Revisiting the Time Needed to Provide Adult Primary Care

Pain and feasibility of capillary self-blood collection in general practice: A cross-sectional investigative study

BACKGROUND

Capillary self-blood collection (SBC) with mailed samples enables remote laboratory monitoring without in-person healthcare visits. This approach may improve continuity of care for patients, especially with chronic conditions.

OBJECTIVES

Compare pain perception between venous blood draws and capillary SBC and evaluate the usability and blood volume yield of SBC devices.

METHODS

In this cross-sectional study, general practice patients from mid of Germany, Germany performed SBC using the Tasso+® upper-arm device and mailed samples to a laboratory. Pain, usability, SBC volume, and associated factors were analysed using bivariate and general linear models.

RESULTS

Of 106 patients, 57.5% performed SBC without assistance. Self-perceived pain was lower among SBC draws (0.13, SD = 0.42) versus venous draws (1.21, SD = 1.60) (p < .001). 59.4% self-collected ≥130 μL blood plasma. Patient characteristics were not associated with SBC volume in regression analysis. Overall, the mean System Usability Scale (SUS) score was 86.2, indicating high usability. Lower school education was associated with lower usability scores, while lower fear of blood and needles were associated with higher usability scores in regression analysis.

CONCLUSIONS

Capillary SBC had high feasibility and usability and caused less pain than venous draws in the general practice setting. SBC shows promises for enabling remote laboratory monitoring.

Primary care staff members' experiences with managing electronic health record inbox messages

OBJECTIVE

Clinical staff often help clinicians review and respond to messages from patients. This study aimed to characterize primary care staff members' experiences with inbox work.

MATERIALS AND METHODS

In this qualitative study, we conducted direct observations and focus groups with clinical staff at 4 academic primary care clinics. We used inductive thematic analysis to code the resulting notes and transcripts for themes in staff members' experience with inbox work.

RESULTS

Nine medical assistants and 3 nurses participated in the study. Staff described inbox work as fragmented, feeling like an assembly line, requiring frequent communication with other team members to clarify and manage tasks, and requiring navigation of expectations that varied between patients, clinicians, and clinics. Staff described some messages as being more difficult to manage due to how requests were posed, challenges with subsequent communication, and mismatches between data from different sources. Staff also described how tools that structured or automated message management aided inbox work.

DISCUSSION

Staff addressed routine messages by following known protocols and appreciated tools that structured their inbox work. However, staff also regularly encountered messages with information that conflicted with clinic records or that contained multiple, redundant, or vague requests. Addressing these messages required additional work to clarify information (ie, data work) and manage resulting tasks (ie, articulation work).

CONCLUSION

Clinic workflows and health information technology should support not only the readily standardized work of addressing routine messages but also the more varied work of preparing messages to be addressed in the first place.

Vocational awe is (not) enough: Learnings from early adopters of serious illness communication

CONTEXT

As part of a broader institutional initiative, the serious illness care program was implemented in a multi-site academic primary care practice. After 2 years, a minority was observed to be documenting serious illness conversations routinely.

OBJECTIVES

We aimed to learn about the motivations and actions of clinicians who routinely conducted and documented serious illness conversations.

METHODS

We identified primary care early adopters of serious illness communication: 17 of 228 physicians (roughly 8%) who were documenting at least 1-2 conversations every 1-2 months for a year. Fifteen physicians agreed to participated in semi-structed interviews and which were then analyzed with thematic analysis.

RESULTS

Early adopters successfully integrate serious illness conversations into clinical practice by using four strategies that amplify vocational awe: their deep sense of their professions core value. Three strategies focus on positive aspects of serious illness communication: (1) reflecting on the meaningful impact of serious illness conversations on clinical care; (2) feeling a resonance between serious illness communication and their personal identity and values; and (3) identifying with the medical community's sense that serious illness communication contributes to good clinical care. The fourth strategy is to minimize system limitations using a range of tactics that include accepting time shortages and streamlining workflow.

CONCLUSION

Vocational awe is a powerful driver for engaging in serious illness communication; however, without system-level resource support, it does not sustainably motivate most clinicians. Serious illness communication needs to be a part of routine healthcare with appropriately allocated time, compensation, and workflow support.

Developing a website to help women aged 55 + incorporate risk in decision-making about breast cancer screening and prevention medications

OBJECTIVES

Guidelines recommend women consider their breast cancer risk and life expectancy when deciding on breast cancer screening (e.g., intervals, when to stop) and prevention medication. We previously developed a competing-risk model to predict 10-year breast cancer risk and non-breast cancer death in women > 55 years to support decision-making. Here, we aimed to develop a decision aid (DA) website incorporating our model's risk estimates.

METHODS

We designed the DA based on international standards using the free R package Shiny. We included a risk-assessment page, risk estimates, and decision support on breast cancer screening and prevention medications. We recruited national experts, Boston-area primary care practitioners (PCPs), and female patients > 55 years without breast cancer history to provide feedback on the DA via questionnaire or personal interview. We used thematic analysis to identify themes in participants' open-ended comments until reaching thematic saturation. Study questionnaires assessed DA helpfulness and ease-of-use.

RESULTS

Forty-five (53.6 %) of 84 eligible patients approached participated. Their mean age was 65.9 years (SD 7.9), 31 (68.9 %) were non-Hispanic White, and 31 (68.9 %) graduated college. Of 52 experts/PCPs contacted, 30 participated. Participants found the DA helpful (35/44 patients [79.5 %] and 28/29 [96.6 %] experts/PCPs) and easy-to-use (39/45 patients [86.7 %] and 28/29 PCPs/experts, [96.6 %]). They described the DA as "informative" and liked the "tailored-risk information." They suggested changes to simplify the DA and to better individualize the decision-support. We iteratively revised the website. We could not program some recommended changes using the free R application.

CONCLUSIONS

We developed an informative and easy-to-use breast cancer screening and prevention medication DA website (https://bcrisk55plus.shinyapps.io/risktool/) for women > 55 using free software. Next, we will program the website using HTML code and test its effects prospectively.

PRACTICE IMPLICATIONS

We anticipate that use of the DA will help women > 55 with breast cancer screening and prevention decisions.

Screening for Health-Related Social Needs: American College of Preventive Medicine's Practice Statement

Interest is rapidly growing around screening for health-related social needs (HRSN) in direct patient care settings. The screening and provision of HRSN is often done in the context of trying to address social determinants of health. While there is emerging evidence that screening and referral for HRSN can improve health outcomes, there are educational, operational, and systemic gaps that need to be filled in order for HRSN screening and referral to be implemented system-wide and result in meaningful improvement in population health outcomes. The American College of Preventive Medicine recommends HRSN screening and referral in patient care settings only when there are sufficient systems in place to support addressing those needs. This paper identifies key considerations to take into account when implementing HRSN screening and referral in healthcare settings and makes recommendations to address those key considerations. The recommendations also frame the broader need to address social determinants of health at a population level. Finally, the paper identifies several knowledge and evidence gaps in the existing literature on the topic of HRSN, which will hopefully drive future research in this area, and result in an evidence-based, population approach to the issue.

Encouraging Pharmacist Referrals for Evidence-Based Statin Initiation: Two Cluster Randomized Clinical Trials

Importance

Despite statins' benefit in preventing major adverse cardiovascular events, most patients with an indication for statin therapy are not appropriately treated. Clinicians' limited time and lack of systematic efforts to address preventive care likely contribute to gaps in statin prescribing.

Objective

To determine the effect on statin prescribing of 2 interventions to refer appropriate patients to a pharmacist for lipid management.

Design, Setting, and Participants

These 2 pragmatic cluster randomized clinical trials were conducted among 12 total primary care practices in a community health system. Trial 1 was a delayed-intervention design of a visit-based intervention with randomization at the clinician level in a single clinic, and trial 2 was a parallel-arm trial of an asynchronous intervention with randomization at the clinic level in 11 clinics. Patients who were assigned to a primary care clinician at a participating practice, had an indication for a high-intensity or moderate-intensity statin, and were either not prescribed a statin or prescribed an inappropriately low statin dose were eligible for inclusion.

