Elucidating the role of weight loss and glycaemic control in patients with type 2 diabetes.

AIMS: To investigate the independent contributions of glycated haemoglobin (HbA1c) reduction and weight loss to clinical outcomes in patients with type 2 diabetes (T2D) treated with antidiabetic drugs, including glucagon-like peptide-1 receptor agonists (GLP-1RAs). MATERIALS AND METHODS: This observational, retrospective cohort study used deidentified electronic health record-derived data from patients evaluated at the Cleveland Clinic (1 January 2000-31 December 2020). Cohort A included 8876 patients with newly diagnosed T2D treated with any of six antidiabetic drug classes. Cohort B included 4161 patients with T2D initiating GLP-1RA treatment. The effects of body mass index (BMI) and HbA1c reduction, variability, and durability on clinical outcomes were investigated. RESULTS: In Cohort A, each 1% BMI reduction was associated with 3%, 1%, and 4% reduced risk of heart failure (p = 0.017), hypertension (p = 0.006), and insulin initiation (p = 0.001), respectively. Each 1% (~11 mmol/mol) HbA1c reduction was associated with 4% and 29% reduced risk of hypertension (p = 0.041) and insulin initiation (p = 0.001), respectively. In Cohort B, each 1% BMI reduction was associated with 4% and 3% reduced risk of cardiovascular disease (p = 0.008) and insulin initiation (p = 0.002), respectively. Each 1% (~11 mmol/mol) HbA1c reduction was associated with 4% and 16% reduced risk of chronic kidney disease (p = 0.014) and insulin initiation (p = 1 × 10-4), respectively. Lower BMI variability and greater BMI durability were associated with decreased risk of clinical outcomes in both cohorts. CONCLUSIONS: Antidiabetic medication-associated, and specifically GLP-1RA-associated, weight loss and HbA1c reductions independently reduce real-world clinical outcome risk.

Trends in Use of High-Cost Antihyperglycemic Drugs Among US Adults with Type 2 Diabetes.

BACKGROUND: Some antihyperglycemic drugs can reduce cardiovascular events, slow the progression of kidney disease, and prevent death, but they are more expensive than older drugs. OBJECTIVES: (1) To estimate trends in use of antihyperglycemic drugs by cost; (2) to examine use of high-cost drugs by race/ethnicity, income, and insurance status DESIGN: Cross-sectional analysis of the 2003-2018 National Health and Nutrition Examination Survey PARTICIPANTS: US adults ≥18 years with type 2 diabetes EXPOSURES: Race/ethnicity, income, and insurance status MAIN MEASURES: Low-cost noninsulin medications included any drugs that had at least one generic version approved by the Food and Drug Administration. Human regular, NPH, and premixed NPH/regular 70/30 insulins were classified as low-cost. All other noninsulin medications and insulins were considered high-cost KEY RESULTS: The sample included 7,394 patients. Prevalence of use of low-cost noninsulin drugs increased from 37% in 2003-2004 to 52% in 2017-2018. Use of high-cost noninsulin drugs decreased from 2003-2004 to 2013-2014 and then slowly increased. Use of low-cost insulin decreased from 7 to 2% while high-cost insulin rose from 4 to 16%. In multivariable analysis, non-White patients had 25-35% lower odds of receiving high-cost drugs than non-Hispanic Whites. Health insurance was associated with more than twice the odds of having high-cost drugs compared to no insurance. Patients with higher HbA1c or moderate obesity were also more likely to use high-cost drugs. Sex, income, and insurance type were not associated with receipt of high-cost drugs. CONCLUSIONS: There was a shift in utilization from high- to low-cost noninsulin drugs, but since 2013-2014 the trend has slowly reversed with increased use of newer, more expensive drug classes. High-cost insulin analogs have almost completely replaced lower cost human insulins. Disparities in receipt of diabetes drugs by race/ethnicity and insurance must be addressed to ensure that cost is not a barrier for disadvantaged populations.

Addressing Therapeutic Inertia: Development and Implementation of an Electronic Health Record-Based Diabetes Intensification Tool.

