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Stults CD, Mazor KM, Cheung M, Ruo B, Li M, Walker A, Saphirak C, Vaida F, Singh S, Fisher KA, Rosen R, Yood R, Garber L, Longhurst C, Kallenberg G, Yu E, Chan A, Millen M, Tai-Seale M. Patients' Perspectives on Plans Generated During Primary Care Visits and Self-Reported Adherence at 3 Months: Data From a Randomized Trial. J Particip Med 2024; 16:e50242. [PMID: 38483458 PMCID: PMC10979329 DOI: 10.2196/50242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/02/2023] [Accepted: 11/12/2023] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Effective primary care necessitates follow-up actions by the patient beyond the visit. Prior research suggests room for improvement in patient adherence. OBJECTIVE This study sought to understand patients' views on their primary care visits, the plans generated therein, and their self-reported adherence after 3 months. METHODS As part of a large multisite cluster randomized pragmatic trial in 3 health care organizations, patients completed 2 surveys-the first within 7 days after the index primary care visit and another 3 months later. For this analysis of secondary outcomes, we combined the results across all study participants to understand patient adherence to care plans. We recorded patient characteristics and survey responses. Cross-tabulation and chi-square statistics were used to examine bivariate associations, adjusting for multiple comparisons when appropriate. We used multivariable logistic regression to assess how patients' intention to follow, agreement, and understanding of their plans impacted their plan adherence, allowing for differences in individual characteristics. Qualitative content analysis was conducted to characterize the patient's self-reported plans and reasons for adhering (or not) to the plan 3 months later. RESULTS Of 2555 patients, most selected the top box option (9=definitely agree) that they felt they had a clear plan (n=2011, 78%), agreed with the plan (n=2049, 80%), and intended to follow the plan (n=2108, 83%) discussed with their provider at the primary care visit. The most common elements of the plans reported included reference to exercise (n=359, 14.1%), testing (laboratory, imaging, etc; n=328, 12.8%), diet (n=296, 11.6%), and initiation or adjustment of medications; (n=284, 11.1%). Patients who strongly agreed that they had a clear plan, agreed with the plan, and intended to follow the plan were all more likely to report plan completion 3 months later (P<.001) than those providing less positive ratings. Patients who reported plans related to following up with the primary care provider (P=.008) to initiate or adjust medications (P≤.001) and to have a specialist visit were more likely to report that they had completely followed the plan (P=.003). Adjusting for demographic variables, patients who indicated intent to follow their plan were more likely to follow-through 3 months later (P<.001). Patients' reasons for completely following the plan were mainly that the plan was clear (n=1114, 69.5%), consistent with what mattered (n=1060, 66.1%), and they were determined to carry through with the plan (n=887, 53.3%). The most common reasons for not following the plan were lack of time (n=217, 22.8%), having decided to try a different approach (n=105, 11%), and the COVID-19 pandemic impacted the plan (n=105, 11%). CONCLUSIONS Patients' initial assessment of their plan as clear, their agreement with the plan, and their initial willingness to follow the plan were all strongly related to their self-reported completion of the plan 3 months later. Patients whose plans involved lifestyle changes were less likely to report that they had "completely" followed their plan. TRIAL REGISTRATION ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/study/NCT03385512. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/30431.
