Primary care patients' and providers' perspectives about an online weight management program integrated with population health management: Post-intervention qualitative results from the PROPS study.

Objective: To assess patients' and providers' attitudes about the online weight management program and population health management approach in the PROPS Study, which examined the effectiveness of these strategies in primary care. Methods: We conducted semi-structured interviews with 22 patients and nine providers. Using thematic analysis, we analyzed transcripts of the interviews to identify key themes. Results: Most patients found the online program to be well-structured and easy to use, although a few noted that the information was overwhelming or could be more personalized. Patients mentioned that the support from the population health managers was critical for their success, and several reported that they would have liked more involvement from their primary care provider or a dietitian. Providers also were satisfied with the interventions, and several stated that the population health management support was helpful because it added accountability. Providers suggested that the interventions could be improved by tailoring the information and integrating the online program with the electronic health record. Conclusion: Most patients and providers were satisfied with the interventions, with several recommendations for improvements. Innovation: These findings give additional information about patients' and providers' experience with this innovative approach for managing overweight and obesity in primary care.

Effects of an Intensive Discharge Intervention on Medication Adherence, Glycemic Control, and Readmission Rates in Patients With Type 2 Diabetes.

OBJECTIVES: Patients with diabetes are at particularly high risk for adverse outcomes after hospitalization. The goals of this study were to design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes. METHODS: We randomly assigned inpatients likely to be discharged home on insulin to an intensive transitional care intervention or usual care. The primary outcome was 90-day postdischarge insulin adherence, using prescription refill information to calculate a medication possession ratio. Unadjusted analyses were conducted using Wilcoxon rank sum; adjusted analyses used multivariable linear regression and weighted propensity scoring methods, with general estimating equations to account for clustering by admitting physician. RESULTS: One hundred eighty patients participated. The mean (SD) medication possession ratio to all insulin types was 84.5% (22.6) among intervention and 76.4% (25.1) among usual care patients (difference = 8.1, 95% confidence interval = -1.0 to 17.2, P = 0.06), with a smaller difference for adherence to all medications (86.3% versus 82.0%). A1c levels decreased in both groups but was larger in the intervention arm (1.09 and 0.11, respectively) (difference = -0.98, 95% confidence interval = -2.03 to -0.07, P = 0.04). Differences between study arms were not significant for rates of hypoglycemic episodes, 30-day readmissions, or emergency department visits. In adjusted/clustered analyses, the difference in A1c reduction remained statistically significant, whereas differences in all other outcomes remained nonsignificant. CONCLUSIONS: The intervention was associated with improvements in glycemic control, with nonsignificant trends toward greater medication adherence. Further research is needed to optimize and successfully implement interventions to improve patient safety and health outcomes during care transitions.

Clinicians' Attitudes and System Capacity Regarding Transitional Care Practices Within a Health System: Survey Results From the Partners-PCORI Transitions Study.

OBJECTIVES: Successful efforts to improve transitional care depend in part on local attitudes, workload, and training. Before implementing a multifaceted transitions intervention within an Accountable Care Organization, an understanding of contextual factors among providers involved in care transitions in inpatient and outpatient settings was needed. METHODS: As part of the Partners-Patient-Centered Outcomes Research Institute (PCORI) Transitions Study, we purposefully sampled inpatient and outpatient providers within the Accountable Care Organization. Survey questions focused on training and feedback on transitional tasks and opinions on the quality of care transitions. We also surveyed unit- and practice-level leadership on current transitional care practices. Results are presented using descriptive statistics. RESULTS: Among 387 providers surveyed, 220 responded (response rate = 57%) from 15 outpatient practices and 26 inpatient units. A large proportion of respondents reported to have never received training (50%) or feedback (68%) on key transitional care activities, and most (58%) reported insufficient time to complete these tasks. Respondents on average reported transitions processes led to positive outcomes some to most of the time (mean scores = 4.70-5.16 on a 1-7 scale). Surveys of leadership showed tremendous variation by unit and by practice in the performance of various transitional care activities. CONCLUSIONS: Many respondents felt that training, feedback, and time allotted to key transitional care activities were inadequate. Satisfaction with the quality of the transitions process was middling. Understanding these results, especially variation by location, was important to customizing implementation of the intervention and will be key to understanding variation in the success of the intervention across locations.

