A Healthcare System-Level Intervention to Increase Naloxone Availability for Patients With Opioid Prescriptions.

BACKGROUND AND OBJECTIVES: National guidelines recommend prescribing naloxone to patients receiving chronic opioids. However, provider adherence to naloxone co-prescribing best practices is poor and knowledge gaps for improvement efforts are large. As part of a system-wide quality improvement intervention to improve opioid safety, we sought to improve access to naloxone for patients with opioid prescriptions. METHODS: A prompt for naloxone co-prescribing was implemented in the electronic health record. Baseline data and data after implementation were collected for naloxone co-prescribing and fill rates on naloxone prescriptions s (n = 9122 pre, 8368 post). RESULTS: In the 9 months following the implementation of the electronic prompt, the total number of naloxone prescriptions increased more than 15-fold. Patients prescribed naloxone filled their naloxone prescriptions similarly (42%) before and after the prompt implementation, resulting in a marked increase in the absolute number of patients with access to naloxone. Patient fill rates varied by clinical area (33% emergency medicine to 47% general medicine). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: An electronic prompt, encouraging providers to prescribe naloxone to at-risk patients led to a marked increase in the percentage of patients with an active naloxone prescription. The availability of naloxone in communities saves lives and this study is the first to demonstrate an intervention, which led to increased naloxone prescribing and reported on actual pharmacy fills of naloxone when co-prescribed with opioids. (Am J Addict 2020;00:00-00).

SARS-CoV-2 Infection among Serially Tested Emergency Medical Services Workers.

BACKGROUND: Emerging research has examined the prevalence of severe acute respiratory syndrome virus 2 (SARS-CoV-2) infections in numerous settings, but a critical gap in knowledge is an understanding of the rate of infection among first responders. METHODS: We conducted a prospective serial serologic survey by recruiting public first responders from Cleveland area emergency medical services agencies and fire departments. Volunteers submitted a nasopharyngeal swab for SARS-CoV-2 PCR testing and serum samples to detect the presence of antibodies to SARS-CoV-2 on two visits scheduled approximately 3 weeks apart. RESULTS: 296 respondents completed a first visit and 260 completed the second. While 71% of respondents reported exposure to SARS-CoV-2, only 5.4% (95% CI 3.1-8.6) had positive serologic testing. No subjects had a positive PCR. On the first visit, eight (50%) of the test-positive subjects had no symptoms and only one (6.2%) sought healthcare or missed school or work. None of the subjects that tested negative on the first visit were positive on their second. CONCLUSIONS: While our results show a relatively low rate of test positivity for SARS-CoV-2 amongst first responders, most were either asymptomatic or mildly symptomatic. The potential risk of asymptomatic transmission both between first responders and from first responders to vulnerable patients requires more study.

Clinician dashboard views and improvement in preventative health outcome measures: a retrospective analysis.

BACKGROUND: Measuring and reporting outcome data is fundamental for health care systems to drive improvement. Our electronic health record built a dashboard that allows each primary care provider (PCP) to view real-time population health quality data of their patient panel and use that information to identify care gaps. We hypothesized that the number of dashboard views would be positively associated with clinical quality improvement. METHODS: We performed a retrospective analysis of change in quality scores compared to number of dashboard views for each PCP over a five-month period (2017-18). Using the manager dashboard, we recorded the number of views for each provider. The quality scores analyzed were: colorectal cancer (CRC) screening rates and diabetic patients with an A1c greater than 9% or no A1c in the past year. RESULTS: Data from 120 PCPs were included. The number of dashboard views by each PCP ranged from 0 to 222. Thirty-one PCPs (25.8%) did not view their dashboard. We found no significant correlation between views and change in quality scores (correlation coefficient = 0.06, 95% CI [- 0.13, 0.25] and - 0.05, 95% CI [- 0.25, 0.14] for CRC and diabetes, respectively). CONCLUSION: Clinical dashboards provide feedback to PCPs and are likely to become more available as healthcare systems continue to focus on improving population health. However, dashboards on their own may not be sufficient to impact clinical quality improvement. Dashboard viewership did not appear to impact clinician performance on quality metrics.

Panel Size, Clinician Time in Clinic, and Access to Appointments.

Large panel sizes are often held responsible for worse access to appointments in primary care. We evaluated the relationship between appointment backlog, panel size, and primary care clinician time in clinic, using Spearman correlation and multiple regression in a retrospective analysis. We found no independent association between panel size and days until third next available appointment, but larger panel size adjusted for clinician time in clinic was associated with worse access. Less clinician time in clinic was independently associated with longer backlogs for appointments. Our findings suggest that patients of part-time clinicians may be less likely to obtain timely appointments than patients of fulltime clinicians, regardless of panel size.

Exploring Attributes of High-Value Primary Care.

