Study protocol for a type III hybrid effectiveness-implementation trial to evaluate scaling interoperable clinical decision support for patient-centered chronic pain management in primary care.

BACKGROUND: The US continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at an estimated yearly cost of over $600 billion. Most patients with chronic pain turn to primary care clinicians who must choose from myriad treatment options based on relative risks and benefits, patient history, available resources, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients for whom opioid-related benefits outweigh risks may be inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, resources, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision-making process. METHODS: The objective of this 3-year project is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, specifically pain and physical function. The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We will adapt and tailor PainManager, an open source interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium. We will evaluate the effect of tailored implementation support on PainManager's adoption for pain treatment shared decision making. This evaluation will establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of PainManager and tailored implementation support on shared decision making and patient-reported pain and physical function. DISCUSSION: This research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records (EHRs). The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05256394 , Registered 25 February 2022.

Referral Rates Vary Widely Between Family Medicine Practices.

INTRODUCTION: Referral rates and patterns to specialists by family physicians have a significant impact on numerous aspects of medical care, including the quality and cost of care provided. The aim of this study was to examine the referral rate and pattern of family physician practices associated with a large academic health center. METHODS: We conducted a retrospective chart review of referrals for patients seen in the family medicine clinics associated with a large academic institution. Basic demographic information was collected. The primary outcome was the monthly referral rate, measured as the proportion of patient visits that resulted in a consult to a specialist outside of the referring family medicine clinic. Binomial and γ generalized linear mixed models were fit to determine the associations between high/medium/low referral rate clinics and patient demographics. RESULTS: The average monthly referral rate for all of the clinics was 20.3%, and the rate varied significantly between clinic groups. Patient gender, race, and being in a committed relationship were noted to be associated with lower referral rate. DISCUSSION: Referral rates among family physician practices differ widely and are associated with gender, race, and relationship status of patients. Referrals to several specific specialties are common among family physicians.

Eigenstate-specific temperatures in two-level paramagnetic spin lattices.

Increasing interest in the thermodynamics of small and/or isolated systems, in combination with recent observations of negative temperatures of atoms in ultracold optical lattices, has stimulated the need for estimating the conventional, canonical temperature Tcconv of systems in equilibrium with heat baths using eigenstate-specific temperatures (ESTs). Four distinct ESTs-continuous canonical, discrete canonical, continuous microcanonical, and discrete microcanonical-are accordingly derived for two-level paramagnetic spin lattices (PSLs) in external magnetic fields. At large N, the four ESTs are intensive, equal to Tcconv, and obey all four laws of thermodynamics. In contrast, for N < 1000, the ESTs of most PSL eigenstates are non-intensive, differ from Tcconv, and violate each of the thermodynamic laws. Hence, in spite of their similarities to Tcconv at large N, the ESTs are not true thermodynamic temperatures. Even so, each of the ESTs manifests a unique functional dependence on energy which clearly specifies the magnitude and direction of their deviation from Tcconv; the ESTs are thus good temperature estimators for small PSLs. The thermodynamic uncertainty relation is obeyed only by the ESTs of small canonical PSLs; it is violated by large canonical PSLs and by microcanonical PSLs of any size. The ESTs of population-inverted eigenstates are negative (positive) when calculated using Boltzmann (Gibbs) entropies; the thermodynamic implications of these entropically induced differences in sign are discussed in light of adiabatic invariance of the entropies. Potential applications of the four ESTs to nanothermometers and to systems with long-range interactions are discussed.