The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial.

BACKGROUND: Transitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission. OBJECTIVES: To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events. DESIGN, SETTING, AND PARTICIPANTS: Two-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO). INTERVENTIONS: Multicomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient "discharge advocate" and a primary care "responsible outpatient clinician," postdischarge phone calls, and postdischarge primary care visit. MAIN OUTCOMES AND MEASURES: The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission. RESULTS: Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates. CONCLUSION: A multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.

Effect of an Online Weight Management Program Integrated With Population Health Management on Weight Change: A Randomized Clinical Trial.

Importance: Online programs may help with weight loss but have not been widely implemented in routine primary care. Objective: To compare the effectiveness of a combined intervention, including an online weight management program plus population health management, with the online program only and with usual care. Design, Setting, and Participants: Cluster randomized trial with enrollment from July 19, 2016, through August 10, 2017, at 15 primary care practices in the US. Eligible participants had a scheduled primary care visit and were aged 20 to 70 years, had a body mass index between 27 and less than 40, and had a diagnosis of hypertension or type 2 diabetes. Follow-up ended on May 8, 2019. Interventions: Participants in the usual care group (n = 326) were mailed general information about weight management. Participants in the online program only group (n = 216) and the combined intervention group (n = 298) were registered for the online program. The participants in the combined intervention group also received weight-related population health management, which included additional support from nonclinical staff who monitored their progress in the online program and conducted periodic outreach. Main Outcomes and Measures: The primary outcome was weight change at 12 months based on measured weights recorded in the electronic health record. Weight change at 18 months was a secondary outcome. Results: Among the 840 participants who enrolled (mean age, 59.3 years [SD, 8.6 years]; 60% female; 76.8% White), 732 (87.1%) had a recorded weight at 12 months and the missing weights for the remaining participants were imputed. There was a significant difference in weight change at 12 months by group with a mean weight change of -1.2 kg (95% CI, -2.1 to -0.3 kg) in the usual care group, -1.9 kg (95% CI, -2.6 to -1.1 kg) in the online program only group, and -3.1 kg (95% CI, -3.7 to -2.5 kg) in the combined intervention group (P < .001). The difference in weight change between the combined intervention group and the usual care group was -1.9 kg (97.5% CI, -2.9 to -0.9 kg; P < .001) and the difference between the combined intervention group and the online program only group was -1.2 kg (95% CI, -2.2 to -0.3 kg; P = .01). At 18 months, the mean weight change was -1.9 kg (95% CI, -2.8 to -1.0 kg) in the usual care group, -1.1 kg (95% CI, -2.0 to -0.3 kg) in the online program only group, and -2.8 kg (95% CI, -3.5 to -2.0 kg) in the combined intervention group (P < .001). Conclusions and Relevance: Among primary care patients with overweight or obesity and hypertension or type 2 diabetes, combining population health management with an online program resulted in a small but statistically significant greater weight loss at 12 months compared with usual care or the online program only. Further research is needed to understand the generalizability, scalability, and durability of these findings. Trial Registration: ClinicalTrials.gov Identifier: NCT02656693.

Integrating an online weight management program with population health management in primary care: Design, methods, and baseline data from the PROPS randomized controlled trial (Partnerships for Reducing Overweight and Obesity with Patient-centered Strategies).

BACKGROUND: Scalable, low-cost weight management strategies are needed in primary care. We conducted a pragmatic, cluster-randomized controlled trial to examine the effectiveness of an online weight management program integrated with population health management support. METHODS: We adapted an online weight management program and integrated it with population health management support in 15 primary care practices (24 clinics). We randomized the 24 clinics to usual care (UC), online program alone (OP), or combined intervention (CI). Eligible participants had to be ages 20 to 70 and have a recent primary care visit, body mass index (BMI) ≥ 27 and < 40 kg/m2, and a diagnosis of hypertension or type 2 diabetes. Participants attended routine visits and completed surveys over 18 months. The primary outcome is absolute weight change at 12 months (± 90 days) after enrollment, calculated from weights measured at primary care visits and recorded in the electronic health record. RESULTS: We enrolled 840 participants between July 2016 and August 2017 (326 UC, 216 OP, and 298 CI.) At enrollment, participants' mean age was 59.3 years, their mean weight was 203.1 pounds, and their mean BMI was 32.5 kg/m2; 60% of participants were female, 76.8% were white, 96.4% had hypertension, and 24.4% had type 2 diabetes. CONCLUSION: It is feasible to adapt an online weight management program and integrate it with population health management support in primary care. The results of this trial will provide valuable information about the effectiveness of these strategies in primary care settings. ClinicalTrials.govregistration number:NCT02656693.