PURPOSE: Medicare's merit-based incentive payment system and narrowing of physician networks by health insurers will stoke clinicians' and policy makers' interest in care delivery attributes associated with value as defined by payers. METHODS: To help define these attributes, we analyzed 2009 to 2011 commercial health insurance claims data for more than 40 million preferred provider organization patients attributed to over 53,000 primary care practice sites. We identified sites ranking favorably on both quality and low total annual per capita health care spending ("high-value") and sites ranking near the median ("average-value"). Sites were selected for qualitative assessment from 64 high-value sites and 102 average-value sites with more than 1 primary care physician who delivered adult primary care and provided services to enough enrollees to permit meaningful spending and quality ranking. Purposeful sampling ensured regional diversity. Physicians experienced in primary care assessment and blinded to site rankings visited 12 high-value sites and 4 average-value sites to identify tangible attributes of care delivery that could plausibly explain a high ranking on value. RESULTS: Thirteen attributes of care delivery distinguished sites in the high-value cohort. Six attributes attained statistical significance: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation. CONCLUSIONS: Awareness of care delivery attributes that distinguish their high-value peers may help physicians respond successfully to incentives from Medicare and private payers to lower annual health care spending and improve quality of care.

In search of joy in practice: a report of 23 high-functioning primary care practices.

We highlight primary care innovations gathered from high-functioning primary care practices, innovations we believe can facilitate joy in practice and mitigate physician burnout. To do so, we made site visits to 23 high-performing primary care practices and focused on how these practices distribute functions among the team, use technology to their advantage, improve outcomes with data, and make the job of primary care feasible and enjoyable as a life's vocation. Innovations identified include (1) proactive planned care, with previsit planning and previsit laboratory tests; (2) sharing clinical care among a team, with expanded rooming protocols, standing orders, and panel management; (3) sharing clerical tasks with collaborative documentation (scribing), nonphysician order entry, and streamlined prescription management; (4) improving communication by verbal messaging and in-box management; and (5) improving team functioning through co-location, team meetings, and work flow mapping. Our observations suggest that a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice.

Estimating a reasonable patient panel size for primary care physicians with team-based task delegation.

PURPOSE Primary care faces the dilemma of excessive patient panel sizes in an environment of a primary care physician shortage. We aimed to estimate primary care panel sizes under different models of task delegation to nonphysician members of the primary care team. METHODS We used published estimates of the time it takes for a primary care physician to provide preventive, chronic, and acute care for a panel of 2,500 patients, and modeled how panel sizes would change if portions of preventive and chronic care services were delegated to nonphysician team members. RESULTS Using 3 assumptions about the degree of task delegation that could be achieved (77%, 60%, and 50% of preventive care, and 47%, 30%, and 25% of chronic care), we estimated that a primary care team could reasonably care for a panel of 1,947, 1,523, or 1,387 patients. CONCLUSIONS If portions of preventive and chronic care services are delegated to nonphysician team members, primary care practices can provide recommended preventive and chronic care with panel sizes that are achievable with the available primary care workforce.

Health coaching to improve hypertension treatment in a low-income, minority population.

PURPOSE: Poor blood pressure control is common in the United States. We conducted a study to determine whether health coaching with home titration of antihypertensive medications can improve blood pressure control compared with health coaching alone in a low-income, predominantly minority population. METHODS: We randomized 237 patients with poorly controlled hypertension at a primary care clinic to receive either home blood pressure monitoring, weekly health coaching, and home titration of blood pressure medications if blood pressures were elevated (n = 129) vs home blood pressure monitoring and health coaching but no home titration (n = 108). The primary outcome was change in systolic blood pressure from baseline to 6 months. RESULTS: Both the home-titration arm and the no-home-titration arm had a reduction in systolic blood pressure, with no significant difference between them. When both arms were combined and analyzed as a before-after study, there was a mean decrease in systolic blood pressure of 21.8 mm Hg (P <.001) as well as a decrease in the number of primary care visits from 3.5 in the 6 months before the study to 2.6 during the 6-month study period (P <.001) and 2.4 in the 6 months after the study (P <.001). The more coaching encounters patients had, the greater their reduction in blood pressure. CONCLUSIONS: Blood pressure control in a low-income, minority population can be improved by teaching patients to monitor their blood pressure at home and having nonprofessional health coaches assist patients, in particular, by counseling them on medication adherence. The improved blood pressure control can be achieved while reducing the time spent by physicians.

Disparities in the Prescription of Statins in the Primary Care Setting: A Retrospective Observational Study.