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Affiliation(s)
- Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Center for Health Systems Research, Sutter Health, Palo Alto, CA, United States
| | - Kathleen M Mazor
- Department of Medicine, UMass Chan Medical School, Worcester, MA, United States
| | - Michael Cheung
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, United States
| | - Bernice Ruo
- Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Martina Li
- Palo Alto Medical Foundation Research Institute, Center for Health Systems Research, Sutter Health, Palo Alto, CA, United States
| | - Amanda Walker
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Cassandra Saphirak
- Department of Medicine, UMass Chan Medical School, Worcester, MA, United States
| | - Florin Vaida
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, United States
| | - Sonal Singh
- Department of Medicine, UMass Chan Medical School, Worcester, MA, United States
| | - Kimberly A Fisher
- Department of Medicine, UMass Chan Medical School, Worcester, MA, United States
| | - Rebecca Rosen
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Robert Yood
- Research Department, Reliant Medical Group, Worcester, MA, United States
| | - Lawrence Garber
- Research Department, Reliant Medical Group, Worcester, MA, United States
| | - Christopher Longhurst
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Gene Kallenberg
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Edward Yu
- Department of Family Medicine, Palo Alto Medical Foundation, Sutter Health, Mountain View, CA, United States
| | - Albert Chan
- Palo Alto Medical Foundation Research Institute, Center for Health Systems Research, Sutter Health, Palo Alto, CA, United States
- Digital Team, Sutter Health, Sacramento, CA, United States
- Department of Medicine, Division of Biomedical Informatics Research, Stanford University, Stanford, CA, United States
| | - Marlene Millen
- Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Ming Tai-Seale
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, United States
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Stults CD, Liang SY, Wilcox J, Nyong’o OL. Amblyopia Care Trends Following Widespread Photoscreener Adoption. JAMA Ophthalmol 2024; 142:188-197. [PMID: 38300546 PMCID: PMC10835608 DOI: 10.1001/jamaophthalmol.2023.6434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/28/2023] [Indexed: 02/02/2024]
Abstract
Importance Amblyopia can result in permanent vision loss if not properly treated before age 7 years. In 2017, the US Preventive Services Task Force recommended that vision screening should occur at least once in all children aged 3 to 5 years to detect amblyopia. Objective To understand trends and factors associated with screening, referral, or diagnosis of amblyopia before and after photoscreening expansion across a relatively large health care system in late 2017. Design, Setting, and Participants This is a retrospective cohort study of electronic health record data from patients with a well child care visit at approximately age 3 years (ages 2.75-3.25 years) in a relatively large, multispecialty group practice in Northern California and linked census data between 2015 and 2022. Data were extracted and analyzed from October 2022 through August 2023. Exposures Patient sex, race and ethnicity, immunization records, previous well child care visits, and census-level median household income. Main Outcomes and Measures Vision screening, pediatric ophthalmology referral, or amblyopia diagnosis, compared using adjusted odds ratios (AORs). Results The study included 2015-2017 data from 23 246 patients aged 3 years with at least 1 well child care visit (11 206 [48.2%] female) compared with 2018-2022 postexpansion data from 34 281 patients (16 517 [48.2%] female). The screening rate increased from 5.7% (424 of 7505) in 2015 to 72.1% (4578 of 6354) in 2022. The referral rate increased from 17.0% (1279 of 7505) in 2015 to 23.6% (1836 of 7792) in 2018. The diagnosis rate was 2.7% (200 of 7505) in 2015, peaked at 3.4% (263 of 7792) in 2018, and decreased to 1.4% (88 of 6354) in 2022. Compared with White patients, patients who were Asian, Black, or Hispanic were less likely to be screened (Asian: AOR, 0.80; 95% CI, 0.72-0.88; Black: AOR, 0.71; 95% CI, 0.53-0.96; Hispanic: AOR, 0.88; 95% CI, 0.80-0.97). Compared with White patients, patients who were Asian or Hispanic were more likely to be referred (Asian: AOR, 1.49; 95% CI, 1.36-1.62; Hispanic: AOR, 1.32; 95% CI, 1.18-1.48) and were more likely to be diagnosed (Asian: AOR, 1.29; 95% CI, 1.07-1.56; Hispanic: AOR, 1.67; 95% CI, 1.33-2.11). Conclusions and Relevance In this study, increased availability of photoscreeners was associated with an increase in overall rates of vision screening for children aged 3 years in a relatively large health care system. Given that US rates of visual impairment are predicted to increase, additional targeted interventions would be needed to address remaining disparities in amblyopia care along patient- and clinician-level factors.