Objective: To assess whether an electronic health record (EHR)-based diabetes intensification tool can improve the rate of A1C goal attainment among patients with type 2 diabetes and an A1C ≥8%. Methods: An EHR-based tool was developed and sequentially implemented in a large, integrated health system using a four-phase, stepped-wedge design (single pilot site [phase 1] and then three practice site clusters [phases 2-4]; 3 months/phase), with full implementation during phase 4. A1C outcomes, tool usage, and treatment intensification metrics were compared retrospectively at implementation (IMP) sites versus nonimplementation (non-IMP) sites with sites matched on patient population characteristics using overlap propensity score weighting. Results: Overall, tool utilization was low among patient encounters at IMP sites (1,122 of 11,549 [9.7%]). During phases 1-3, the proportions of patients achieving the A1C goal (<8%) were not significantly improved between IMP and non-IMP sites at 6 months (range 42.9-46.5%) or 12 months (range 46.5-53.1%). In phase 3, fewer patients at IMP sites versus non-IMP sites achieved the goal at 12 months (46.7 vs. 52.3%, P = 0.02). In phases 1-3, mean changes in A1C from baseline to 6 and 12 months (range -0.88 to -1.08%) were not significantly different between IMP and non-IMP sites. Times to intensification were similar between IMP and non-IMP sites. Conclusion: Utilization of a diabetes intensification tool was low and did not influence rates of A1C goal attainment or time to treatment intensification. The low level of tool adoption is itself an important finding highlighting the problem of therapeutic inertia in clinical practice. Testing additional strategies to better incorporate, increase acceptance of, and improve proficiency with EHR-based intensification tools is warranted.

Erratum: Addressing Therapeutic Inertia: Development and Implementation of an Electronic Health Record-Based Diabetes Intensification Tool. Diabetes Spectrum 2023;36:161-170 (https://doi.org/10.2337/ds22-0031).

[This corrects the article DOI: 10.2337/ds22-0031.].

Reduced Cognitive Burden and Increased Focus: A Mixed-methods Study Exploring How Implementing Scribes Impacted Physicians.

BACKGROUND: Understanding how medical scribes impact care delivery can inform decision-makers who must balance the cost of hiring scribes with their contribution to alleviating clinician burden. OBJECTIVE: The objective of this study was to understand how scribes impacted provider efficiency and satisfaction. DESIGN: This was mixed-methods study. PARTICIPANTS: Internal and family medicine clinicians were included. MEASURES: We administered structured surveys and conducted unstructured interviews with clinicians who adopted scribes. We collected average days to close charts and quantity of after-hours clinical work in the 6 months before and after implementation using electronic health record data. We conducted a difference in difference (DID) analysis using a multilevel Poisson regression. RESULTS: Three themes emerged from the interviews: (1) charting time is less after training; (2) clinicians wanted to continue working with scribes; and (3) scribes did not reduce the overall inbox burden. In the 6-month survey, 76% of clinicians endorsed that working with a scribe improved work satisfaction versus 50% at 1 month. After implementation, days to chart closure decreased [DID=0.38 fewer days; 95% confidence interval (CI): -0.61, -0.15] the average minutes worked after hours on clinic days decreased (DID=-11.5 min/d; 95% CI: -13.1, -9.9) as did minutes worked on nonclinical days (DID=-24.9 min/d; 95% CI: -28.1, -21.7). CONCLUSIONS: Working with scribes was associated with reduced time to close charts and reduced time using the electronic health record, markers of efficiency. Increased satisfaction accrued once scribes had experience.

Patient Perspectives on Self-Monitoring of Blood Glucose When not Using Insulin: a Cross-sectional Survey.

BACKGROUND: Professional societies have recommended against use of self-monitoring blood glucose (SMBG) in non-insulin-treated type 2 diabetes (NITT2D) to control blood sugar levels, but patients are still monitoring. OBJECTIVE: To understand patients' motivation to monitor their blood sugar, and whether they would stop if their physician suggested it. DESIGN: Cross-sectional in-person and electronic survey conducted between 2018 and 2020. PARTICIPANTS: Adults with type 2 diabetes not using insulin who self-monitor their blood sugar. MAIN MEASURES: The survey included questions about frequency and reason for using SMBG, and the impact of SMBG on quality of life and worry. It also asked, "If your doctor said you could stop checking your blood sugar, would you?" We categorized patients based on whether they would stop. To identify the characteristics independently associated with desire to stop SMBG, we performed a logistic regression using backward stepwise selection. KEY RESULTS: We received 458 responses. The common reasons for using SMBG included the doctor wanted the patient to check (67%), desire to see the number (65%), and desire to see if their medications were working (61%). Forty-eight percent of respondents stated that using SMBG reduced their worry about their diabetes and 61% said it increased their quality of life. Fifty percent would stop using SMBG if given permission. In the regression model, respondents who said that they check their blood sugar levels because "I was told to" were more likely to want to stop (AOR: 1.69, 95%CI: 1.11, 2.58). Those that used SMBG due to habit and to understand their diabetes better had lower odds of wanting to stop (AOR: 0.33, 95%CI: 0.18-0.62; AOR: 0.60, 95%CI: 0.39-0.93, respectively). CONCLUSIONS: Primary care physicians should discuss patients' reasons for using SMBG and offer them the option of discontinuing.