Despite the high disease burden of atherosclerosis, evidence exists for the disparity in the prescription of guideline-indicated medications between genders, racial groups, socioeconomic groups, and ages. We aim to perform a retrospective study looking at the disparity in statin prescription for primary and secondary prevention in these groups. Data were collected from a single center and included patients with an LDL level >190 mg/dL, diagnosis of diabetes mellitus with LDL level >70 mg/dL, and diagnosis of cardiovascular disease regardless of LDL level. Patients older than 75 or younger than 21 were excluded from the study. Complex samples multivariable logistic and linear regression models were used to calculate the adjusted odds ratio and 95% confidence interval. The total study population was n = 56,995. Of those, 57.89% (n = 32,992) were female. Only 59.56 % of these patients for whom statin therapy was indicated received it. Most patients were White (53.21%) followed by African Americans (35.98%), Asians (2.43%), American Indian/Native Alaskans (0.40%), and Native Hawaiian/Pacific Islander (0.18%). There is a clear disparity in statin prescription favoring males, the elderly, and people of white ethnicity. Interestingly, Asians were more likely to be prescribed statins as opposed to whites. Self-pay patients were more likely to receive statins than patients on Medicare.Despite being indicated, Statins are under prescribed. Disparities based on race, gender, and insurance type mirror previous trends in the literature. Some results have shown a reversal in trends such as the higher prescription for Asian-Americans. Multiple patient-specific, provider-related, institutional factors might explain these disparities and must be investigated.

On the Front (Phone) Lines: Results of a COVID-19 Hotline.

BACKGROUND: Severe acute respiratory syndrome coronavirus (SARS-CoV-2) and the associated coronavirus disease of 2019 (COVID-19) have presented immense challenges for health care systems. Many regions have struggled to adapt to disruptions to health care practice and use systems that effectively manage the demand for services. METHODS: This was a cohort study using electronic health records at a health care system in northeast Ohio that examined the effectiveness of the first 5 weeks of a 24/7 physician-staffed COVID-19 hotline including social care referrals for patients required to self-isolate. We describe clinical diagnosis, patient characteristics (age, sex race/ethnicity, smoking status, insurance status), and visit disposition. We use logistic regression to evaluate associations between patient characteristics, visit disposition and subsequent emergency department use, hospitalization, and SARS-Cov-2 PCR testing. PARTICIPANTS: In 5 weeks, 10,112 patients called the hotline (callers). Of these, 4213 (42%) were referred for a physician telehealth visit (telehealth patients). Mean age of callers was 42 years; 67% were female, 51% white, and 46% were on Medicaid/uninsured. RESULTS: Common caller concerns included cough, fever, and shortness of breath. Most telehealth patients (79%) were advised to self-isolate at home, 14% were determined to be unlikely to have COVID-19, 3% were advised to seek emergency care, and 4% had miscellaneous other dispositions. A total of 287 patients (7%) had a subsequent emergency department visit, and 44 (1%) were hospitalized with a COVID-19 diagnosis. Of the callers, 482 (5%) had a COVID-19 test reported, with 69 (14%) testing positive. Among patients advised to stay at home, 83% had no further face-to-face visits. In multivariable results, only a physician recommendation to seek emergency care was associated with emergency department use (odds ratio = 4.73, 95% confidence interval = 1.37-16.39, P = .014). Only older age was associated with having a positive test result. Patients with social needs and interest in receiving help were offered services to meet their needs including food deliveries (n = 92), behavioral health telephone visits (n = 49), and faith-based comfort calls from pastoral care personnel (n = 37). CONCLUSIONS AND RELEVANCE: Robust, physician-directed telehealth services can meet a wide range of clinical and social needs during the acute phase of a pandemic, conserving scarce resources such as personal protective equipment and testing supplies and preventing the spread of infections to patients and health care workers.

Nonsteroidal anti-inflammatory drug colopathy mimicking malignant masses of the colon: a report of three cases and review of the literature.

The adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on the colon have been reported as a wide spectrum of symptoms, signs, and endoscopic findings. Despite the extensive use of NSAIDs, and the potential seriousness of NSAID colopathy, this condition often goes unrecognized or misdiagnosed. We report three cases of NSAID colopathy in which the diagnosis of malignancy was incorrectly made based on endoscopic findings. Before any surgical intervention, we entertained the diagnosis of NSAID colopathy based on clinical presentation. Ultimately, in two of the three cases, surgery was avoided and the lesions resolved. We present their clinical course and a review of the pertinent literature reviewing theories of the pathophysiology, the range of clinical presentations, and the pathological findings of this entity.

Primary Care Physician Factors Associated with Inbox Message Volume.

