Complex patients' effect on family physicians: high cognitive load and negative emotional impact.

BACKGROUND AND OBJECTIVES: Complex patients present an increasing challenge to the health care system and family physicians play an important role in their care. As part of a larger project exploring family physicians' perceptions of complex patients, we sought to understand how complex patients affect family physicians and if these effects might be related to physician burnout. METHODS: We conducted a qualitative study involving interviews with family physicians from various practice settings. We invited the physicians to choose three of their patients between the ages of 18 and 64 whom they considered to have complex medical problems and to have access to their medical records during a telephone interview using a semi-structured interview guide. Interviews were audio-recorded, professionally transcribed and coded. Using qualitative analytical software, research team members worked together to analyse the interview data and determine emerging themes. RESULTS: Eleven family physicians participated in the interviews and described 29 unique complex patients, including challenges and effects on them personally. Analysis of the available 10 family physicians' interviews revealed two themes related to complexity's impact on physicians: (i) high cognitive load and (ii) negative emotional impact. CONCLUSION: Although preliminary, this study offers a previously unconsidered understanding of drivers of physician burnout, including high cognitive load and negative emotional impact on family physicians created by caring for complex patients. Interventions to improve health care, including addressing physician wellness and burnout, should include the provision of resources to assist them with decreasing cognitive load and negative emotional impact when caring for complex patients.

Complex patients present an increasing challenge to the health care system and family physicians play an important role in their care. We interviewed family physicians from various practice settings, inviting them to choose complex patients between the ages of 18 and 64 from their practices and to have access to their medical records during the interview. We then analysed the interviews for recurring themes regarding the care of their complex patients. Ten family physicians described 26 unique complex patients, including challenges and effects on them personally. Two themes related to the complexity's impact on physicians emerged from our analysis: (i) high cognitive load (the total amount of mental effort required) and (ii) negative emotional impact. It is possible that these two effects of complex patients on family physicians may contribute to physician burnout. Interventions to improve health care, including addressing physician wellness and burnout, should include the provision of resources to assist them with decreasing their cognitive load and negative emotional impact when caring for complex patients.

Tobacco cigarette and cannabis use among new mothers.

BACKGROUND AND AIMS: In the United States, the prevalence of cannabis use during pregnancy has increased whereas tobacco smoking has decreased. This study aimed to estimate the prevalence of tobacco cigarette smoking and cannabis use among new mothers, stratified by breastfeeding status. Additionally, trend analysis was used to examine changes in tobacco and cannabis use over time. DESIGN: Cross-sectional study based on the National Health and Nutrition Examination Survey (NHANES, 2001-18). SETTING: United States. PARTICIPANTS: Population-based sample of new mothers (within 2 years of childbirth) aged 20-44 years (n = 1332). MEASUREMENTS: For each NHANES data cycle, the prevalence of tobacco smoking measured by self-report or serum cotinine was estimated. Additionally, we estimated the prevalence of cannabis use measured by self-report. Using Joinpoint Regression, we tested for significant changes in trends and produced the average 'data-cycle' percentage change (APC). FINDINGS: From 2001 to 2018, more than one in five new mothers were tobacco cigarette smokers. New mothers who were breastfeeding were less likely to smoke cigarettes [7.4%, 95% confidence interval (CI) = 4.9%, 10.9% compared with mothers who were not breastfeeding (25.7%, 95% CI = 22.3%, 29.3%]. Results from Joinpoint regression indicated no robust temporal trends for self-reported tobacco smoking (APC = -1.3, 95% CI = -8.6, 6.7; P = 0.7) or for cotinine levels ≥ 4.47 ng/ml (APC = 0.3, 95% CI = -5.0, 5.9; P = 0.9), whereas cannabis use had increased among new mothers (APC = 23.7, 95% CI = 4.8, 46.0; P = 0.02). CONCLUSIONS: Consistent with the increase seen among other subgroups, cannabis use has approximately doubled among US new mothers since 2005. There is no significant evidence of a change in tobacco smoking among US new mothers since 2001.

Deprescribing Inappropriate Proton Pump Inhibitors in a Family Medicine Residency Practice Office.

INTRODUCTION: Proton pump inhibitors (PPIs) are often prescribed beyond their medically-approved duration of use. Long-term PPI use has been linked with numerous adverse effects and contributes to polypharmacy. This study sought to understand the effect of evidence-based education to resident and faculty physicians on deprescribing inappropriate PPIs. We hypothesized that this educational intervention would result in fewer inappropriate PPI prescriptions. METHODS: We performed a chart review on all adult patients in a family medicine residency program practice, identifying those inappropriately taking PPIs. All physicians in the practice participated in an educational intervention regarding deprescribing inappropriate PPIs and were given frequent reminders to continue their deprescribing efforts. We reviewed charts at the end of the study to identify patients with successful deprescribing attempts. RESULTS: Of the 187 patients prescribed inappropriate PPIs in the study, 100 remained on PPIs at the end of the study (46.6% success rate). There was a significant decrease in the number of patients inappropriately prescribed PPIs by each physician over the course of the study, from a mean of 17.0 (beginning) to 9.1 (end). CONCLUSION: Physician education with reminders is an effective means of reducing the number of inappropriate PPIs prescribed in a family medicine residency practice. Future studies could investigate the effectiveness of educational interventions with other medication classes that are often prescribed inappropriately.