Implementation Experience with a 30-Day Hospital Readmission Risk Score in a Large, Integrated Health System: A Retrospective Study.

BACKGROUND: Driven by quality outcomes and economic incentives, predicting 30-day hospital readmissions remains important for healthcare systems. The Cleveland Clinic Health System (CCHS) implemented an internally validated readmission risk score in the electronic medical record (EMR). OBJECTIVE: We evaluated the predictive accuracy of the readmission risk score across CCHS hospitals, across primary discharge diagnosis categories, between surgical/medical specialties, and by race and ethnicity. DESIGN: Retrospective cohort study. PARTICIPANTS: Adult patients discharged from a CCHS hospital April 2017-September 2020. MAIN MEASURES: Data was obtained from the CCHS EMR and billing databases. All patients discharged from a CCHS hospital were included except those from Oncology and Labor/Delivery, patients with hospice orders, or patients who died during admission. Discharges were categorized as surgical if from a surgical department or surgery was performed. Primary discharge diagnoses were classified per Agency for Healthcare Research and Quality Clinical Classifications Software Level 1 categories. Discrimination performance predicting 30-day readmission is reported using the c-statistic. RESULTS: The final cohort included 600,872 discharges from 11 Northeast Ohio and Florida CCHS hospitals. The readmission risk score for the cohort had a c-statistic of 0.6875 with consistent yearly performance. The c-statistic for hospital sites ranged from 0.6762, CI [0.6634, 0.6876], to 0.7023, CI [0.6903, 0.7132]. Medical and surgical discharges showed consistent performance with c-statistics of 0.6923, CI [0.6807, 0.7045], and 0.6802, CI [0.6681, 0.6925], respectively. Primary discharge diagnosis showed variation, with lower performance for congenital anomalies and neoplasms. COVID-19 had a c-statistic of 0.6387. Subgroup analyses showed c-statistics of > 0.65 across race and ethnicity categories. CONCLUSIONS: The CCHS readmission risk score showed good performance across diverse hospitals, across diagnosis categories, between surgical/medical specialties, and by patient race and ethnicity categories for 3 years after implementation, including during COVID-19. Evaluating clinical decision-making tools post-implementation is crucial to determine their continued relevance, identify opportunities to improve performance, and guide their appropriate use.

Treatment of Patients with Prediabetes in a Primary Care Setting 2011-2018: an Observational Study.

BACKGROUND: Over one third of American adults are at high risk for developing diabetes, which can be delayed or prevented using interventions such as medical nutrition therapy (MNT) or metformin. Physicians' self-reported rates of prediabetes treatment are improving, but patterns of actual referral, prescription, and MNT visits are unknown. OBJECTIVE: To characterize treatment of prediabetes in primary care. DESIGN: We conducted a retrospective cohort study using electronic health record data. We described patterns of treatment and used multivariable logistic regression to evaluate the association of patient factors and PCP-specific treatment rate with patient treatment. PATIENTS: We included overweight or obese outpatients who had a first prediabetes-range hemoglobin A1c (HbA1c) during 2011-2018 and had primary care provider (PCP) follow-up within a year. MAIN MEASURES: We collected patient characteristics and the following treatments: metformin prescription; referral to MNT, diabetes education, endocrinology, or bariatric medicine; and MNT visit. We did not capture within-visit physician counseling. KEY RESULTS: Of 16,713 outpatients with prediabetes, 20.4% received treatment, including metformin prescriptions (7.8%) and MNT referrals (11.3%), but only 7.4% of referred patients completed a MNT visit. The strongest predictor of treatment was the patient's PCP's treatment rate. Some PCPs never treated prediabetes, but two treated more than half of their patients; 62% had no patients complete a MNT visit. Being younger or female and having higher body mass index or HbA1c were also positively associated with treatment. Compared to white patients, black patients were more likely to receive MNT referral and less likely to receive metformin. CONCLUSIONS: Almost 80% of patients with new prediabetes never received treatment, and those who did receive referrals had very poor visit completion. Treatment rates appear to reflect provider rather than patient preferences.