INTRODUCTION: The objective of this study was to better understand the relationship between panel size, full-time status, and estimated socioeconomic status of a patient panel with types and number of primary care clinician inbox messages. METHODS: The study used data from the Epic Signal database to examine inbox volume and types of messages for 86 primary care clinicians at 19 primary care sites. We measured correlations and performed multiple regression analysis to understand the relationship between inbox volume and types of messages and 3 factors: panel size, full-time status, and estimated socioeconomic status of patient panels. RESULTS: The study found positive correlation between the number of messages and panel size, full-time status, and estimated socioeconomic status of patient panels. The number of patient portal messages generated from patient panels with higher socioeconomic status accounted for the positive correlation in total inbox messages and that factor. DISCUSSION: These findings contribute to our understanding of primary care workload, specifically as it relates to panel size, full-time status, and patient panel socioeconomic status. Increase in clinical time or panel size needs to come with trained team members or additional time to address inbox messages.

The effectiveness of health coaching, home blood pressure monitoring, and home-titration in controlling hypertension among low-income patients: protocol for a randomized controlled trial.

BACKGROUND: Despite the many antihypertensive medications available, two-thirds of patients with hypertension do not achieve blood pressure control. This is thought to be due to a combination of poor patient education, poor medication adherence, and "clinical inertia." The present trial evaluates an intervention consisting of health coaching, home blood pressure monitoring, and home medication titration as a method to address these three causes of poor hypertension control. METHODS/DESIGN: The randomized controlled trial will include 300 patients with poorly controlled hypertension. Participants will be recruited from a primary care clinic in a teaching hospital that primarily serves low-income populations.An intervention group of 150 participants will receive health coaching, home blood pressure monitoring, and home-titration of antihypertensive medications during 6 months. The control group (n=150) will receive health coaching plus home blood pressure monitoring for the same duration. A passive control group will receive usual care. Blood pressure measurements will take place at baseline, and after 6 and 12 months. The primary outcome will be change in systolic blood pressure after 6 and 12 months. Secondary outcomes measured will be change in diastolic blood pressure, adverse events, and patient and provider satisfaction. DISCUSSION: The present study is designed to assess whether the 3-pronged approach of health coaching, home blood pressure monitoring, and home medication titration can successfully improve blood pressure, and if so, whether this effect persists beyond the period of the intervention. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01013857.

Why Compensation Tied to Group Quality Metrics Makes Sense.

Incorporation of group quality metrics into an adult primary care compensation track facilitates team-based care and accountability for shared groups of patients. This article describes the reasoning behind group quality metrics and shares lessons learned and improvements in health outcomes as a result. Take-away points are as follows: 1) group quality metrics in a compensation plan help foster team-based care toward quality goals and shared accountability for the health outcomes of attributed patients; 2) definition of the work team is important and should include members who share responsibility for the same groups of patients; 3) information technology infrastructure and dashboards for performance and feedback are critical to the success of a quality incentive program; 4) inclusion of key stakeholders early in the process of designing team-based incentives is important for acceptance; and 5) ongoing education is needed to ensure continued focus on quality goals.

Primary Care Practice Workplace Social Capital: A Potential Secret Sauce for Improved Staff Well-Being and Patient Experience.

Patient experiences with the health-care system are increasingly seen as a vital measure of health-care quality. This study examined whether workplace social capital and employee outcomes are associated with patients' perceptions of care quality across multiple clinic sites in a diverse, urban safety net care setting. Data from clinic staff were collected using paper and pencil surveys and data from patients were collected via a telephone survey. A total of 8392 adult primary care patients and 265 staff (physicians, nurses, allied health, and support staff) were surveyed at 10 community health clinics. The staff survey included brief measures of workplace social capital, burnout, and job satisfaction. The patient-level outcome was patients' overall rating of the quality of care. Factor analysis and reliability analysis were conducted to examine measurement properties of the employee data. Data were aggregated and measures were examined at the clinic site level. Workplace social capital had moderate to strong associations with burnout (r = -0.40, P < .01) and job satisfaction (r = 0.59, P < .01). Mean patient quality of care rating was 8.90 (95% confidence interval: 8.86-8.94) ranging from 8.57 to 9.18 across clinic sites. Pearson correlations with patient-rated care quality were high for workplace social capital (r = 0.88, P = .001), employee burnout (r = -0.74, P < .05), and satisfaction (r = 0.69, P < .05). Patient-perceived clinic quality differences were largely explained by differences in workplace social capital, staff burnout, and satisfaction. Investments in workplace social capital to improve employee satisfaction and reduce burnout may be key to better patient experiences in primary care.

A call for a statewide medication reconciliation program.

In the outpatient setting, it is exceedingly difficult to know what medications our patients have been prescribed and are taking. Each encounter with a specialist, hospital, or pharmacy can generate a change to a patient's list of medications, and in most systems, this information is not communicated back to the primary care practice's electronic health record-the exception being opiate prescriptions. Prescription drug monitoring programs in 48 states list every opiate prescription, the name of the prescriber, and the date and location the prescription was picked up. We propose that policy makers act to expand these programs to all medications, thus improving the likelihood that any provider prescribing a new medication would know what medicines their patient is already taking.