Maternity Care Tracks at US Family Medicine Residency Programs.

BACKGROUND AND OBJECTIVES: The number of family physicians providing maternity care continues to decline, jeopardizing access to needed care for underserved populations. Accreditation changes in 2014 provided an opportunity to create family medicine residency maternity care tracks, providing comprehensive maternity care training only for interested residents. We examined the relationship between maternity care tracks and residents' educational experiences and postgraduate practice. METHODS: We included questions on maternity care tracks in an omnibus survey of family medicine residency program directors (PDs). We divided respondent programs into three categories: "Track," "No Track Needed," and "No Track." We compared these program types by their characteristics, number of resident deliveries, and number of graduates practicing maternity care. RESULTS: The survey response rate was 40%. Of the responding PDs, 79 (32%) represented Track programs, 55 (22%) No Track Needed programs, and 94 (38%) No Track programs. Residents in a track attended more deliveries than those not in a track (at Track programs) and those at No Track Needed and No Track programs. No Track Needed programs reported the highest proportion of graduates accepting positions providing inpatient maternity care in 2019 (21%), followed by Track programs (17%) and No Track programs (5%; P<.001). CONCLUSIONS: Where universal robust maternity care education is not feasible, maternity care tracks are an excellent alternative to provide maternity care training and produce graduates who will practice maternity care. Programs that cannot offer adequate experience to achieve competence in inpatient maternity care may consider instituting a maternity care track.

Blood glucose monitor quick reference guides: are they suitable for patients?

BACKGROUND: The purpose of this study was to assess readability and related characteristics of English-language Quick Reference Guides (QRGs) accompanying home blood glucose monitors (HBGMs), including reading grade level, dimensions, text point size, illustrations, and layout features. METHODS: Using the 2006 Diabetes Forecast Resource Guide, we identified HBGMs currently available in the United States. Reading grade level was calculated using Flesch Reading Ease (FRE). Text point size was determined by measuring the distance from the ascent line to the descent line with a C-Thru (Bloomfield, CT) Ruler. Total number of illustrations per QRG was tallied. Illustration dimensions were measured to the nearest millimeter. We also assessed layout features-derived from the Suitability of Materials Assessment and User-Friendliness Tool-including, font style type, use of white space, sentence structure, language style, limited math skill, focus on "Need to Know," and appropriateness of illustrations. RESULTS: FRE scores ranged from 5(th) to approximately 13(th) grade, while text point size averaged 9.9 +/- 1.6 (range, 8-12). QRGs averaged 15.8.2 +/- 6.0 (range, 6-25) clear and realistic illustrations, most slightly larger than a quarter. Most QRGs avoided use of specialty fonts (85.7%) and limited information to "Need to Know" (92.9%). All instructions required little math skill; however, ample white space was used in five (35.7%) QRGs. CONCLUSIONS: HBGM manufacturers should increase the size of QRG fold-outs, thereby allowing for larger text size and illustrations, and increasing the amount of white space. Making these relatively small formatting changes would ensure that all patients with diabetes, particularly those with visual impairments, are able to follow HBGM instructions.

Suitability and readability of consumer medical information accompanying prescription medication samples.

OBJECTIVE: To examine readability and formatting characteristics of consumer medication information (CMI) accompanying prescription medication samples. METHODS: We collected the most commonly used prescription medication samples (n=100) from four out-patient clinics at a large teaching hospital in the Southeastern US. Seventeen percent of samples were not pills/tablets and of such diverse nature (e.g., injections, drops, and creams) that there were not enough in any category to draw conclusions. Therefore, our analyses were limited to 83pill/tablet samples, belonging to 11 drug classes (e.g., cardiovascular, and psychiatric). We noted if CMI was present, and if so we assessed it for how instructions were presented, reading level, text size, format/layout, and comprehensibility. RESULTS: No CMI was present in 39 (46.9%) samples. In 19 (22.9%), CMI was contained in a package insert and in 25 (30.2%) it was printed on the medication package. Average reading difficulty of CMI was at the 10th grade level (range=6-15) using the Fry formula, and text point size was small (mean 9.9+/-2.2 on package inserts and 9.4+/-2.6 when printed on packages). CONCLUSIONS: Almost half of samples did not include any type of CMI. For those that had CMI, it was often written at a reading difficulty level higher than the average reading skills of American adults, and the format of most CMI was not optimal for comprehensibility. It is likely that many patients do not understand the instructions accompanying medication samples they receive from clinicians. PRACTICE IMPLICATIONS: Clinicians should be cognizant of the shortcomings of CMI accompanying medication samples and thereby, distribute them to patients with caution. Manufacturers too should consider revising CMI to comply with low-literacy guidelines.