Associations of weight loss with obesity-related comorbidities in a large integrated health system.

AIMS: To determine the health outcomes associated with weight loss in individuals with obesity, and to better understand the relationship between disease burden (disease burden; ie, prior comorbidities, healthcare utilization) and weight loss in individuals with obesity by analysing electronic health records (EHRs). MATERIALS AND METHODS: We conducted a case-control study using deidentified EHR-derived information from 204 921 patients seen at the Cleveland Clinic between 2000 and 2018. Patients were aged ≥20 years with body mass index ≥30 kg/m2 and had ≥7 weight measurements, over ≥3 years. Thirty outcomes were investigated, including chronic and acute diseases, as well as psychological and metabolic disorders. Weight change was investigated 3, 5 and 10 years prior to an event. RESULTS: Weight loss was associated with reduced incidence of many outcomes (eg, type 2 diabetes, nonalcoholic steatohepatitis/nonalcoholic fatty liver disease, obstructive sleep apnoea, hypertension; P < 0.05). Weight loss >10% was associated with increased incidence of certain outcomes including stroke and substance abuse. However, many outcomes that increased with weight loss were attenuated by disease burden adjustments. CONCLUSIONS: This study provides the most comprehensive real-world evaluation of the health impacts of weight change to date. After comorbidity burden and healthcare utilization adjustments, weight loss was associated with an overall reduction in risk of many adverse outcomes.

Shared Medical Appointments and Prediabetes: The Power of the Group.

Shared medical appointments, which allow greater access to care and provide peer support, may be an effective treatment modality for prediabetes. We used a retrospective propensity-matched cohort analysis to compare patients attending a prediabetes shared medical appointment to usual care. Primary outcome was patient's weight change over 24 months. Secondary outcomes included change in hemoglobin A1c, low density lipoprotein, and systolic blood pressure. The shared medical appointments group lost more weight (2.88 kg vs 1.29 kg, P = .003), and achieved greater reduction in hemoglobin A1c (-0.87% vs +0.87%, P = .001) and systolic blood pressure (-4.35 mmHg vs +0.52 mmHg, P = .044). The shared medical appointment model can be effective in treating prediabetes.

Impact of the COVID-19 Pandemic on Healthcare Workers' Risk of Infection and Outcomes in a Large, Integrated Health System.

BACKGROUND: Understanding the impact of the COVID-19 pandemic on healthcare workers (HCW) is crucial. OBJECTIVE: Utilizing a health system COVID-19 research registry, we assessed HCW risk for COVID-19 infection, hospitalization, and intensive care unit (ICU) admission. DESIGN: Retrospective cohort study with overlap propensity score weighting. PARTICIPANTS: Individuals tested for SARS-CoV-2 infection in a large academic healthcare system (N = 72,909) from March 8-June 9, 2020, stratified by HCW and patient-facing status. MAIN MEASURES: SARS-CoV-2 test result, hospitalization, and ICU admission for COVID-19 infection. KEY RESULTS: Of 72,909 individuals tested, 9.0% (551) of 6145 HCW tested positive for SARS-CoV-2 compared to 6.5% (4353) of 66,764 non-HCW. The HCW were younger than the non-HCW (median age 39.7 vs. 57.5, p < 0.001) with more females (proportion of males 21.5 vs. 44.9%, p < 0.001), higher reporting of COVID-19 exposure (72 vs. 17%, p < 0.001), and fewer comorbidities. However, the overlap propensity score weighted proportions were 8.9 vs. 7.7 for HCW vs. non-HCW having a positive test with weighted odds ratio (OR) 1.17, 95% confidence interval (CI) 0.99-1.38. Among those testing positive, weighted proportions for hospitalization were 7.4 vs. 15.9 for HCW vs. non-HCW with OR of 0.42 (CI 0.26-0.66) and for ICU admission: 2.2 vs. 4.5 for HCW vs. non-HCW with OR of 0.48 (CI 0.20-1.04). Those HCW identified as patient facing compared to not had increased odds of a positive SARS-CoV-2 test (OR 1.60, CI 1.08-2.39, proportions 8.6 vs. 5.5), but no statistically significant increase in hospitalization (OR 0.88, CI 0.20-3.66, proportions 10.2 vs. 11.4) and ICU admission (OR 0.34, CI 0.01-3.97, proportions 1.8 vs. 5.2). CONCLUSIONS: In a large healthcare system, HCW had similar odds for testing SARS-CoV-2 positive, but lower odds of hospitalization compared to non-HCW. Patient-facing HCW had higher odds of a positive test. These results are key to understanding HCW risk mitigation during the COVID-19 pandemic.