An On-Treatment Analysis of the MARQUIS Study: Interventions to Improve Inpatient Medication Reconciliation.

It is unclear which medication reconciliation interventions are most effective at reducing inpatient medication discrepancies. Five United States hospitals' interdisciplinary quality improvement (QI) teams were virtually mentored by QI-trained physicians. Sites implemented one to seven evidence-based interventions in 791 patients during the 25-month implementation period. Three interventions were associated with significant decreases in potentially harmful discrepancy rates: (1) defining clinical roles and responsibilities, (2) training, and (3) hiring staff to perform discharge medication reconciliation. Two interventions were associated with significant increases in potentially harmful discrepancy rates: training staff to take medication histories and implementing a new electronic health record (EHR). Hospitals should focus first on hiring and training pharmacy staff to assist with medication reconciliation at discharge and delineating roles and responsibilities of clinical staff. We caution hospitals implementing a large vendor EHR, as medication discrepancies may increase. Finally, the effect of medication history training on discrepancies needs further study.

Primary Care Patients' and Providers' Perspectives about an Online Weight Management Program: a Qualitative Study.

BACKGROUND: Primary care providers (PCPs) often take the lead role in caring for patients with overweight and obesity; however, few PCPs counsel patients about weight loss. Online weight management programs that are integrated within primary care may help address this gap in care. OBJECTIVE: To identify perceptions of and experience with online weight management programs in general and with a proposed online program, to identify barriers to use, and to improve the design and content of our intervention, which included an online program plus population health management (PHM) support from primary care practices. DESIGN: A mixed qualitative methods study including three patient focus groups and seven semi-structured interviews with healthcare providers. PARTICIPANTS: A total of 13 adult patients (age range, 20-70) with body mass index (BMI) 27-35 kg/m2 attended the focus groups. In-person semi-structured interviews were conducted with seven healthcare providers (three PCPs, two population health managers, one primary care nurse, and one registered dietitian). MAIN MEASURES: We developed and used semi-structured focus groups and interview guides. The focus group and interviews were recorded and transcribed. Using grounded theory, we analyzed the transcripts to identify and extract common concepts and themes. KEY RESULTS: Although patients and healthcare providers expressed positive opinions about online weight management programs, few patients had experience with them, and providers stated that such programs are not being widely implemented in primary care settings. Some participants highlighted the flexibility and low cost as strengths of online weight management tools compared with in-person programs. All participants had favorable opinions about our proposed intervention and were overwhelmingly positive about the combination of an online program and PHM support. CONCLUSIONS: This study highlights the potential value of online weight management programs and PHM support in primary care. CLINICAL TRIALS REGISTRATION: NCT02656693.

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.

BACKGROUND: Unintentional discrepancies across care settings are a common form of medication error and can contribute to patient harm. Medication reconciliation can reduce discrepancies; however, effective implementation in real-world settings is challenging. METHODS: We conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The intervention consisted of local implementation of medication reconciliation best practices, utilising an evidence-based toolkit with 11 intervention components. Trained QI mentors conducted monthly site phone calls and two site visits during the intervention, which lasted from December 2011 through June 2014. The primary outcome was number of potentially harmful unintentional medication discrepancies per patient; secondary outcome was total discrepancies regardless of potential for harm. Time series analysis used multivariable Poisson regression. RESULTS: Across five sites, 1648 patients were sampled: 613 during baseline and 1035 during the implementation period. Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month (95% CI 0.86 to 1.08), p=0.53. The intervention was associated with a reduction in total medication discrepancies, IRR 0.92 per month (95% CI 0.87 to 0.97), p=0.002. Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR. CONCLUSIONS: Mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. The effect of EHR implementation on medication discrepancies warrants further study. TRIAL REGISTRATION NUMBER: NCT01337063.