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Affiliation(s)
- Cheryl D. Stults
- Palo Alto Medical Foundation Research Institute, Center for Health Systems Research, Sutter Health, Palo Alto, California
| | - Su-Ying Liang
- Palo Alto Medical Foundation Research Institute, Center for Health Systems Research, Sutter Health, Palo Alto, California
| | - Joseph Wilcox
- Center for Health Systems Research, Sutter Health, Walnut Creek, California
| | - Omondi L. Nyong’o
- Crescendo MD, Portola Valley, California
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California
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Li J, Stults CD, Liang SY, Martinez M. Factors associated with adherence to provider referrals for lung cancer screening with low dose computed tomography before and during COVID-19 pandemic. BMC Cancer 2023; 23:809. [PMID: 37644406 PMCID: PMC10463613 DOI: 10.1186/s12885-023-11256-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Lung cancer has been the leading cause of American deaths from cancer. Although Medicare started covering lung cancer screening (LCS) with low-dose computed tomography (LDCT) in 2015, the uptake of LDCT-LCS remains low. This study examines the changes in adherence to provider referrals for LDCT-LCS and the factors at patient, provider, and health system levels that influence the completion rate of LDCT-LCS orders before and during the COVID-19 pandemic. METHODS Our study examined electronic health record data (December 2013 - December 2020) from a large, community-based clinical healthcare delivery system in California. We plotted monthly trends in the frequency of LDCT-LCS orders and completion rate and compared the annual LDCT-LCS completion rate between LCS-eligible, LCS-ineligible, and unknown eligibility groups. We then explored multilevel factors associated with the completion of LDCT-LCS orders using hierarchical generalized linear models. RESULTS There was an increase in LDCT-LCS orders (N = 12,469) from 2013 to 2019, followed by a sharp decline in March 2020 due to the onset of the COVID-19 pandemic. Thereafter, LDCT-LCS orders slowly increased again in June 2020. The completion rate of LDCT-LCS increased from 0% in December 2013 to approximately 70% in 2018-2019 but declined to 50-60% in 2020 during the pandemic. Ineligible patients had lower completion rates of LDCT-LCS. Patients who were new to the healthcare system, Black, received the LDCT-LCS order in the first few years after Medicare coverage (2016 or 2017), during the pandemic, had major comorbidities, and smoked less than 30 pack-years were less likely to complete an order. Patients were more likely to complete LDCT-LCS orders if they were younger, received the LDCT-LCS order from a physician (vs. nonphysician provider), from family medicine or other specialties (vs. internal medicine), or saw a provider with more experience in LDCT-LCS. CONCLUSIONS The beginning of the COVID-19 pandemic largely decreased the volume of LDCT-LCS orders, but rates have since been slowing recovering. Future interventions to improve lung cancer screening should consider doing more targeted outreach to new patients and Black patients as well as providing additional education to nonphysician practitioners and those providers with lower rates of LDCT-LCS referral orders.
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Affiliation(s)
- Jiang Li
- Palo Alto Medical Foundation Research Institute, Center for Health Systems Research, Sutter Health, 795 El Camino Real, 94301, Palo Alto, CA, USA.
| | - Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Center for Health Systems Research, Sutter Health, 795 El Camino Real, 94301, Palo Alto, CA, USA
| | - Su-Ying Liang
- Palo Alto Medical Foundation Research Institute, Center for Health Systems Research, Sutter Health, 795 El Camino Real, 94301, Palo Alto, CA, USA
| | - Meghan Martinez
- Palo Alto Medical Foundation Research Institute, Center for Health Systems Research, Sutter Health, 795 El Camino Real, 94301, Palo Alto, CA, USA
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Martinez MC, Stults CD, Li J. Provider and patient perspectives to improve lung cancer screening with low-dose computed tomography 5 years after Medicare coverage: a qualitative study. BMC Prim Care 2022; 23:332. [PMID: 36539693 PMCID: PMC9768892 DOI: 10.1186/s12875-022-01925-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022]
Abstract
Lung cancer remains the leading cause of cancer-related deaths for both men and women in the U.S., yet uptake of preventive cancer screening for people with a heavy smoking history remains low. This qualitative interview study of patients and providers from a large ambulatory healthcare system in northern and central California reevaluated perceptions of lung cancer screening with low-dose computed tomography (LCS-LDCT) 5 years after Medicare coverage. We hypothesized that initial attitudes and barriers within the LCS-LDCT discussion and process have likely persisted with little change since Medicare coverage and we sought to understand how these attitudes continue to impact effective implementation and uptake of screening with the goal of identifying opportunities for improvement. Between 2019 and 2020, interviews were conducted with 10 primary care physicians and 30 patients using semi-structured interview guides. Providers and patients expressed that they were both aware and supportive of LCS-LDCT, a change from earlier studies, but continued to report little to no shared decision making nor use of a decision aid despite being Medicare requirements. Creation and incorporation of a single-page, graphic heavy decision aid may help address many of the persistent barriers around implementation for both providers and patients. Given recently expanded guidelines from the U.S. Preventive Services Task Force for LCS-LDCT screening and their coverage by Medicare, it is important for healthcare systems to understand provider and patient perceptions to further improve the implementation of LCS-LDCT to ultimately reduce lung cancer mortality.