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study.

IMPORTANCE: Inappropriate antibiotic use for upper respiratory tract infections (URTIs) is an ongoing problem in primary care. There is extreme variation in the prescribing practices of individual physicians, which cannot be explained by clinical factors. OBJECTIVE: To identify factors associated with high and low prescriber status for management of URTIs in primary care practice. DESIGN AND PARTICIPANTS: Exploratory sequential mixed-methods design including interviews with primary care physicians in a large health system followed by a survey. Twenty-nine physicians participated in the qualitative interviews. Interviews were followed by a survey in which 109 physicians participated. MAIN MEASURES: Qualitative interviews were used to obtain perspectives of high and low prescribers on factors that influenced their decision making in the management of URTIs. A quantitative survey was created based on qualitative interviews and responses compared to actual prescribing rates. An assessment of self-prescribing pattern relative to their peers was also conducted. RESULTS: Qualitative interviews identified themes such as clinical factors (patient characteristics, symptom duration, and severity), nonclinical factors (physician-patient relationship, concern for patient satisfaction, preference and expectation, time pressure), desire to follow evidence-based medicine, and concern for adverse effects to influence prescribing. In the survey, reported concern regarding antibiotic side effects and the desire to practice evidence-based medicine were associated with lower prescribing rates whereas reported concern for patient satisfaction and patient demand were associated with high prescribing rates. High prescribers were generally unaware of their high prescribing status. CONCLUSIONS AND RELEVANCE: Physicians report that nonclinical factors frequently influence their decision to prescribe antibiotics for URTI. Physician concerns regarding antibiotic side effects and patient satisfaction are important factors in the decision-making process. Changes in the health system addressing both physicians and patients may be necessary to attain desired prescribing levels.

Physician Empathy Is Not Associated with Laboratory Outcomes in Diabetes: a Cross-sectional Study.

BACKGROUND: One widely cited study suggested a link between physician empathy and laboratory outcomes in patients with diabetes, but its findings have not been replicated. While empathy has a positive impact on patient experience, its impact on other outcomes remains unclear. OBJECTIVE: To assess associations between physician empathy and glycosylated hemoglobin (HgbA1c) as well as low-density lipoprotein (LDL) levels in patients with diabetes. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Patients with diabetes who received care at a large integrated health system in the USA between January 1, 2011, and May 31, 2014, and their primary care physicians. MAIN MEASURES: The main independent measure was physician empathy, as measured by the Jefferson Scale of Empathy (JSE). The JSE is scored on a scale of 20-140, with higher scores indicating greater empathy. Dependent measures included patient HgbA1c and LDL. Mixed-effects linear regression models adjusting for patient sociodemographic characteristics, comorbidity index, and physician characteristics were used to assess the association between physician JSE scores and their patients' HgbA1c and LDL. KEY RESULTS: The sample included 4176 primary care patients who received care with one of 51 primary care physicians. Mean physician JSE score was 118.4 (standard deviation (SD) = 12). Median patient HgbA1c was 6.7% (interquartile range (IQR) = 6.2-7.5) and median LDL concentration was 83 (IQR = 66-104). In adjusted analyses, there was no association between JSE scores and HgbA1c (ß = - 0.01, 95%CI = - 0.04, 0.02, p = 0.47) or LDL (ß = 0.41, 95%CI = - 0.47, 1.29, p = 0.35). CONCLUSION: Physician empathy was not associated with HgbA1c or LDL. While interventions to increase physician empathy may result in more patient-centered care, they may not improve clinical outcomes in patients with diabetes.

Antidiabetic treatment patterns and specialty care utilization among patients with type 2 diabetes and cardiovascular disease.