The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial.

BACKGROUND: Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up. KEY RESULTS: Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03). CONCLUSIONS: Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern. CLINICAL TRIALS IDENTIFIER: NCT01153451.

Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial.

BACKGROUND AND OBJECTIVE: Physician awareness of the results of tests pending at discharge (TPADs) is poor. We developed an automated system that notifies responsible physicians of TPAD results via secure, network email. We sought to evaluate the impact of this system on self-reported awareness of TPAD results by responsible physicians, a necessary intermediary step to improve management of TPAD results. METHODS: We conducted a cluster-randomized controlled trial at a major hospital affiliated with an integrated healthcare delivery network in Boston, Massachusetts. Adult patients with TPADs who were discharged from inpatient general medicine and cardiology services were assigned to the intervention or usual care arm if their inpatient attending physician and primary care physician (PCP) were both randomized to the same study arm. Patients of physicians randomized to discordant study arms were excluded. We surveyed these physicians 72 h after all TPAD results were finalized. The primary outcome was awareness of TPAD results by attending physicians. Secondary outcomes included awareness of TPAD results by PCPs, awareness of actionable TPAD results, and provider satisfaction. RESULTS: We analyzed data on 441 patients. We sent 441 surveys to attending physicians and 353 surveys to PCPs and received 275 and 152 responses from 83 different attending physicians and 112 different PCPs, respectively (attending physician survey response rate of 63%). Intervention attending physicians and PCPs were significantly more aware of TPAD results (76% vs 38%, adjusted/clustered OR 6.30 (95% CI 3.02 to 13.16), p<0.001; 57% vs 33%, adjusted/clustered OR 3.08 (95% CI 1.43 to 6.66), p=0.004, respectively). Intervention attending physicians tended to be more aware of actionable TPAD results (59% vs 29%, adjusted/clustered OR 4.25 (0.65, 27.85), p=0.13). One hundred and eighteen (85%) and 43 (63%) intervention attending physician and PCP survey respondents, respectively, were satisfied with this intervention. CONCLUSIONS: Automated email notification represents a promising strategy for managing TPAD results, potentially mitigating an unresolved patient safety concern. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01153451).

A randomized trial of treatments for high-utilizing somatizing patients.

BACKGROUND: Somatization and hypochondriacal health anxiety are common sources of distress, impairment, and costly medical utilization in primary care practice. A range of interventions is needed to improve the care of these patients. OBJECTIVE: To determine the effectiveness of two cognitive behavioral interventions for high-utilizing, somatizing patients, using the resources found in a routine care setting. DESIGN: Patients were randomly assigned to a two-step cognitive behavioral treatment program accompanied by a training seminar for their primary care physicians, or to relaxation training. Providers routinely working in these patients' primary care practices delivered the cognitive behavior therapy and relaxation training. A follow-up assessment was completed immediately prior to treatment and 6 and 12 months later. SUBJECTS: Eighty-nine medical outpatients with elevated levels of somatization, hypochondriacal health anxiety, and medical care utilization. MEASUREMENTS: Somatization and hypochondriasis, overall psychiatric distress, and role impairment were assessed with well-validated, self-report questionnaires. Outpatient visits and medical care costs before and after the intervention were obtained from the encounter claims database. RESULTS: At 6 month and 12 month follow-up, both intervention groups showed significant improvements in somatization (p < 0.01), hypochondriacal symptoms (p < 0.01), overall psychiatric distress (p < 0.01), and role impairment (p < 0.01). Outcomes did not differ significantly between the two groups. When both groups were combined, ambulatory visits declined from 10.3 to 8.8 (p = 0.036), and mean ambulatory costs decreased from $3,574 to $2,991 (pp = 0.028) in the year preceding versus the year following the interventions. Psychiatric visits and costs were unchanged. CONCLUSIONS: Two similar cognitive behavioral interventions, delivered with the resources available in routine primary care, improved somatization, hypochondriacal symptoms, overall psychiatric distress, and role function. They also reduced the ambulatory visits and costs of these high utilizing outpatients.

Responsiveness of hypochondriacal patients with chronic low-back pain to cognitive-behavioral therapy.