Intervention

Trial 1 tested an interruptive electronic health record alert that appeared during eligible patients' visits and facilitated referral to a pharmacist, while trial 2 tested an order for pharmacist referral placed by the study team for cosignature by the primary care clinician without regard to the timing of a clinic visit.

Main Outcome and Measure

The primary outcome was the proportion of patients prescribed a statin.

Results

Overall, 1412 patients were enrolled in trial 1 and 1950 in trial 2. Across both trials, mean (SD) patient age was 65.6 (9.9) years, and 1485 patients (44.2%) were female. Mean (SD) baseline 10-year risk of major cardiovascular events was 17.9% (9.4). In trial 1, the interruptive alert was not associated with a significant increase in statin prescriptions compared with usual care (15.6% vs 11.6%; unadjusted absolute difference, 3.9 percentage points; 95% CI, -0.4 to 8.3). In trial 2, semiautomated pharmacist referrals were associated with an increase in statin prescriptions by 16 percentage points compared with usual care (31.6% vs 15.2%; unadjusted absolute difference, 16.4 percentage points; 95% CI, 12.7-20.1).

Conclusions and Relevance

In these 2 cluster randomized clinical trials, visit-based interruptive alerts were not associated with a significant increase in statin prescribing compared with usual care, whereas a strategy of asynchronous semiautomated referral for pharmacist comanagement was associated with a substantial increase. This strategy of asynchronous semiautomated referrals for pharmacist involvement in lipid management could be a scalable and effective approach to increasing statin prescribing for patients at high risk.

Trial Registration

ClinicalTrials.gov Identifier: NCT05537064.

Culinary medicine in medical education: a pilot study targeting cancer risk reduction strategies through culinary and lifestyle medicine education

Introduction

Culinary Medicine (CM) is an avenue for interdisciplinary nutrition education intervention utilizing the expertise of dietitians, physicians, and other health care professionals (HCP). Despite the positive impacts that CM interventions can have on health, physician CM knowledge is lacking due in part to inadequate nutrition education in medical school curriculum. CM as a nutrition education modality promotes health and disease management for patients and providers, so it is critical to increase competency in CM. This pilot study evaluated the impact of a cancer prevention specific CM curriculum on medical students' (i) cancer risk reduction (CRR) knowledge, (ii) CRR assessment/counseling attitudes and self-efficacy in clinical care, and (iii) personal health behaviors and cooking skills.

Methods

Thirty-one 2nd year medical students (CALM students) participated in seven, 3-hour CRR focused CM education sessions and were compared to 55 non-enrolled students (control group). Education sessions incorporated a lecture, learning activity, and cooking experience focused on topics including dietary patterns, gut health, inflammation, metabolic health, hormone balance, environmental exposures, and prevention in practice/at home. A 46-item online pre-test (09/23) and post-test (03/24) survey assessed standardized measures of general nutrition/cancer knowledge, attitudes/beliefs, perceived control and self-efficacy around CRR diet/ lifestyle modifications; and intentions of integrating CRR strategies in practice.

Results

78 students (91%) completed both surveys and the findings indicate that CALM students showed significant improvement over their peers in knowledge scores (β = 0.265, t = 2.14, p < 0.05), attitudes toward nutrition in the clinical setting (β = 0.203, t = 2.00, p < 0.05) and confidence in integrating CRR strategies in patient care (β = 0.401, t = 4.05, p < 0.001). Most significant changes occurred in confidence of being able to make a CRR plan and follow through with patients on the plan (p < 0.001).

Discussion

This pilot study is among the first to incorporate and evaluate CRR-specific CM competencies in medical education. Given that the lifetime risk for developing cancer is high for Americans (~40%), education and implementation of CRR strategies among patients and providers must be emphasized. If research continues to demonstrate curriculum success in future cohorts, it is an innovative approach to teaching nutrition and CM competencies to HCP that is applicable to numerous disease states.

Designing better systems to navigate the sepsis-antimicrobial stewardship tension

Sepsis is a leading cause of preventable death and requires timely antimicrobial treatment to reduce mortality. Despite extensive sepsis management guidelines, high-income countries continue to have considerable rates of sepsis mortality, indicating a gap between guideline quality, usability, and practical application. Simultaneously, the rise of antimicrobial resistance threatens the efficacy of antimicrobial therapies for infection control, underscoring the tension between sepsis management and antimicrobial stewardship. This Personal View explores how system factors, such as people, environments, tools, technologies, and tasks, influence the sepsis-antimicrobial stewardship tension. With the Systems Engineering Initiative for Patient Safety, we use a case study to highlight how organisational pressures, inadequate diagnostic tools, and sociocultural factors drive the gap between work-as-imagined and work-as-done. These latent safety risks that impede guideline adherence and contribute to unintended antimicrobial use highlight the need to design better systems, not blame individuals for non-compliance. We argue that addressing sepsis and antimicrobial resistance requires a holistic systems approach and that every discipline, including policy makers, clinicians, researchers, and drug developers, should adopt systems thinking in the design of interventions intended to address this problem. This shift is essential to ensuring effective care for patients today while safeguarding the effectiveness of antimicrobials tomorrow.

Improving Early Dementia Detection Among Diverse Older Adults With Cognitive Concerns With the 5-Cog Paradigm: Protocol for a Hybrid Effectiveness-Implementation Clinical Trial

BACKGROUND

The 5-Cog paradigm is a 5-minute brief cognitive assessment coupled with a clinical decision support tool designed to improve clinicians' early detection of cognitive impairment, including dementia, in their diverse older primary care patients. The 5-Cog battery uses picture- and symbol-based assessments and a questionnaire. It is low cost, simple, minimizes literacy bias, and is culturally fair. The decision support component of the paradigm helps nudge appropriate care provider response to an abnormal 5-Cog battery.

OBJECTIVE

The objective of our study is to evaluate the effectiveness, implementation, and cost of the 5-Cog paradigm.

METHODS

We will enroll 6600 older patients with cognitive concerns from 22 primary care clinics in the Bronx, New York, and in multiple locations in Indiana for this hybrid type 1 effectiveness-implementation trial. We will analyze the effectiveness of the 5-Cog paradigm to increase the rate of new diagnoses of mild cognitive impairment syndrome or dementia using a pragmatic, cluster randomized clinical trial design. The secondary outcome is the ordering of new tests, treatments, and referrals for cognitive indications within 90 days after the study visit. The 5-Cog's decision support component will be deployed as an electronic medical record feature. We will analyze the 5-Cog's implementation process, context, and outcomes through the Consolidated Framework for Implementation Research using a mixed methods design (surveys and interviews). The study will also examine cost-effectiveness from societal and payer (Medicare) perspectives by estimating the cost per additional dementia diagnosis.

RESULTS

The study is funded by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health (2U01NS105565). The protocol was approved by the Albert Einstein College of Medicine Institutional Review Board in September 2022. A validation study was completed to select cut scores for the 5-Cog battery. Among the 76 patients enrolled, the resulting clinical diagnoses were as follows: dementia in 32 (42%); mild cognitive impairment in 28 (37%); subjective cognitive concerns without objective cognitive impairment in 12 (16%); no cognitive diagnosis assigned in 2 (3%). The mean scores were Picture-Based Memory Impairment Screen 5.8 (SD 2.7), Symbol Match 27.2 (SD 18.2), and Subjective Motoric Cognitive Risk 2.4 (SD 1.7). The cut scores for an abnormal or positive result on the 5-Cog components were as follows: Picture-Based Memory Impairment Screen ≤6 (range 0-8), Symbol Match ≤25 (range 0-65), and Subjective Motoric Cognitive Risk >5 (range 0-7). As of December 2024, a total of 12 clinics had completed the onboarding processes, and 2369 patients had been enrolled.

CONCLUSIONS

The findings of this study will facilitate the rapid adaptation and dissemination of this effective and practical clinical tool across diverse primary care clinical settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05515224; https://www.clinicaltrials.gov/study/NCT05515224.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60471.

Improving Workflow With a Task Buddy System in a Family Medicine Residency

Introduction

Inbox management in outpatient primary care consumes a substantial amount of time, and residency training programs face unique challenges related to provider schedules. Long work hours, provider burnout, and worse patient outcomes can all be attributed to task management burden. Team-based care models can provide support through coverage systems and group inboxes. However, more empirical study of these systems may help to inform their implementation in interdisciplinary medical residency outpatient clinics.