Perceptions of healthcare providers' communication skills: do they differ between urban and non-urban residents?

We examined the association of place of residence--urban versus non-urban--with patients' perceptions regarding communication and interactions with healthcare providers. Respondents' perceptions of their healthcare providers' communication skills were assessed by responses to six items from the 2002 Medical Expenditure Panel Survey, a nationally representative survey of the civilian, non-institutionalized US population. After controlling for several covariates, respondents in urban areas reported poorer communication by their healthcare providers than non-urban respondents. Differences in perceived quality of communication could contribute to reduce use of preventive healthcare and indicates a need to improve healthcare provider-patient communication in the urban setting.

Development and validation of a low-literacy opioid contract.

UNLABELLED: Opioid contracts (OPCs) are often used to outline the criteria and circumstances for which opioid medications are prescribed. The purpose of this study was to develop and validate an English-language, low-literacy OPC. Specifically, the low-literacy OPC was designed to outline proper administration of prescribed medication(s) as well as highlight patient responsibilities and expectations. A 4-step process was used to develop and validate the low-literacy OPC, including: (1) content identification; (2) attention to low-literacy guidelines; (3) evaluation based on Suitability Assessment of Materials (SAM) criteria; and (4) pilot testing with patients (n = 18) to assess comprehension. Final OPC content, presented largely in bulleted format, was based on current literature and consensus of the first 3 authors. The 4-part OPC was formatted on 8(1/2) x 11 inch paper using 16- to 24-point size Arial-style font. The 6-page OPC, written at the 7(th) reading grade level, included 12 recognizable clipart-type illustrations to supplement written text. Two reviewers scored the OPC in the superior range based on total SAM percentage scores. Nineteen (n = 19) of the 26 statements were comprehended by all patients completing the pilot testing. Overall, the low-literacy OPC is comprehensive, valid, readable, and formatted according to established low-literacy guidelines. PERSPECTIVE: This study describes the development and validation of a low-literacy, English-language OPC. The OPC was formatted using low-literacy guidelines and validated with a sample of patients to confirm understanding of content. Accordingly, the low-literacy OPC is suitable for use in routine clinical practice.

Literacy demands and formatting characteristics of opioid contracts in chronic nonmalignant pain management.

UNLABELLED: Chronic nonmalignant pain affects a significant number of adults, with many requiring opioid medications to manage their symptoms. Although the content of typical opioid contracts (OCs) has been explored, no studies have examined the literacy demands and formatting characteristics of OCs currently used throughout the United States. We evaluated 162 English-language OCs submitted to us by current American Pain Society members residing in the United States. OCs were evaluated for reading grade level and formatting characteristics. The mean readability of OCs was at grade level 13.8 +/- 1.3 (range = 10-17), whereas the average text point size was 11.0 +/- 1.4 (range = 6-16). Active voice was used exclusively in almost half of OCs (n = 79, 48.8%). Most OCs contained not only sophisticated medical language but multisyllable, nonmedical terms and vocabulary not used in typical everyday conversation. Overall, most OCs reviewed presented information at much too high a reading grade level, and with formatting characteristics that probably would make these documents difficult for the average patient to fully comprehend. PERSPECTIVE: This study indicates that there is a mismatch between the reading demands of most OCs and the actual health literacy skills of American adults. Accordingly, those developing OCs should be cognizant of the actual literacy abilities of their patient population and design and evaluate OCs accordingly.

Brief report: screening items to identify patients with limited health literacy skills.

BACKGROUND: Patients with limited literacy skills are routinely encountered in clinical practice, but they are not always identified by clinicians. OBJECTIVE: To evaluate 3 candidate questions to determine their accuracy in identifying patients with limited or marginal health literacy skills. METHODS: We studied 305 English-speaking adults attending a university-based primary care clinic. Demographic items, health literacy screening questions, and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered to patients. To determine the accuracy of the candidate questions for identifying limited or marginal health literacy skills, we plotted area under the receiver operating characteristic (AUROC) curves for each item, using REALM scores as a reference standard. RESULTS: The mean age of subjects was 49.5; 67.5% were female, 85.2% Caucasian, and 81.3% insured by TennCare and/or Medicare. Fifty-four (17.7%) had limited and 52 (17.0%) had marginal health literacy skills. One screening question, "How confident are you filling out medical forms by yourself?" was accurate in detecting limited (AUROC of 0.82; 95% confidence interval [CI]=0.77 to 0.86) and limited/marginal (AUROC of 0.79; 95% CI=0.74 to 0.83) health literacy skills. This question had significantly greater AUROC than either of the other questions (P<.01) and also a greater AUROC than questions based on demographic characteristics. CONCLUSIONS: One screening question may be sufficient for detecting limited and marginal health literacy skills in clinic populations.