BACKGROUND: To evaluate real-world patient characteristics, medication use, and health care utilization patterns in patients with type 2 diabetes with established cardiovascular disease (CVD). METHODS: Cross-sectional analysis of patients with type 2 diabetes seen at Cleveland Clinic from 2005 to 2016, divided into two cohorts: with-CVD and without-CVD. Patient demographics and antidiabetic medications were recorded in December 2016; department encounters included all visits from 1/1/2016 to 12/31/2016. Comorbidity burden was assessed by the diabetes complications severity index (DCSI) score. RESULTS: Of 95,569 patients with type 2 diabetes, 40,910 (42.8%) were identified as having established CVD. Patients with CVD vs. those without were older (median age 69.1 vs. 58.2 years), predominantly male (53.8% vs. 42.6%), and more likely to have Medicare insurance (69.4% vs. 35.3%). The with-CVD cohort had a higher proportion of patients with a DCSI score ≥ 3 than the without-CVD cohort (65.0% vs. 10.3%). Utilization rates of glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors were low in both with-CVD (4.1 and 2.5%) and without-CVD cohorts (5.4 and 4.1%), respectively. The majority of patient visits (75%) were seen by a primary care provider. During the 1-year observation period, 81.9 and 62.0% of patients with type 2 diabetes and CVD were not seen by endocrinology or cardiology, respectively. CONCLUSIONS: These data indicated underutilization of specialists and antidiabetic medications reported to confer CV benefit in patients with type 2 diabetes and CVD. The impact of recently updated guidelines and cardiovascular outcome trial results on management patterns in such patients remains to be seen.

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system.

BACKGROUND: Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care. OBJECTIVE: To identify practice setting components contributing to uptake of new team-based care models. DESIGN: Convergent mixed-methods design. PARTICIPANTS: Employees and patients of primary care practices implementing two team-based models in a large, integrated health system. MAIN MEASURES: Field observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team. KEY RESULTS: Based on analysis of observations and interviews, the 9 practices were categorized into 3 groups-high, partial, and low uptake of new team-based models. Uptake was related to (1) practices' responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices' ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices. CONCLUSION: Uptake of new team-based care delivery models is related to practices' ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices.

Physicians' Views of Self-Monitoring of Blood Glucose in Patients With Type 2 Diabetes Not on Insulin.

This qualitative study examines to what extent and why physicans still prescribe self-monitoring of blood glucose (SMBG) in patients with non-insulin-treated type 2 diabetes (NITT2D) when the evidence shows it increases cost without improving hemoglobin A1c (HbA1c), general well being, or health-related quality of life. Semistructured phone interviews with 17 primary care physicians indicated that the majority continue to recommend routine self-monitoring of blood glucose due to a compelling belief in its ability to promote the lifestyle changes needed for glycemic control. Targeting physician beliefs about the effectiveness of self-monitoring of blood glucose, and designing robust interventions accordingly, may help reduce this practice.

Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections.

OBJECTIVES: Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes. METHODS: This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic. RESULTS: Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt. CONCLUSIONS: Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.

Prostate cancer screening practices in a large, integrated health system: 2007-2014.

OBJECTIVES: To assess prostate cancer screening practices in primary care since the initial United States Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen (PSA) testing for older men, and to assess primary provider variation associated with prostate cancer screening. PATIENTS AND METHODS: Our study population included 160 211 men aged ≥40 years with at least one visit to a primary care clinic in any of the study years in a large, integrated health system. We conducted a retrospective cohort study using electronic medical record data from January 2007 to December 2014. Yearly rates of screening PSA testing by primary care providers (PCPs), rates of re-screening, and rates of prostate biopsies were assessed. RESULTS: Annual PSA-screening testing declined from 2007 to 2014 in all age groups, as did biennial and quadrennial screening. Yearly rates declined for men aged ≥70 years, from 22.8% to 8.9%; ages 50-69 years, from 39.2% to 20%; and ages 40-49 years, from 11% to 4.6%. Overall rates were lower for African-American (A-A) men vs non-A-A men; for men with a family history of prostate cancer, rates were similar or slightly higher than for those without a family history. PCP variation associated with ordering of PSA testing did not substantially change after the USPSTF recommendations. While the number of men screened and rates of follow-up prostate cancer screening declined in 2011-2014 compared to 2007-2010, similar re-screening rates were noted for men aged 45-75 years with initial PSA levels of <1 ng/mL or 1-3 ng/mL in both the earlier and later cohorts. For men aged >75 years with initial PSA levels of <3 ng/mL screened in both cohorts, follow-up screening rates were similar. Rates of prostate biopsy declined for men aged ≥70 years in 2014 compared to 2007. For men who had PSA screening, rates of first prostate biopsy increased in later years for A-A men and men with a family history of prostate cancer. CONCLUSIONS: Prostate cancer screening declined from 2007 to 2014 even in higher-risk groups and follow-up screening rates were not related to previous PSA level. However, rates of first prostate biopsy in men who were screened with a PSA test were higher for men with an increased risk of prostate cancer in later years. Variation in PSA testing was noted among PCPs. Future work should further explore sources of variation in screening practices and implementation of risk-based strategies for prostate cancer screening in primary care.