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Affiliation(s)
- Meghan C. Martinez
- grid.416759.80000 0004 0460 3124Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Sutter Health, 795 El Camino Real, Ames Building, Palo Alto, CA 94301 USA
| | - Cheryl D. Stults
- grid.416759.80000 0004 0460 3124Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Sutter Health, 795 El Camino Real, Ames Building, Palo Alto, CA 94301 USA
| | - Jiang Li
- grid.416759.80000 0004 0460 3124Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Sutter Health, 795 El Camino Real, Ames Building, Palo Alto, CA 94301 USA
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Yan X, Stults CD, Deng S, Liang SY, Dillon E, Mudiganti S, Oscarson B, Jones JB, Frosch DL. Do Patients Continue to Use Video Visits? Factors Related to Continued Video Visit Use. Popul Health Manag 2022; 25:462-471. [PMID: 35353619 DOI: 10.1089/pop.2021.0353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Many studies have assessed the factors associated with overall video visit use during the COVID-19 pandemic, but little is known about who is most likely to continue to use video visits and why. The authors combined a survey with electronic health record data to identify factors affecting the continued use of video visit. In August 2020, a stratified random sample of 20,000 active patients from a large health care system were invited to complete an email survey on health care seeking preferences during the COVID. Weighted logistic regression models were applied, adjusting for sampling frame and response bias, to identify factors associated with video visit experience, and separately for preference of continued use of video visits. Actual video visit utilization was also estimated within 12 months after the survey. Three thousand three hundred fifty-one (17.2%) patients completed the survey. Of these, 1208 (36%) reported having at least 1 video visit in the past, lowest for African American (33%) and highest for Hispanic (41%). Of these, 38% would prefer a video visit in the future. The strongest predictors of future video visit use were comfort using video interactions (odds ratio [OR] = 5.30, 95% confidence interval [95% CI]: 3.57-7.85) and satisfaction with the overall quality (OR = 3.94, 95% CI: 2.66-5.86). Interestingly, despite a significantly higher satisfaction for Hispanic (40%-55%) and African American (40%-50%) compared with Asian (29%-39%), Hispanic (OR = 0.46, 95% CI: 0.12-0.88) and African American (OR = 0.54, 95% CI: 0.16-0.90) were less likely to prefer a future video visit. Disparity exists in the use of video visit. The association between patient satisfaction and continued video visit varies by race/ethnicity, which may change the future long-term video visit use among race/ethnicity groups.
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Affiliation(s)
- Xiaowei Yan
- Center for Health System Research, Sutter Health, Walnut Creek, California, USA
| | - Cheryl D Stults
- Center for Health System Research, Sutter Health, Walnut Creek, California, USA.,Palo Alto Medical Foundation Research Institute, Palo Alto Medical Foundation, Palo Alto, California, USA
| | - Sien Deng
- Center for Health System Research, Sutter Health, Walnut Creek, California, USA.,Palo Alto Medical Foundation Research Institute, Palo Alto Medical Foundation, Palo Alto, California, USA
| | - Su-Ying Liang
- Center for Health System Research, Sutter Health, Walnut Creek, California, USA.,Palo Alto Medical Foundation Research Institute, Palo Alto Medical Foundation, Palo Alto, California, USA
| | - Ellis Dillon
- Center for Health System Research, Sutter Health, Walnut Creek, California, USA.,Palo Alto Medical Foundation Research Institute, Palo Alto Medical Foundation, Palo Alto, California, USA
| | - Satish Mudiganti
- Center for Health System Research, Sutter Health, Walnut Creek, California, USA
| | - Brandon Oscarson
- Center for Health System Research, Sutter Health, Walnut Creek, California, USA
| | - James B Jones
- Center for Health System Research, Sutter Health, Walnut Creek, California, USA
| | - Dominick L Frosch
- Health Science Diligence Advisors, LLC, Redwood City, California, USA
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Stults CD, Yan X, Deng S, Dillon EC, Liang SY, Jones JB, Bhanushali M, Frosch DL. Patient Preferences for Preventive Healthcare During the COVID-19 Pandemic in a Large Integrated Health System. J Patient Exp 2022; 9:23743735221113160. [PMID: 35860789 PMCID: PMC9289907 DOI: 10.1177/23743735221113160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The COVID-19 pandemic caused healthcare systems and patients to cancel or
postpone healthcare services, particularly preventive care. Many patients still
have not received these services raising concerns about the potential for
preventable morbidity and mortality. At Sutter Health, a large integrated
healthcare system in Northern California, we conducted a population-based email
survey in August 2020 to evaluate perceptions and preferences about where, when,
and how healthcare is delivered during the COVID-19 pandemic. In total, 3351
patients completed surveys, and 42.6% reported that they would “wait until they
felt safe” before receiving a colonoscopy as compared to 22.4% for a mammogram.