Methods

The current study investigated the implementation of a "task buddy" system, which paired providers in teams to manage electronic health record (EHR) tasks. Data were collected on average task age and number of late tasks preimplementation, postimplementation, and 6 months postimplementation. Paired samples t tests were used to compare average task age for each task team. Participation was encouraged through a small monetary reward.

Results

A total of 23 resident physicians and 13 faculty from multiple disciplines participated. Our data demonstrated that the average age of tasks was more than 1 day lower with this system, but total late tasks did not improve.

Conclusions

The task buddy system resulted in quicker response time to complete tasks, but the number of late tasks stayed stagnant. Future studies should assess any correlation between improved patient outcomes with more efficient EHR task management. Additional studies across multiple residencies and specialties could better elucidate generalizability and provider perspectives of this pilot program.

Person-Centered Preventive Health Care: Gathering Stakeholder Input on Evidence and Implementation

Introduction

Clinical preventive services, such as screening tests, vaccinations, behavioral counseling, or preventive medication, are offered to most people on the basis of age, sex, health behaviors, or clinical risk factors, with goals of detecting early disease, preventing future disease, or mitigating the impact of unhealthy behaviors on future health. However, many people do not receive all the recommended services for which they are eligible.

Methods

The Agency for Healthcare Research and Quality identified 4 topics for gathering stakeholder input on evidence and implementation for the equitable delivery of clinical preventive services. These included technology, innovative delivery models, public health linkages, and disparities. For each topic, the authors conducted an environmental scan to identify existing programs or interventions to promote the delivery of clinical preventive services, a technical expert panel meeting, and key informant interviews. The authors synthesized input from each topic's technical expert panel and key informant interviews and used inductive reasoning to identify themes. Within each overarching theme, the authors identified subthemes supported by specific statements, examples, and illustrative quotes.

Results

A total of 90 individuals participated on stakeholder panels, technical expert panels, or key informant interviews; some individuals participated in multiple roles. Across the topics, the authors identified 3 overarching themes from synthesis of the technical expert panel and key informant interview comments across topics: (1) transitioning to holistic healthcare delivery and financing models, (2) including community and patient voice in healthcare system design, and (3) leveraging technology to improve clinical preventive services delivery.

Conclusions

Promoting the equitable delivery of clinical preventive services requires improving access to primary care but also expanding efforts beyond clinical settings to encompass public health and community infrastructure and engagement. Experts recommended that person-centered preventive care should empower patients to make informed decisions about clinical preventive services on the basis of their values, risks, and preferences. This more individualized approach tailored to needs and context may reduce barriers to receipt of clinical preventive services.

The Organization of Academic General Internal Medicine Practice at the Top Primary Care Schools

BACKGROUND

While prior studies have explored staffing infrastructure for primary care practices in general, little is known about the range of academic primary care practice models and supports available for academic general internists.

OBJECTIVE

To characterize the range of practice arrangements and expectations for attending academic physicians in general internal medicine (GIM) practices at the top 22 medical schools across the USA.

DESIGN

Cross-sectional survey administered electronically between October 30, 2022, and December 28, 2022.

PARTICIPANTS

Clinical leaders in GIM at the top 22 primary care medical schools, as identified by the 2023 US News and World Report Rankings.

MAIN MEASURES

Clinical load, productivity expectations, cross-coverage, and team-based care models.

KEY RESULTS

Twenty-two leaders responded, representing 68% (15/22) of medical schools surveyed. The practices were mostly in urban locations (18/22, 82%) and 86% (19/22) included residents. Practices ranged from 7 to 200 PCPs and from 3 to 112 clinical FTEs. A full-time (1.0 FTE) clinical role for academic attending GIM physicians entailed a median of 9 (IQR 8, 10) weekly half-day clinic sessions, with a median panel size expectation of 1600 (IQR 1450, 1850) patients and a median yearly RVU expectation of 5200 (IQR 4161, 5891) yearly RVUs generated. Staff support was most commonly present for prescription refills and patient portal message checks. It was less commonly available for time sensitive form completion. Occasional clinical coverage for other physicians was an expectation at all practices.

CONCLUSIONS

In this study, we characterize the organization of and supports available in academic GIM practices affiliated with the top primary care medical schools. Our findings provide comparative information for leaders of academic GIM practices seeking to enhance primary care delivery for their faculty and trainees. They also highlight areas where standardization may be beneficial across academic GIM.

Automated lifestyle interventions and weight loss: a systematic review of randomized controlled trials

BACKGROUND/OBJECTIVES

Overweight and obesity drive cardiometabolic disease and high-intensity lifestyle interventions are standard. However, many health-systems cannot offer these interventions and many patients cannot participate even when available. Trials have assessed automated digital lifestyle interventions to improve accessibility. This systematic review identified automated digital lifestyle interventions and assessed their impact on weight loss.

SUBJECTS/METHODS

The review (CRD42023435700) identified randomized controlled trials of at least 3-months duration assessing automated digital lifestyle interventions' impact on weight loss. Data were managed through Covidence with double-blinded screening of titles/abstracts and double-blinded full-text review to determine study inclusion. Data extraction was completed by one reviewer (NWC) and verified by a second (MM, JS, TE, CE). The Cochrane Collaboration's tool was used to assess bias risk and study quality was rated as High, Moderate, Low, or Very Low.

RESULTS

The search identified 1817 citations. The full-text of 60 reports were assessed and 17 reports of 16 studies were included. The majority (63%) were of moderate quality. No intervention produced 5% weight loss from baseline. Intervention components with the largest impact were text message encouragement and education with a cognitive behavioral approach. No specific form of self-monitoring was most effective, though some form of self-monitoring was included in most trials.

CONCLUSIONS

Some components of the automated digital lifestyle interventions showed promise. Research is needed to optimize these components (e.g., tailored messaging, cognitive-behavioral approaches) balanced with human contact. Considering the magnitude of the problem and its disproportionate impact on low socioeconomic and minority patients, interventions optimized for effect and scalability are needed to address overweight and obesity.

Connecticut providers knowledge and attitudes towards use of extreme risk protection orders

BACKGROUND

Extreme Risk Protection Orders (ERPOs) are a legislative tool that temporarily restrict firearm access and purchasing ability in patients at risk for harm. Data from four states with ERPO legislation, including Connecticut, estimates 17 to 23 filed ERPOs can prevent 1 suicide. Connecticut medical providers are permitted to independently file an ERPO directly to the courthouse. This survey assesses provider knowledge and attitudes towards use of ERPOs.

METHODS

This study electronically surveyed providers from six hospitals regarding their current knowledge of the Connecticut ERPO law, perceived barriers to the use of the law and procedures that might make use more likely.

RESULTS

114 providers completed the survey in 2022. 66 (57.8%) providers encountered at least 1 patient per year at risk for suicide with firearm access. Only 2 (1.7%) providers had ever initiated an ERPO, but both found it extremely helpful. Only 1 provider was extremely familiar with ERPO while 91 (78.9%) were not familiar. Barriers to using ERPO include negatively impacting the patient relationship, and not enough time to call and follow up. ERPO specific training, and trained on-site coordinators to help file and follow through were ways to encourage to ERPO utilization.

CONCLUSION

The majority of providers encounter at least one patient annually who may benefit from ERPO utilization. However, providers are largely unfamiliar with ERPO and the filing process. Time cost is the greatest barrier to its utilization. Provider training and trained coordinators to process ERPO were the two most requested supports to encourage providers to initiate ERPOs.