Financial Incentives and Diabetes Disease Control in Employees: A Retrospective Cohort Analysis.

BACKGROUND: Many employers offer worksite wellness programs, including financial incentives to achieve goals. Evidence supporting such programs is sparse. OBJECTIVE: To assess whether diabetes and cardiovascular risk factor control in employees improved with financial incentives for participation in disease management and for attaining goals. DESIGN: Retrospective cohort study using insurance claims linked with electronic medical record data from January 2008-December 2012. PARTICIPANTS: Employee patients with diabetes covered by the organization's self-funded insurance and propensity-matched non-employee patient comparison group with diabetes and commercial insurance. INTERVENTION: Financial incentives for employer-sponsored disease management program participation and achieving goals. MAIN MEASURES: Change in glycosylated hemoglobin (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SBP), and weight. RESULTS: A total of 1092 employees with diabetes were matched to non-employee patients. With increasing incentives, employee program participation increased (7 % in 2009 to 50 % in 2012, p < 0.001). Longitudinal mixed modeling demonstrated improved diabetes and cardiovascular risk factor control in employees vs. non-employees [HbA1c yearly change -0.05 employees vs. 0.00 non-employees, difference in change (DIC) p <0.001]. In their first participation year, employees had larger declines in HbA1c and weight vs. non-employees (0.33 vs. 0.14, DIC p = 0.04) and (2.3 kg vs. 0.1 kg, DIC p < 0.001), respectively. Analysis of employee cohorts corresponding with incentive offerings showed that fixed incentives (years 1 and 2) or incentives tied to goals (years 3 and 4) were not significantly associated with HbA1c reductions compared to non-employees. For each employee cohort offered incentives, SBP and LDL also did not significantly differ in employees compared with non-employees (DIC p > 0.05). CONCLUSIONS: Financial incentives were associated with employee participation in disease management and improved cardiovascular risk factors over 5 years. Improvements occurred primarily in the first year of participation. The relative impact of specific incentives could not be discerned.

Physician, Scribe, and Patient Perspectives on Clinical Scribes in Primary Care.

BACKGROUND: Extending medical assistants and nursing roles to include in-visit documentation is a recent innovation in the age of electronic health records. Despite the use of these clinical scribes, little is known regarding interactions among and perspectives of the involved parties: physicians, clinical scribes, and patients. OBJECTIVE: The purpose of this project is to describe perspectives of physicians, clinical scribes, and patients regarding clinical scribes in primary care. DESIGN: We used qualitative content analysis, using Interpretive Description of semi-structured audio-recorded in-person and telephone interviews. PARTICIPANTS: Participants included 18 physicians and 17 clinical scribes from six healthcare systems, and 36 patients from one healthcare system. KEY RESULTS: Despite physician concerns regarding terminology within notes, physicians, clinical scribes, and patients perceived more detailed notes because of real-time documentation by scribes. Most patients were comfortable with the scribe's presence and perceived increased attention from their physicians. Clinical scribes also performed more active roles during a patient visit, leading to formation of positive scribe-patient relationships. The resulting shift in workflow, however, led to stress. Our theoretical model for successful physician-scribe teams emphasizes the importance of interpersonal aspects such as communication, mutual respect, and adaptability, as well as system level support such as training and staffing. CONCLUSIONS: Both interpersonal fit between physician and scribe, and system level support including adequate training, transition time, and staffing support are necessary for successful use of clinical scribes. Future directions for research regarding clinical scribes include study of care continuity, scribe medical knowledge, and scribe burnout.