BACKGROUND: Evidence has suggested that cognitive-behavioral therapy (CBT) is effective in reducing hypochondriacal symptoms, and another line of evidence has suggested that CBT is also effective in reducing pain and the psychological conditions associated with chronic low-back pain (CLBP). The purpose of this study was to examine the effectiveness of CBT among hypochondriacal patients with and without CLBP. METHODS: A total of 182 hypochondriacal patients were randomly assigned to a CBT or control group. The Somatic Symptom Inventory was used to define CLBP, and the Symptom Checklist 90R (SCL90R) was used to assess psychological symptoms. The outcome measures for hypochondriasis, the Whiteley Index (WI) and the Health Anxiety Inventory (HAI) were administered before the intervention and at 6 and 12 months after completion of the intervention. RESULTS: In the total sample, both WI and HAI scores were significantly decreased after treatment in the CBT group compared with the control group. Ninety-three (51%) patients had CLBP; the SCL90R scores for somatization, depression, phobic anxiety, paranoid ideation, and general severity were significantly higher in CLBP(+) group than in the CLBP(-) group at baseline. Although the WI and HAI scores were significantly decreased after treatment in the CLBP(-) group, such significant pre- to post-changes were not found in the CLBP(+) group. CONCLUSIONS: CBT was certainly effective among hypochondriacal patients without CLBP, but it appeared to be insufficient for hypochondriacal patients with CLBP. The core psychopathology of hypochondriacal CLBP should be clarified to contribute to the adequate management of hypochondriacal symptoms in CLBP patients.

Design and implementation of an automated email notification system for results of tests pending at discharge.

Physicians are often unaware of the results of tests pending at discharge (TPADs). The authors designed and implemented an automated system to notify the responsible inpatient physician of the finalized results of TPADs using secure, network email. The system coordinates a series of electronic events triggered by the discharge time stamp and sends an email to the identified discharging attending physician once finalized results are available. A carbon copy is sent to the primary care physicians in order to facilitate communication and the subsequent transfer of responsibility. Logic was incorporated to suppress selected tests and to limit notification volume. The system was activated for patients with TPADs discharged by randomly selected inpatient-attending physicians during a 6-month pilot. They received approximately 1.6 email notifications per discharged patient with TPADs. Eighty-four per cent of inpatient-attending physicians receiving automated email notifications stated that they were satisfied with the system in a brief survey (59% survey response rate). Automated email notification is a useful strategy for managing results of TPADs.

The prevalence of personality disorders in hypochondriasis.

BACKGROUND: Although Axis I hypochondriasis is closely related to certain personality characteristics, the nature and extent of personality dysfunction in these patients still needs clarification. This study assessed the prevalence of personality disorders observed in hypochondriacal patients, described the types and comorbidity of personality disorders, and compared the psychological distress of patients with and without the most common comorbid personality disorder. METHOD: One hundred fifteen patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for hypochondriasis completed self-administered assessments, including the Personality Diagnostic Questionnaire-4+ (PDQ-4+), the Hopkins Symptom Checklist-90-Revised (SCL-90-R), the Whiteley Index, and the Somatic Symptom Inventory. These data were taken from a study conducted between September 1997 and November 2001. RESULTS: Eighty-eight patients (76.5%) had 1 or more personality disorders, whereas 27 patients (23.5%) had no personality disorders. Fifty-one patients (44.3%) had more than 3 personality disorders. The most common personality disorder in the hypochondriacal patients was obsessive-compulsive personality disorder (OCPD; 55.7%), followed by avoidant personality disorder (40.9%). The comorbidity of OCPD and avoidant personality disorder was 53.1% (34 of 64 patients with OCPD). The total PDQ-4+ score of the 64 patients with OCPD was significantly higher than that of the 51 patients without OCPD. On the SCL-90-R, the 64 patients with OCPD showed significantly higher scores on all of 3 global indices and 7 of 10 primary symptom dimensions (paranoid ideation, depression, anxiety, phobic anxiety, obsessive-compulsive, interpersonal sensitivity, and psychoticism) on the SCL-90-R compared to the 51 patients without OCPD. CONCLUSIONS: The high prevalence of personality disorders, particularly OCPD, among patients with hypochondriasis suggests that consideration of personality features is important in assessment and therapeutic interventions for hypochondriasis.