Prediction of major liver-related events in the population using prognostic models

Liver disease poses a significant global health burden, with steatotic liver disease related to metabolic dysfunction and/or alcohol use being the most prevalent type. Current risk stratification strategies emphasize detecting advanced fibrosis as a surrogate marker for liver-related events (LREs), such as hospitalization, liver cancer, or death. However, fibrosis alone does not adequately predict imminent outcomes, particularly in fast-progressing individuals without advanced fibrosis at evaluation. This underscores the need for models designed specifically to predict LREs, enabling timely interventions. The Chronic Liver Disease (CLivD) risk score, the dynamic aspartate aminotransferase-to-alanine aminotransferase ratio (dAAR), and the Cirrhosis Outcome Risk Estimator (CORE) were explicitly developed to predict LRE risk rather than detect fibrosis. Derived from general population cohorts, these models incorporate either standard liver enzymes (dAAR and CORE) or risk factors (CLivD), enabling broad application in primary care and population-based settings. They directly estimate the risk of future LREs, improving on traditional fibrosis-focused approaches. Conversely, widely used models like the Fibrosis-4 index and newer ones, such as the LiverRisk and LiverPRO scores, were initially developed to detect significant/advanced fibrosis or liver stiffness. While not designed for LRE prediction, they have later been analyzed for this purpose. Integrating fibrosis screening with LRE-focused models like CLivD, dAAR, and CORE can help healthcare systems adopt proactive, preventive care. This approach emphasizes identifying individuals at imminent risk of severe outcomes, potentially ensuring better resource allocation and personalized interventions.

Identifying, Engaging, and Supporting Care Partners in Clinical Settings: Protocol for a Patient Portal-Based Intervention

BACKGROUND

In the United States, the landscape of unpaid care delivery is both challenging and complex, with millions of individuals undertaking the vital role of helping families (broadly defined) manage their health care and well-being. This includes 48 million caregivers of adults, 42 million of whom are caregivers of adults aged 50 years or older. These family care partners provide critical and often daily support for tasks such as dressing and bathing, as well as managing medications, medical equipment, appointments, and follow-up care plans.

OBJECTIVE

This study aimed to implement a novel patient portal-based intervention to identify, engage, and support care partners in clinical settings.

METHODS

The project team collaborated with 3 health care organizations (6 primary care practices in total) to design and implement a patient portal-based intervention. Three days in advance of a visit, patients were invited to log on to their patient portal account and answer a brief questionnaire as part of the routine electronic check-in process asking them to (1) identify themselves as the patient or someone answering for the patient, (2) report major life changes, (3) set the agenda for the upcoming visit, and (4) report on care partner responsibilities. Respondents' answers to this brief questionnaire were available to providers ahead of the visit. Patients with care partner responsibilities, as well as care partners answering the questionnaire on behalf of patients, were provided a link to the ARCHANGELS Caregiver Intensity Index to measure the intensity of their caregiving role and motivate care partners to connect with suggested state and local resources.

RESULTS

The intervention was launched in September 2022 at Organization A. Organization B launched in May 2023 in one clinic and June 2023 in the other. In focus groups, staff and clinicians reported that the intervention was easy to implement and did not cause workflow disruption. At 6 months post implementation, across both organizations, a total of 22,152 patients had received questionnaires and 13,825 (62.4%) had submitted completed questionnaires. Full data will be reported at the completion of the intervention period.

CONCLUSIONS

Early results suggest that the intervention could be an easily scalable and adaptable method of identifying and supporting care partners in clinical settings.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/66708.

Clinician Prescribing Practices Involving Medications for Alcohol Use Disorder

INTRODUCTION

Despite the heavy toll of alcohol use disorder (AUD) in the U.S., efficacious medications for AUD (MAUD) are rarely used. Minimal research has explored clinician prescribing practices involving MAUD.

METHODS

Using a large national database of electronic health records, this cross-sectional analysis, conducted in 2023-2024, identified clinicians with at least 1 prescription order for an FDA-approved MAUD (naltrexone, acamprosate, or disulfiram) for a patient with AUD during 2016-2021. Descriptive statistics captured clinician-level prescribing volume and type of medication prescribed. Logistic regression models estimated the association between clinician characteristics and number of MAUD patients and type of medications prescribed.

RESULTS

Among the 38,626 clinician-years identified in the EHR data (representing 19,840 unique clinicians), 59% prescribed MAUD to a single patient. Psychiatrists (AOR=4.4, 95% CI=3.8, 4.9) and advanced practice providers (AOR=1.8, 95% CI=1.6, 2.0) were significantly more likely than primary care physicians to prescribe MAUD to 4 or more patients. Clinicians in the top tertile in the percentage of patients with a substance use disorder diagnosis were also more likely to prescribe MAUD to more patients (AOR=8.1, 95% CI=7.1, 9.7). These same clinician characteristics were also associated with greater odds of prescribing more than 1 type of AUD medication.

CONCLUSIONS

Most clinicians prescribing MAUD in a year did so rarely. Policy and health system change is needed to improve clinicians' pharmacologic treatment of AUD, with a focus on primary care physicians, with whom individuals with AUD may have the most frequent contact.

Development and validation of a multivariable Prediction Model for Pre-diabetes and Diabetes using Easily Obtainable Clinical Data

Importance

In the US, pre-diabetes and diabetes are increasing in prevalence alongside other chronic diseases. Hemoglobin A1c is the most common diagnostic test for diabetes performed in the US, but it has known inaccuracies in the setting of other chronic diseases.

Objective

To determine if easily obtained clinical data could be used to improve the diagnosis of pre-diabetes and diabetes compared to hemoglobin A1c alone.

Design Setting and Participants

This cross-sectional study analyzed nationally representative data obtained from six 2-year cycles (2005 to 2006 through 2015 to 2016) of the National Health and Nutrition Examination Survey in the US. We excluded participants without hemoglobin A1c, oral glucose tolerance test, or sample weight data. The sample comprised 13,800 survey participants. Data analyses were performed from May 1, 2024 to February 9, 2025.

Main Outcomes and Measures

We estimated 2-hour glucose from a gradient boosted machine decision tree machine learning model to diagnose pre-diabetes and diabetes as defined by oral glucose tolerance test 2-hour glucose of greater than or equal to 140 mg/dL but less than 200 mg/dL and greater than or equal to 200 mg/dL, respectively. We compared the area-under-the-receiver-operating-curve (AUROC), the calibration, positive predictive value, and the net benefit by decision curve analysis to hemoglobin A1C alone.

Results

A 20-feature Model outperformed the hemoglobin A1c and fasting plasma glucose for diagnosis, with AUROC improvement from 0.66/0.71 to 0.77 for pre-diabetes and from 0.87/0.88 to 0.91 for diabetes. The Model also had improved positive predictive value compared to the A1c for diagnosis and for net benefit on decision curve analysis. Main features that improved diagnosis of pre-diabetes and diabetes were the standard vitals: age, height, weight, waist circumference, blood pressure, pulse, the fasting labs plasma glucose, insulin, triglycerides, and iron, the non-fasting labs cholesterol, gamma-glutamyl transferase, creatinine, platelet count, segmented neutrophil percentage, urine albumin, and urine creatinine, and the social determinant of health factor Poverty Ratio.

Conclusions and Relevance

In this cross-sectional study of NHANES participants, we identified risk factors that could be incorporated into the electronic medical record to identify patients with potentially undiagnosed pre-diabetes and diabetes. Implementation could improve diagnosis and lead to earlier intervention on disease before it becomes severe and complications develop.

Key Points

Question: Can readily-available clinical data improve diagnosis of pre-diabetes and diabetes compared to hemoglobin A1c testing alone?Findings: In this cross-sectional study of 13,800 adults with paired hemoglobin A1c and oral glucose tolerance testing in the National Health and Nutrition Examination Survey, the rate of pre-diabetes undiagnosed by 8.6% and rate of diabetes undiagnosed by the hemoglobin A1c was 3.5%. A novel multivariable prediction model that included fasting plasma glucose, insulin, basic body measurements, and routinely available dyslipidemia and hepatic function labs for was significantly more accurate (AUROC 0.66/0.71 to 0.77 for pre-diabetes, 0.87/0.88 to 0.91 for diabetes) than hemoglobin A1C or fasting plasma glucose alone.Meaning: Incorporation of easily obtainable clinical data can improve diagnosis of pre-diabetes and diabetes compared to hemoglobin A1C alone.

Telemedicine and time management in primary care

BACKGROUND

Information and communication technologies (ICTs) can enable workers to structure work in novel ways, allow for better time management, and increase work scheduling autonomy. Time management and work scheduling are important factors in the field of clinical practice in primary care. Time limits on consultation are a key constraint on the delivery of good care since the length of patient-physician consultation impacts its quality.

OBJECTIVES

This research aimed to examine the experiences of primary care physicians (PCPs) when using telemedicine technologies (TTs), a type of ICT, in their communication with patients.