Readability of consumer medication information for intranasal corticosteroid inhalers.

PURPOSE: The readability of consumer medication information (CMI) inserts accompanying intranasal corticosteroid (INCS) inhalers currently prescribed in the United States was studied. METHODS: INCS inhalers were identified (n = 7) using Epocrates R(x) Pro and English- language CMI was obtained from each inhaler's manufacturer. The CMI was evaluated for reading grade level (using Fry's readability formula) and font size, dimensions (length and width), illustrations (diagrams and figures), and directions for use. RESULTS: The mean +/- S.D. reading grade level of the CMI was 6.9 +/- 0.7 (range, 6-8). The mean +/- S.D. font size was 9.0 +/- 2.2 (range, 6-12). The mean +/- S.D. CMI page length and width were 31.3 +/- 22.5 cm and 14.0 +/- 12.9 cm, respectively. A device-overview figure was included in three of the seven educational samples. The mean size of illustrations was 7.9 cm(2) (range, 2.9-25.9 cm(2)), with a mean +/- S.D. of 7.6 +/- 3.2 (range, 3-11) figures per CMI insert. Directions followed a logical, step-by-step chronological sequence in every CMI insert. CONCLUSION: Most CMI for INCS inhalers is written at a reading level slightly higher than recommended, printed in a font size smaller than recommended, and illustrated inadequately for successful patient education.

Comprehensibility and readability of patient self-administered opioid assessment screening tools.

OBJECTIVE: The aims of this study were to evaluate the cognitive complexity and reading demands of patient self-administered Opioid Assessment Screening Tools (OASTs) for use in adults with nonmalignant pain. METHODS: Using comprehensive search strategies, we identified english-language OASTs with established validity and reliability for inclusion in our study. Cognitive complexity of individual OAST statements or questions were assessed using three techniques (number of items, number of words, and linguistic problems), whereas readability was measured using the Flesch-Kinkaid formula. RESULTS: Four (n=4) were identified and included in our review: Current Opioid Misuse Measure (COMM), Pain Medication Questionnaire (PMQ), Screener and Opioid Assessment for Patient with Pain, and Screening Tool for Addiction Risk (STAR). Number of total OAST statements or questions ranged from a low of 14 (STAR) to a high of 26 (PMQ), whereas number of words (length) per statement or question averaged from a low of 10.2 +/- 1.1 (STAR) to a high of 15.9 +/- 3.8 (PMQ). The STAR (1.3 +/- 1.1) had the fewest number of linguistic problems per statement or question, whereas the PMQ (3.0 +/- 1.4) had the most linguistic problems per statement or question. Although, readability of OASTs ranged from approximately sixth (STAR) to eighth (COMM, PMQ) grade, there was notable variation in readability across individual statements or questions. CONCLUSIONS: Our study demonstrates that formatting characteristics, including linguistic problems, and high readability of several OAST statements or questions may hinder many patients' ability to accurately complete and comprehend OASTs independently.

Readability characteristics of consumer medication information for asthma inhalation devices.

PURPOSE: Successful control of asthma relies heavily on patient adherence to prescribed inhalation therapies. Many patients are unable to use inhalers correctly and, therefore, do not reap the full therapeutic benefits. The purpose of this study was to assess the readability and related characteristics of Consumer Medication Information (CMI) for all prescription asthma inhalation devices currently available in the United States. METHODS: We identified all brand-name (n = 18) and generic (n = 2) asthma inhalation devices currently available in the United States. English language CMI was obtained from pharmaceutical manufacturers of each identified product. The CMI from these products was evaluated for readability characteristics, including reading grade level using the Fry formula, text point size, dimensions (length and width), diagrams, and directions. RESULTS: The mean Fry readability of the CMI was at grade level 8.2 +/- 1.5 (range = 5-11), while the average text point size was 9.2 +/- 2.2 (range = 6-12). The mean length of the pages on which the CMI was printed was 33.7 +/- 21.5 cm, while the average width of pages was 12.9 +/- 9.5 cm. There was an average of 6.2 +/- 3.6 (range = 2-12) illustrations per CMI, while a device overview diagram was included in 14 (70%). Eleven (n = 11) instructions included detailed step-by-step diagrams to supplement directions. CONCLUSIONS: Overall, most CMI for prescription inhalers is presented with a reading difficulty level, text size, diagrams, and instructions that make it suboptimal for patient education. Prescription inhaler manufacturers should consider revising their CMI to comply with generally accepted guidelines preparing patient education information.