?

AIM: To evaluate whether statin use was associated with decreased tooth loss among patients with chronic periodontitis. MATERIAL AND METHODS: We evaluated administrative health plan data from 1996 to 2002 covering dental and periodontal treatment utilization, dental extractions, and prescription medication fills of 12,631 adults aged 48-64 in 2002. With tooth loss as the outcome, we evaluated a number of different patterns of statin prescription across time in multivariate generalized linear models. RESULTS: Unadjusted, statin use was associated with increased tooth loss. After adjustment for potential confounders, there was no suggestion of either increased or decreased tooth loss associated with statin use. CONCLUSIONS: Statin use was not associated with either a decreased or an increased risk of tooth loss.