METHODS

During 2023 in-depth interviews were conducted with 20 Israeli PCPs: family physicians and pediatricians.

FINDINGS

Perception and management of time emerged as a focal subject in the interviews. The PCPs interviewed described several effects of TTs on time management in primary care. They portrayed TTs as saving time for patients and having a mixed effect on the healthcare organization: both saving and wasting their work time. TTs were described as impacting their time management in the context of work-life balance, allowing them to manage their time during and between appointments.

DISCUSSION

For PCPs, TTs can be beneficial for managing time in the clinic, which can contribute to better healthcare. This article, concerning TTs as a type of ICT, contributes to the existing literature which suggests that ICTs can allow for better time management and increase work scheduling autonomy. It also presents several recommendations for better implementation of TTs in healthcare organizations.

Recommendations for Clinicians, Technologists, and Healthcare Organizations on the Use of Generative Artificial Intelligence in Medicine: A Position Statement from the Society of General Internal Medicine

Generative artificial intelligence (generative AI) is a new technology with potentially broad applications across important domains of healthcare, but serious questions remain about how to balance the promise of generative AI against unintended consequences from adoption of these tools. In this position statement, we provide recommendations on behalf of the Society of General Internal Medicine on how clinicians, technologists, and healthcare organizations can approach the use of these tools. We focus on three major domains of medical practice where clinicians and technology experts believe generative AI will have substantial immediate and long-term impacts: clinical decision-making, health systems optimization, and the patient-physician relationship. Additionally, we highlight our most important generative AI ethics and equity considerations for these stakeholders. For clinicians, we recommend approaching generative AI similarly to other important biomedical advancements, critically appraising its evidence and utility and incorporating it thoughtfully into practice. For technologists developing generative AI for healthcare applications, we recommend a major frameshift in thinking away from the expectation that clinicians will "supervise" generative AI. Rather, these organizations and individuals should hold themselves and their technologies to the same set of high standards expected of the clinical workforce and strive to design high-performing, well-studied tools that improve care and foster the therapeutic relationship, not simply those that improve efficiency or market share. We further recommend deep and ongoing partnerships with clinicians and patients as necessary collaborators in this work. And for healthcare organizations, we recommend pursuing a combination of both incremental and transformative change with generative AI, directing resources toward both endeavors, and avoiding the urge to rapidly displace the human clinical workforce with generative AI. We affirm that the practice of medicine remains a fundamentally human endeavor which should be enhanced by technology, not displaced by it.

Colorectal Cancer (CRC) Screening in Occupational Health Surveillance Exams Is Associated With Decreased CRC Mortality

BACKGROUND

Colorectal cancer (CRC) screening is recommended for adults aged 45 to 75. Using data from a national screening program, we examined the impact of CRC screening in a population with occupational exposures.

METHODS

Since 1998, the Building Trades National Medical Screening Program (BTMed) has offered CRC screening every 3 years. Tests used were: guaiac fecal occult blood test (gFOBT), 1998-2008; high sensitivity (HS)-gFOBT, 2009-2015; and fecal immunochemical test (FIT) since 2015. Data from the National Death Index through December 31, 2021 were used to compute standardized mortality ratios (SMRs) to compare the mortality experience of exam participants to nonparticipants. Internal analyses used Poisson regression and Cox regression to evaluation impact of CRC screening participation on CRC mortality.

RESULTS

Participation in gFOBT was 68.2%; HS-gFOBT, 78.7%; and FIT, 85.9%. The SMR for CRC was significantly higher for BTMed exam nonparticipants (SMR = 2.04, 95% CI 1.40-2.86) than exam participants (SMR = 1.07, 95% CI 0.88-1.28). Impact of CRC screening participation on reducing CRC mortality by type of test was 2% for gFOBT, 12% for HS-FOBT, and 61% for FIT.

DISCUSSION

This study found higher CRC screening participation than in the general population, with mortality reduction from screening similar to what is found in the general population, even though BTMed screening was conducted every 3 years rather than annually.

CONCLUSIONS

Participation in CRC screening had a significant impact on CRC mortality. Innovations in stool tests have led to greater convenience, participation, and impact, particularly for the FIT test. Occupational health practices should consider including CRC screening.

Enhancing access to primary care is critical to the future of an equitable health service: using process visualisation to understand the impact of national policy in the UK

Access to UK general practice is complicated by the need to provide equitable and universal care within a system adapting to workforce challenges, digital innovation, and unprecedented demand. Despite the importance of accessing primary care in meeting the overall aim of delivering equitable care, this is the first time the direct and indirect influence of policies intended to facilitate access have been systematically explored. Further consideration by policymakers is needed to accommodate the difference between what patients need and what patients want when accessing primary care, and the differences in their ability to utilise digital options. The designation of care was hindered by long-standing issues of reliable data and variations in the interpretation of local and national protocols and guidelines.

Mind the gap in kidney care: Translating what we know into what we do

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Primary care in the COVID-19 pandemic and beyond: Lessons from Ontario

OBJECTIVE

To understand the role of primary care in the COVID-19 pandemic to provide insight into its functioning and inform potential reforms.

COMPOSITION OF THE COMMITTEE

The now dissolved Ontario COVID-19 Science Advisory Table (Science Table) was formed in July 2020 to provide decision makers and the public with a synthesis of rapidly evolving evidence related to COVID-19. The Science Table was based at the Dalla Lana School of Public Health at the University of Toronto, and supported by Public Health Ontario.

METHODS

Authors worked with the leadership and secretariat of the Science Table to synthesize evidence and inputs. Authors drew on their expertise in research, policy, and front-line care delivery and coupled this with data analysis and reviews of the literature relevant to the topic areas discussed. Data analysis and literature reviews were done with the support of the Ontario Medical Association, the INSPIRE-Primary Health Care research program, and the Department of Family and Community Medicine at the University of Toronto. Experts conducted a rapid review of the briefs prior to publication, and authors presented the briefs' content at a series of meetings attended by Science Table members for their input. As Science Table briefs were intended to provide rapid-response answers to important health system questions in real time, the intent was not to conduct a systematic review but rather to gather available relevant evidence and present it in a form that could be used by policy-makers.

REPORT

This summary describes the work of primary care during the COVID-19 pandemic in Ontario up to September 2022; outlines current challenges in primary care capacity and structure; and makes recommendations for strengthening the sector to better address population needs for current and future public health priorities. While the focus is on Ontario, many of the findings are relevant to other jurisdictions in Canada and elsewhere.

CONCLUSION

Universal formal attachment to an accountable interprofessional primary care team supported by adequate infrastructure should be the cornerstone of pandemic recovery planning.

Resource Management Challenges in Rural Dermatological Care: A Mapping Review

Skin cancer prevalence in the United States is rapidly on the rise, particularly in rural communities where individuals are subjected to heavy sunlight exposure through occupations such as agricultural work and construction. These geographic regions are often lacking in dermatologic specialty care, thus increasing the disease burden of skin conditions in primary care settings. Access barriers to specialized dermatology care are exacerbated by prolonged wait times to schedule an appointment, travel demands, and a relative paucity of dermatology providers in rural areas as compared to urban areas. In rural communities, the high burden of skin diseases, the logistical challenges, and the shortage of dermatologists lead to increased reliance on primary care physicians (PCPs) for dermatological care. This review aims to identify barriers to dermatology care in rural communities, understand challenges faced by PCPs related to dermatological management, and explore modalities that are currently being used to streamline clinical workflows for PCPs. Dermatology training for PCPs consists primarily of pre-clinical exposure to the field, and it has been reported that there is a relative lack of opportunity for training to further enhance postgraduate dermatology knowledge. Recent studies demonstrate that novel educational and infrastructural support to primary care clinics has had substantial positive impacts on the ability of primary caregivers to provide accurate, cost-effective dermatologic care in addressing skin conditions, as well as increasing diagnostic confidence. Regular skin examinations, dermoscopy, and digital transformation of images are also shown to improve detection and diagnostic accuracy. Interventions like the use of smartphones, teledermatology, and dermoscopy show potential for improving care but must be thoroughly evaluated for effectiveness before widespread adoption in primary care settings.