The doctor's office was the most common preferred location for receiving
vaccines/shots (79.9%), though many also reported preferring an outdoor setting
or in a car (63.7%). With over 40% of patients reporting that they would “wait
until they feel safe” for a colonoscopy, healthcare systems could focus on
promoting other evidence-based options such a fecal-occult blood test to ensure
timely colon cancer screening.
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Affiliation(s)
| | | | | | | | | | - JB Jones
- Sutter Health, Walnut Creek, CA, USA
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Dillon EC, Stults CD, Deng S, Martinez M, Szwerinski N, Koenig PT, Gregg L, Cobb JK, Mahler E, Frosch DL, Le Sieur S, Hanley M, Pertsch S. Women, Younger Clinicians', and Caregivers' Experiences of Burnout and Well-being During COVID-19 in a US Healthcare System. J Gen Intern Med 2022; 37:145-153. [PMID: 34729697 PMCID: PMC8562379 DOI: 10.1007/s11606-021-07134-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/02/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The COVID-19 pandemic brought rapid changes to the work and personal lives of clinicians. OBJECTIVE To assess clinician burnout and well-being during the COVID-19 pandemic and guide healthcare system improvement efforts. DESIGN A survey asking about clinician burnout, well-being, and work experiences. PARTICIPANTS Surveys distributed to 8141 clinicians from June to August 2020 in 9 medical groups and 17 hospitals at Sutter Health, a large healthcare system in Northern California. MAIN MEASURES Burnout was the primary outcome, and other indicators of well-being and work experience were also measured. Descriptive statistics and multivariate logistic regression analyses were performed. All statistical inferences were based on weighted estimates adjusting for response bias. KEY RESULTS A total of 3176 clinicians (39.0%) responded to the survey. Weighted results showed 29.2% reported burnout, and burnout was more common among women than among men (39.0% vs. 22.7%, p<0.01). In multivariate models, being a woman was associated with increased odds of reporting burnout (OR=2.19, 95% CI: 1.51-3.17) and being 55+ years old with lower odds (OR=0.54, 95% CI: 0.34-0.87). More women than men reported that childcare/caregiving was impacting work (32.9% vs. 19.0%, p<0.01). Even after controlling for age and gender, clinicians who reported childcare/caregiving responsibilities impacted their work had substantially higher odds of reporting burnout (OR=2.19, 95% CI: 1.54-3.11). Other factors associated with higher burnout included worrying about safety at work, being given additional work tasks, concern about losing one's job, and working in emergency medicine or radiology. Protective factors included believing one's concerns will be acted upon and feeling highly valued. CONCLUSIONS This large survey found the pandemic disproportionally impacted women, younger clinicians, and those whose caregiving responsibilities impacted their work. These results highlight the need for a holistic and targeted strategy for improving clinician well-being that addresses the needs of women, younger clinicians, and those with caregiving responsibilities.
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Affiliation(s)
- Ellis C Dillon
- Center for Health Systems Research, Sutter Health and Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA.
