Does de-implementation of low value care impact the patient-clinician relationship? A mixed methods study.

Context: In the U.S., provision of LVC is prevalent (up to 20% of total health services), costly ($350 billion annually), and associated with patient harm. Concern about a negative impact on the patient-clinician relationship has been cited by primary care clinicians as a barrier to reducing LVC. Study Design: Mixed-methods study. Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading one of three vignettes about a clinician declining to provide a requested LVC service (antibiotics for sinusitis, screening EKG, or screening vitamin D test) or a comparison vignette. A different sample of participants was asked to imagine that their own clinician did not order requested antibiotics or screening EKG and then to respond to structured interview questions about satisfaction and trust. Setting: Primary care patients of a southwest Virginia health system. Population: Adults (n= 232 questionnaire/n= 24 interview). Outcome Measures: Participant demographics data, PDRQ-9 score for each vignette (higher score = greater relationship integrity), and thematic analysis of interview responses. Results: Among questionnaire participants, a lower PDRQ-9 score was associated with the vignette about not providing LVC vitamin D screening (31.2) compared with antibiotics (38.9), EKG screening (37.5), and the comparison vignette (36.4) (p<0.05). There was a statistically significant, but weak, correlation between education and PDRQ-9 score (r=0.2, p<0.01). More than half of interviewees believed that their satisfaction and trust would not be negatively impacted by not receiving the LVC service, citing the strength of their relationship with their clinician and faith in their guidance. Some even felt that not providing the service would increase their satisfaction and trust. Participants who believed their satisfaction and trust may be impacted seemed to recognize the complexity of the scenario, discussing medical necessity, potential harm, insurance, and the option to go elsewhere (ex: urgent care or a new doctor). However, most emphasized that negative impacts could be mitigated if the clinician listened to them, spent time with them, and offered understandable advice. Conclusions: Findings emphasize prioritization of the patient-clinician relationship in LVC de-implementation interventions and suggest minimal impact of such interventions on the patient-clinician relationship. Evidence of service-specific differences was observed.

Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study.

BACKGROUND: The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. METHODS: Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. RESULTS: Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician's guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05). CONCLUSIONS: In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings.

MRD in Philadelphia Chromosome-Positive ALL: Methodologies and Clinical Implications.

PURPOSE OF REVIEW: Measurable residual disease (MRD) is integral in the management of Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL). This review discusses the current methods used to evaluate MRD as well as the interpretation, significance, and incorporation of MRD in current practice. RECENT FINDINGS: New molecular technologies have allowed the detection of MRD to levels as low as 10- 6. The most used techniques to evaluate MRD are multiparametric flow cytometry (MFC), quantitative reverse transcription polymerase chain reaction (RT-qPCR), and high-throughput next-generation sequencing (NGS). Each method varies in terms of advantages, disadvantages, and MRD sensitivity. MRD negativity after induction treatment and after allogeneic hematopoietic cell transplantation (HCT) is an important prognostic marker that has consistently been shown to be associated with improved outcomes. Blinatumomab, a new targeted therapy for Ph + ALL, demonstrates high efficacy in eradicating MRD and improving patient outcomes. In the relapsed/refractory setting, the use of inotuzumab ozogamicin and tisagenlecleucel has shown promise in eradicating MRD. The presence of MRD has become an important predictive measure in Ph + ALL. Current studies evaluate the use of MRD in treatment decisions, especially in expanding therapeutic options for Ph + ALL, including tyrosine kinase inhibitors, targeted antibody therapies, chimeric antigen receptor cell therapy, and HCT.

Risk Factors for Norovirus Gastroenteritis among Nicaraguan Children.

Norovirus is a leading cause of pediatric gastroenteritis. Understanding norovirus epidemiology is essential for reducing disease burden. We conducted a case-control study to describe the distribution, clinical features, and risk factors of norovirus gastroenteritis among children < 5 years of age in León, Nicaragua. Cases were children testing positive for norovirus and controls were children living in the cases' communities. Study staff interviewed mothers of enrolled cases and controls to obtain detailed exposure information including food, water, and sanitation sources; recent exposures; household characteristics; and handwashing practices. In addition, study staff requested stool samples to be tested for norovirus from select household members. We used descriptive statistics to understand the epidemiologic and clinical features of gastroenteritis episodes. To analyze potential risk factors, we used Firth's penalized logistic regression to estimate crude and adjusted odds ratios (ORs) and corresponding 95% confidence intervals (CIs). There were 102 children with gastroenteritis, 18 cases of norovirus and 31 controls. Norovirus cases occurred later in the year, corresponding to a delay in the rainy season. Cases were more likely to have a household member with norovirus in their stool as compared with controls [crude OR: 13.3 (95% CI: 2.5, 136.2) and adjusted OR: 11.5 (95% CI: 1.6, 223.2)]. In addition, alcohol-based hand sanitizer use among household members was reported for 10 (32%) of controls and but never for cases. Further research is needed to understand household transmission of norovirus in low- and middle-income countries and the potential impact of hand sanitizer use.

Harnessing Nature's Diversity: Discovering organophosphate bioscavenger characteristics among low molecular weight proteins.

Organophosphate poisoning can occur from exposure to agricultural pesticides or chemical weapons. This exposure inhibits acetylcholinesterase resulting in increased acetylcholine levels within the synaptic cleft causing loss of muscle control, seizures, and death. Mitigating the effects of organophosphates in our bodies is critical and yet an unsolved challenge. Here, we present a computational strategy that integrates structure mining and modeling approaches, using which we identify novel candidates capable of interacting with a serine hydrolase probe (with equilibrium binding constants ranging from 4 to 120 µM). One candidate Smu. 1393c catalyzes the hydrolysis of the organophosphate omethoate (kcat/Km of (2.0 ± 1.3) × 10-1 M-1s-1) and paraoxon (kcat/Km of (4.6 ± 0.8) × 103 M-1s-1), V- and G-agent analogs respectively. In addition, Smu. 1393c protects acetylcholinesterase activity from being inhibited by two organophosphate simulants. We demonstrate that the utilized approach is an efficient and highly-extendable framework for the development of prophylactic therapeutics against organophosphate poisoning and other important targets. Our findings further suggest currently unknown molecular evolutionary rules governing natural diversity of the protein universe, which make it capable of recognizing previously unseen ligands.