Determining Patient Panel Size in Primary Care: A Meta-Narrative Review

The optimal patient panel size (PPS) in primary care and the factors determining it remain unclear. We conducted a meta-narrative review of the literature to evaluate factors influencing PPS and assess its association with patient outcomes. A comprehensive search of electronic databases was performed from inception through December 2023, focusing on original studies reporting factors used to determine PPS and related outcomes (eg, clinical outcomes, process measures, and resource utilization). A total of 48 studies were included, identifying 7 key factors influencing PPS. Smaller panels were associated with improved patient satisfaction, continuity of care, and health promotion, while clinical outcomes, utilization, and costs showed minimal impact by PPS. Panel size was primarily associated with patient age, sex, comorbidities, and practice type and structure. Community-based centers typically managed smaller panels, often staffed by female clinicians and serving socioeconomically disadvantaged populations with greater health needs than hospital-based practices. Female clinicians were also independently associated with managing smaller panels, higher quality care indicators, fewer emergency department visits, and improved patient satisfaction. Determining the ideal PPS is a multifaceted process influenced by practice setting, patient demographics, and clinician characteristics. While practice-related factors showed limited association with PPS, patient-reported outcomes were more closely linked to it. Primary care practices should tailor panel sizes to their patient populations, emphasizing a patient-centered approach and ensuring adequate infrastructure support to optimize care delivery.

Barriers to Integrating Tobacco Dependence Treatment into Lung Cancer Screening: A Qualitative Assessment

INTRODUCTION/OBJECTIVE

We qualitatively assessed current practices and perceived barriers surrounding the integration of tobacco dependence treatment (TDT) into lung cancer screening (LCS).

METHODS

Informed by the Practical, Robust Implementation and Sustainability Model, we conducted semi-structured interviews with clinicians (n = 18) at 6 Veterans Affairs medical centers in the Midwest.

RESULTS

TDT was usually addressed at an initial shared decision-making visit but often not with subsequent rounds of screening or nodule follow-up. No site was aware that any TDT-related outcomes were tracked within their program. While the LCS clinical reminders included some aspects of tobacco use (eg, tobacco pack-years), they did not support clinicians in offering TDT or capture outcomes and were perceived as "checkboxes to nowhere." This was contrasted with other clinical reminders linked to dashboards that provide rolling feedback for important clinical outcomes (eg, diabetes care). Interviewees reported competing demands and limited expertise in motivational interventions as additional barriers. A dedicated team for TDT and a "one-click referral" were perceived as key success factors.

CONCLUSIONS

TDT remains poorly integrated into LCS. Addressing identified barriers will require considerable investment in TDT resources and improvements to LCS tools to support the provision of cessation support.

Point of view: Challenges in implementation of new immunotherapies for Alzheimer's disease

The advancement of disease-modifying treatments (DMTs) for Alzheimer's disease (AD), along with the approval of three amyloid-targeting therapies in the US and several other countries, represents a significant development in the treatment landscape, offering new hope for addressing this once untreatable chronic progressive disease. However, significant challenges persist that could impede the successful integration of this class of drugs into clinical practice. These challenges include determining patient eligibility, appropriate use of diagnostic tools and genetic testing in patient care pathways, effective detection and monitoring of side effects, and improving the healthcare system's readiness by engaging both primary care and dementia specialists. Additionally, there are logistical concerns related to infrastructure, as well as cost-effectiveness and reimbursement issues. This article brings together insights from a diverse group of international researchers and dementia experts and outlines the potential challenges and opportunities, urging all stakeholders to prepare for the introduction of DMTs. We emphasize the need to develop appropriate use criteria, including patient characteristics, specifically for the European healthcare system, to ensure that treatments are administered to the most suitable patients. It is crucial to improve the skills and knowledge of physicians to accurately interpret biomarker results, share decision-making with patients, recognize treatment-related side effects, and monitor long-term treatment. We advocate for investment in patient registries and unbiased follow-up studies to better understand treatment effectiveness, evaluate treatment-related side effects, and optimize long-term treatment. Utilizing amyloid-targeting therapies as a starting point for combination therapies should also be a priority.

Mind the gap in kidney care: translating what we know into what we do

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

Knowledge, Attitude and Practice Regarding Nonsteroidal Anti-inflammatory Drugs and Corticosteroids Use Among Patients With Chronic Rheumatology Condition: A Cross-Sectional Study From Vietnam

Objectives

To identify gaps in knowledge, attitude, and practice regarding the use of corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) among patients with chronic rheumatic diseases.

Methods

A cross-sectional study was conducted using a questionnaire including 12 knowledge questions, 13 attitude assessment statements, 5 barrier assessment statements, and 7 practical scenarios. We counted the total numbers of correct answers in knowledge, positive attitudes, barriers, and appropriate practices and fitted using Poisson regression to examine factors associated with knowledge, attitudes, and practices.

Results

A total of 182 participants were included in this study, a large proportion of them had never heard of corticosteroids (34%) and NSAIDs (54%) before. Physicians were the source of information regarding corticosteroids and NSAIDs in 83% and 84% of the cases, respectively. Gastric ulcer was the most commonly recognized adverse drug reaction (ADR) for corticosteroids (64%) and the only ADR recognized for NSAIDs (95%), while only few patients were aware of life-threatening ADRs. The primary barrier, with a 40% agreement, was health care providers' time constraints in providing medication information to patients. Our study findings did not reveal any gaps in practice, nor did they show any correlation between patients' knowledge and attitudes to the practice of using corticosteroids and NSAIDs.

Conclusion

There were gaps in knowledge, attitudes, and barriers to information access regarding NSAIDs and corticosteroid use in Vietnamese patients with chronic rheumatic diseases. Potential solutions include allocating more time for information exchange between physicians and patients, creating new channels to provide reliable information for patients, and emphasizing the important ADRs.

Evaluation of the German living guideline "Protection against the Overuse and Underuse of Health Care" - an online survey among German GPs

BACKGROUND

The aim of this study was to evaluate the awareness and use of the German guideline "Protection against the overuse and underuse of health care" from the general practitioners' (GPs') perspective. In addition, the study assessed how GPs perceive medical overuse and what solutions they have for reducing it.

METHODS

We performed a cross-sectional online survey with recruitment from 15.06. to 31.07.2023. Participants were members of the German College of General Practitioners and Family Physicians (DEGAM). The main outcomes were the awareness and use of the guideline.

RESULTS

The analysis included data from 626 physicians. 51% were female and the median age was 50 years. The guideline is known by 81% of the participants, 32% read it in more detail. The majority considered the guideline a helpful tool in reducing overuse (67%). Almost 90% wished to have more guidelines with clear do-not-do recommendations. Physicians indicated in mean (M) that 30.2% (SD = 19.3%) of patients ask them for medical services that they do not consider to be necessary and that M = 30.2% (SD = 18.1%) of all GP services can be attributed to medical overuse. About half of the participants thought that overuse is a moderate or major problem in their practice (52%) and in general practice overall (58%). More participants rated that it is especially a problem in specialist (87%) and inpatient care (82%). Changes in the reimbursement system, raising awareness for the problem and more evidence-based guidelines were considered helpful in mitigating overuse.

CONCLUSIONS

Although the guideline is seen as a useful tool in mitigating medical overuse, there is still further potential for its implementation and utilisation. GPs see more overuse in the inpatient and outpatient specialist areas than in their area of practice. Instead of self-critically approaching the problem, the proposed strategies are aimed at the healthcare system itself.

Combined telemedicine-first and direct primary care as a promising model of healthcare delivery

Telemedicine is comparable in quality to in-person care, adequate for many primary care concerns, acceptable to patients, and can overcome barriers to care. However, patients are reluctant to pay the same for telemedicine as in-person care and uncertainty about future payor reimbursement makes it risky to base a clinical practice primarily on telemedicine. Physical exam-supported information collection and relationship-building are limited in telemedicine, but can be mitigated through remote patient monitoring and ample access to a provider and clinical team. Subscription-based direct primary care models disconnect payment from episodes of care, which can support enhanced communication between the patient and care team and support time for asynchronous tasks such as remote patient monitoring data review. A "telemedicine first, direct primary care" model in which most care is provided through telemedicine and financed via subscription would retain the convenience of telemedicine, mitigate relationship-limiting deficiencies due to the lack of physical contact, and provide a stable revenue stream to support a telemedicine-based approach to care. Paired with specialist access via eConsults and options to refer to in-person care when necessary, this model would support telemedicine as the foundation for practice and connect underserved populations to primary and specialty care.

Stepwise identification of prodromal dementia: Testing a practical model for primary care

BACKGROUND

Prodromal dementia is largely underdiagnosed in primary care.

OBJECTIVE

To develop a clinical model for detecting prodromal dementia within the operative boundaries of primary care practice.

METHODS

The study employed the Functional Activities Questionnaire (FAQ) and Montreal Cognitive Assessment (MoCA) to evaluate a "functional-cognitive" step-down screening model, in which the MoCA is administered subsequent to reported symptoms on the FAQ. It classified participants from the Alzheimer's Disease Imaging Initiative to three diagnostic categories: (1) healthy cognition (n = 396), (2) mild cognitive impairment without conversion (n = 430), and (3) prodromal dementia assessed 24 months before diagnosis (n = 164).

RESULTS

Analyses indicated that the step-down model (Model 1) performed significantly better than an alternative model that applied the FAQ as a single measure (Model 2) and compared well with another model that administered both screening measures to all participants (Model 3). Gradient Boosting Trees classifications yielded the following estimations for Model 1/Model 2/ Model 3, respectively: Sensitivity = 0.87/0.77/0.89, Specificity = 0.68/0.47/0.70, PPV = 0.73/0.40/0.75, NVP = 0.84/0.81/0.87, F1 Score = 0.79/0.52/0.81, AUC = 0.78/0.67/0.79.

CONCLUSIONS

These analyses support the proposed model. The study offers algorithms for validated measures, which were developed from a well characterized clinical sample. Their accuracy will likely improve further with new data from diverse clinical settings. These results can serve primary care in a timely manner in light of the recent advances in pharmacological treatment of dementia and the expected increase in demand for screening.

"Being ill was the easy part": exploring cancer survivors' reactions to perceived challenges in engaging with primary healthcare

PURPOSE

Cancer survivors experience barriers to primary healthcare (PHC) services. The aim was to explore reactions to and opinions about perceived challenges associated with PHC access and quality among cancer survivors in Sweden, including how they have acted to adapt to challenges.

METHODS

Five semi-structured focus group interviews were conducted with cancer survivors (n = 20) from Skåne, Sweden, diagnosed with breast, prostate, lung, or colorectal cancer or malignant melanoma. Focus groups were mixed in regard to diagnosis. Data were analysed using a descriptive template analysis approach.

RESULTS

In light of perceived challenges associated with access to adequate PHC, participants experienced that they had been forced to work hard to achieve functioning PHC contacts. The demands for self-sufficiency were associated with negative feelings such as loneliness and worry. Participants believed that cancer survivors who lack the ability to express themselves, or sufficient drive, risk missing out on necessary care due to the necessity of being an active patient.

CONCLUSIONS

The findings highlight negative patient experiences. They have implications for the organization of care for cancer survivors as they indicate a need for more efficient post-treatment coordination between cancer specialist care and PHC providers, as well as increased support for patients leaving primary cancer treatment.

Opportunity and Opportunism in Artificial Intelligence-Powered Data Extraction: A Value-Centered Approach

Radiologists' traditional role in the diagnostic process is to respond to specific clinical questions and reduce uncertainty enough to permit treatment decisions to be made. This charge is rapidly evolving due to forces such as artificial intelligence (AI), big data (opportunistic imaging, imaging prognostication), and advanced diagnostic technologies. A new modernistic paradigm is emerging whereby radiologists, in conjunction with computer algorithms, will be tasked with extracting as much information from imaging data as possible, often without a specific clinical question being posed and independent of any stated clinical need. In addition, AI algorithms are increasingly able to predict long-term outcomes using data from seemingly normal examinations, enabling AI-assisted prognostication. As these algorithms become a standard component of radiology practice, the sheer amount of information they demand will increase the need for streamlined workflows, communication, and data management techniques. In addition, the provision of such information raises reimbursement, liability, and access issues. Guidelines will be needed to ensure that all patients have access to the benefits of this new technology and guarantee that mined data do not inadvertently create harm. In this Review, we discuss the challenges and opportunities relevant to radiologists in this changing landscape, with an emphasis on ensuring that radiologists provide high-value care.

Inbox message prioritization and management approaches in primary care

Objectives

Patient messaging to clinicians has dramatically increased since the pandemic, leading to informatics efforts to categorize incoming messages. We examined how message prioritization (as distinct from categorization) occurs in primary care, and how primary care clinicians managed their inbox workflows.

Materials and Methods

Semi-structured interviews and inbox work observations with 11 primary care clinicians at MedStar Health. We analyzed interview and observation transcripts and identified themes and subthemes related to prioritization and inbox workflows.

Results

Clinicians widely reported that they did not prioritize messages due to time constraints and the necessity of attending to all messages, which made any prioritization purely additive to overall inbox time. We identified 6 themes and 14 subthemes related to managing inbox workloads. The top themes were (1) establishing workflow norms with different teams, primarily medical assistants (MAs); (2) boundary-setting with patients, other clinicians, and with themselves; and (3) message classification heuristics that allowed clinicians to mentally categorize messages that required follow-up, messages that could be quickly deleted or acknowledged, and purely informational messages that ranged in clinical utility from tedious to valuable for care coordination.

Discussion

Time constraints in primary care prevent clinicians from prioritizing their inbox messages for increased efficiency. Involvement of MAs and co-located staff was successful; however, standardization was needed for messaging workflows that involved centralized resources like call centers. Organizations should consider ways in which they can support the establishment and maintenance of boundaries, to avoid this responsibility falling entirely on clinicians.

Conclusion

Clinicians generally lack the time to prioritize patient messages. Future research should explore the efficacy of collaborative inbox workflows for time-savings and management of patient messages.

Developing a prediction model for cognitive impairment in older adults following critical illness

BACKGROUND

New or worsening cognitive impairment or dementia is common in older adults following an episode of critical illness, and screening post-discharge is recommended for those at increased risk. There is a need for prediction models of post-ICU cognitive impairment to guide delivery of screening and support resources to those in greatest need. We sought to develop and internally validate a machine learning model for new cognitive impairment or dementia in older adults after critical illness using electronic health record (EHR) data.

METHODS

Our cohort included patients > 60 years of age admitted to a large academic health system ICU in North Carolina between 2015 and 2021. Patients were included in the cohort if they were admitted to the ICU for ≥ 48 h with ≥ 2 ambulatory visits prior to hospitalization and at least one visit in the post-discharge year. We used a machine learning model, oblique random survival forests (ORSF), to examine the multivariable association of 54 structured data elements available by 3 months after discharge with incident diagnoses of cognitive impairment or dementia over 1-year.

RESULTS

In this cohort of 8,299 adults, 22% died and 4.9% were diagnosed with dementia or cognitive impairment within one year. The ORSF model showed reasonable discrimination (c-statistic = 0.83) and stability with little difference in the model's c-statistic across time.

CONCLUSION

Machine learning using readily available EHR data can predict new cognitive impairment or dementia at 1-year post-ICU discharge in older adults with acceptable accuracy. Further studies are needed to understand how this tool may impact screening for cognitive impairment in the post-discharge period.

Patterns of gastroenterology specialty referral for primary care patients with metabolic dysfunction-associated steatotic liver disease

BACKGROUND

As metabolic dysfunction-associated steatotic liver disease (MASLD) management extends into primary care, little is known about patterns of specialty referral for affected patients. We determined the proportion of primary care patients with MASLD that received a gastroenterology (GI) consultation and compared advanced fibrosis risk between patients with and without a referral.

METHODS

This retrospective study of electronic health record data from a primary care clinic included patients with MASLD, no competing chronic liver disease diagnoses, and no history of cirrhosis. Referral to GI for evaluation and management (E/M) any time after MASLD ascertainment was the outcome. Fibrosis-4 Index (FIB-4) scores were calculated, categorized by advanced fibrosis risk, and compared by receipt of a GI E/M referral. Logistic regression models were developed to determine the association of FIB-4 risk with receipt of a GI referral.

RESULTS

The cohort included 652 patients of which 12% had FIB-4 scores (≥2.67) at high-risk for advanced fibrosis. Overall, 31% of cohort patients received a GI referral for E/M. There was no difference in the proportion of patients with high (12% vs. 12%, p=0.952) risk FIB-4 scores by receipt of a GI E/M referral. In adjusted logistic regression models, high-risk FIB-4 scores (OR 1.01; 95% CI 0.59 - 1.71) were not associated with receipt of a referral.

CONCLUSIONS

Only 30% of patients in this primary care MASLD cohort received a GI E/M referral during the study period, and those patients with a referral did not differ by FIB-4 advanced fibrosis risk.

L-Thyroxin bei Hypothyreose – absetzen oder nicht?

Hintergrund

L‑Thyroxin ist eines der am häufigsten verordneten Arzneimittel in Deutschland. Es wird hauptsächlich zur Behandlung der Hypothyreose eingesetzt. Aufgrund von Verordnungsdaten ist davon auszugehen, dass L‑Thyroxin häufiger verordnet wird als es medizinisch indiziert ist.

Ziel der Arbeit

Sind hausärztlich Tätige bereit, Dosisreduktionen oder Absetzversuche von L‑Thyroxin vorzunehmen?

Methodik

Auf der Jahrestagung der Sächsischen Gesellschaft für Allgemeinmedizin erfolgte eine Querschnittserhebung mittels Fragebogen. Dieser beinhaltete 3 konstruierte Fälle, deren L‑Thyroxin-Therapie auf Änderungspotenzial zu bewerten war. Es erfolgte eine deskriptive Analyse der quantitativen Daten sowie eine qualitative Inhaltsanalyse.

Ergebnisse

Insgesamt nahmen 33 hausärztlich Tätige an der Befragung teil. Am häufigsten wurde eine Beibehaltung der Dosis oder sogar eine Dosiserhöhung favorisiert. Dies wurde mit guter Therapieeinstellung, mutmaßlich fehlendem Nachteil einer geringen Dosis oder der Vermeidung von Komplikationen begründet. Selten wurde eine Reduktion oder ein Absetzen vorgeschlagen. Für das Absetzen oder Dosisreduktion wurde sich mit Verweis auf die fehlende medizinische Indikation ausgesprochen.

Diskussion

Auch bei fehlender medizinischer Indikation waren die Teilnehmenden zurückhaltend, eine bestehende Therapie zu verändern. Dies deckt sich mit Angaben aus der existierenden Literatur. Die Annahme der Vermeidung von Folgeerkrankungen, begrenzte Zeit für Beratungsgespräche und mangelnde Kommunikation zwischen Verordnenden wurden in anderen Studien als Ursachen identifiziert. Dabei gibt es Hinweise auf den Nutzen von Deprescribing. Es besteht diesbezüglich im deutschen primärärztlichen Bereich noch großer Forschungsbedarf.

Diabetes Management: A Case Study to Drive National Policy Change in Primary Care Settings

Despite medical advances, diabetes management remains a considerable challenge in the United States, with little to no improvement in patient outcomes and stark disparities in underserved communities. One acute challenge is that, as the US population with diabetes grows steadily-numbering 38.4 million people today-there are too few endocrinologists available to treat the disease and the burdens on primary care professionals, who treat more than 90% of cases currently, are staggering. This disconnect between need and care capacity presents what may be the greatest of many threats to the care of diabetic Americans. To understand what is required to solve this need-to-capacity mismatch, we examine the critical role of primary care professionals and propose national policy approaches to empower and improve the nation's primary care architecture for the nearly 12% of Americans who have diabetes. Policy recommendations encompass the integration of the chronic care model and the patient-centered medical home approach, expansion of workforce development initiatives, and payment reform to incentivize team-based care with the aim of ensuring equitable access to essential diabetes management tools. We urge policy makers to prioritize primary care workforce development, enhance reimbursement models, and implement strategies to mitigate disparities in diabetes care. Evidence reviewed here highlights the critical need for a comprehensive, multidimensional approach to diabetes management in primary care, emphasizing the importance of decisive action by policy makers to equip primary care professionals with the necessary resources and support to effectively address the nation's diabetes epidemic.

Clinically sound and person centred: streamlining clinical decision support guidance for multiple long-term condition care

The care of people with multiple long-term conditions (MLTCs) is complex and time-consuming, often denying them the agency to self-manage their conditions-or for the clinician they visit to provide streamlined, person-centred care. We reconfigured The Practical Approach to Care Kit, our established, evidence-based, policy-aligned clinical decision support tool for low-resource primary care settings, to provide consolidated clinical guidance for a patient journey through a primary care facility. This places the patient at the centre of that journey and shifts the screening, monitoring and health education activities of multimorbidity care more equitably among the members of the primary care team. This work forms part of a study called ENHANCE, exploring how best to streamline MLTC care in South Africa with its high burden of communicable, non-communicable and mental health conditions. This practice paper describes the four steps of codeveloping this clinical decision support tool for eleven common long-term conditions with local stakeholders (deciding the approach, constructing the content, clinical editing, and design and formatting) along with the features of the tool designed to facilitate its usability at point of care. The process highlighted tensions around prioritising one condition over another, curative over preventive treatment and pharmacological therapies over advice-giving, along with the challenges of balancing the large volume of content with a person-centred approach. If successful, the tool could augment the response to MLTC care in South Africa and other low-resource settings. In addition, our development process may contribute to scant literature around methodologies for clinical decision support development.

Proof-of-concept study of a small language model chatbot for breast cancer decision support - a transparent, source-controlled, explainable and data-secure approach

PURPOSE

Large language models (LLM) show potential for decision support in breast cancer care. Their use in clinical care is currently prohibited by lack of control over sources used for decision-making, explainability of the decision-making process and health data security issues. Recent development of Small Language Models (SLM) is discussed to address these challenges. This preclinical proof-of-concept study tailors an open-source SLM to the German breast cancer guideline (BC-SLM) to evaluate initial clinical accuracy and technical functionality in a preclinical simulation.

METHODS

A multidisciplinary tumor board (MTB) is used as the gold-standard to assess the initial clinical accuracy in terms of concordance of the BC-SLM with MTB and comparing it to two publicly available LLM, ChatGPT3.5 and 4. The study includes 20 fictional patient profiles and recommendations for 5 treatment modalities, resulting in 100 binary treatment recommendations (recommended or not recommended). Statistical evaluation includes concordance with MTB in % including Cohen's Kappa statistic (κ). Technical functionality is assessed qualitatively in terms of local hosting, adherence to the guideline and information retrieval.

RESULTS

The overall concordance amounts to 86% for BC-SLM (κ = 0.721, p < 0.001), 90% for ChatGPT4 (κ = 0.820, p < 0.001) and 83% for ChatGPT3.5 (κ = 0.661, p < 0.001). Specific concordance for each treatment modality ranges from 65 to 100% for BC-SLM, 85-100% for ChatGPT4, and 55-95% for ChatGPT3.5. The BC-SLM is locally functional, adheres to the standards of the German breast cancer guideline and provides referenced sections for its decision-making.

CONCLUSION

The tailored BC-SLM shows initial clinical accuracy and technical functionality, with concordance to the MTB that is comparable to publicly-available LLMs like ChatGPT4 and 3.5. This serves as a proof-of-concept for adapting a SLM to an oncological disease and its guideline to address prevailing issues with LLM by ensuring decision transparency, explainability, source control, and data security, which represents a necessary step towards clinical validation and safe use of language models in clinical oncology.

Building machines that learn and think with people

What do we want from machine intelligence? We envision machines that are not just tools for thought but partners in thought: reasonable, insightful, knowledgeable, reliable and trustworthy systems that think with us. Current artificial intelligence systems satisfy some of these criteria, some of the time. In this Perspective, we show how the science of collaborative cognition can be put to work to engineer systems that really can be called 'thought partners', systems built to meet our expectations and complement our limitations. We lay out several modes of collaborative thought in which humans and artificial intelligence thought partners can engage, and we propose desiderata for human-compatible thought partnerships. Drawing on motifs from computational cognitive science, we motivate an alternative scaling path for the design of thought partners and ecosystems around their use through a Bayesian lens, whereby the partners we construct actively build and reason over models of the human and world.