| | - Cheryl D Stults
- Center for Health Systems Research, Sutter Health and Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Sien Deng
- Center for Health Systems Research, Sutter Health and Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Meghan Martinez
- Center for Health Systems Research, Sutter Health and Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Nina Szwerinski
- Center for Health Systems Research, Sutter Health and Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - P T Koenig
- Sutter Medical Group, Sacramento, CA, USA
| | - Laurie Gregg
- Sutter Medical Center Sacramento and Sutter Independent Physicians, Sacramento, CA, USA
| | | | | | - Dominick L Frosch
- Center for Health Systems Research, Sutter Health and Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
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Liang SY, Stults CD, Jones VG, Huang Q, Sutton J, Tennyson G, Chan AS. The Effects of Behavioral Economics-based Nudge on Online Scheduling and Appointment Completion: Observational Study (Preprint). JMIR Hum Factors 2021; 9:e34090. [PMID: 35353051 PMCID: PMC9008532 DOI: 10.2196/34090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/17/2021] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background Behavioral economics–based techniques have been an increasingly utilized method in health care to influence behavior change by modifying language in patient communication (through choice architecture and the framing of words). Patient portals are a key tool for facilitating patient engagement in their health, and interventions deployed via patient portals have been effective in improving utilization of preventive health services. Objective We examined the impacts of behavioral economics–based nudge health maintenance reminders on appointment scheduling through a patient portal and appointment completion for 2 preventive services: Medicare wellness visits and Pap smear. Methods We conducted a retrospective observational study using electronic health record data from an integrated health care system in Northern California. Nudge health maintenance reminders with behavioral economics–based language were implemented for all sites in November 2017 for Medicare wellness visits and for selected sites in February 2018 for Pap smears. We analyzed 125,369 health maintenance reminders for Medicare wellness visits, and 585,358 health maintenance reminders for Pap smear sent between January 2017 and February 2020. The primary outcomes were rate of appointments scheduled through the patient portal and appointment completion rate. We compared the outcomes between those who received the new, behavioral economics–based health maintenance reminders (the nudge group) and those who received the original, standard health maintenance reminders (the control group). We used segmented regression with interrupted time series to assess the immediate and gradual effect of the nudge for Medicare wellness visits, and we used logistic regression to assess the association of nudge health maintenance reminders, adjusting for the propensity to receive a nudge health maintenance reminder, for Pap smear. Results The rates of appointments scheduled through the patient portal were higher for nudge health maintenance reminder recipients than those for control health maintenance reminder recipients (Medicare wellness visits—nudge: 12,537/96,839, 13.0%; control: 2,769/28,530, 9.7%, P<.001; Pap smear—nudge: 8,239/287,149, 2.9%; control: 1,868/120,047, 1.6%; P<.001). Rates of appointment completion were higher for nudge health maintenance reminders for Pap smear (nudge: 67,399/287,149, 23.5% control: 20,393/120,047, 17.0%; P<.001) but were comparable for Medicare wellness visits (nudge: 49,835/96,839, 51.5% control: 14,781/28,530, 51.8%; P=.30). There was a marginally gradual effect of nudge on number of appointments scheduled through the patient portal for the overall Medicare wellness visits sample (at a monthly rate of 0.26%, P=.09), and a significant gradual effect among scheduled appointments (at a monthly rate of 0.46%, P=.04). For Pap smear, nudge health maintenance reminders were positively associated with number of appointments scheduled through the patient portal (overall sample: propensity adjusted odds ratio [OR] 1.62; 95% CI 1.50-1.74; among scheduled appointments: propensity adjusted OR 1.61, 95% CI 1.47-1.76) and with appointment completion (propensity adjusted OR 1.07; 1.04-1.10). Conclusions Nudges, a behavioral economics–based approach to providing health maintenance reminders, increased the number of appointments scheduled through the patient portal for Medicare wellness visits and Pap smear. Our study demonstrates that a simple approach—framing and modifying language in an electronic message—can have a significant and long-term impact on patient engagement and access to care.
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Affiliation(s)
- Su-Ying Liang
- Sutter Health Center for Health Systems Research, Palo Alto, CA, United States
| | - Cheryl D Stults
- Sutter Health Center for Health Systems Research, Palo Alto, CA, United States
| | - Veena G Jones
- Clinical Leadership Team, Sutter Health, Sacramento, CA, United States
| | - Qiwen Huang
- Sutter Health Center for Health Systems Research, Palo Alto, CA, United States
| | - Jeremy Sutton
- Clinical Leadership Team, Sutter Health, Sacramento, CA, United States
| | - Guy Tennyson
- Clinical Leadership Team, Sutter Health, Sacramento, CA, United States
| | - Albert S Chan
- Clinical Leadership Team, Sutter Health, Sacramento, CA, United States
- Center for Biomedical Informatics Research, Stanford University, Stanford, CA, United States
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Tai-Seale M, Rosen R, Ruo B, Hogarth M, Longhurst CA, Lander L, Walker AL, Stults CD, Chan A, Mazor K, Garber L, Millen M. Implementation of Patient Engagement Tools in Electronic Health Records to Enhance Patient-Centered Communication: Protocol for Feasibility Evaluation and Preliminary Results. JMIR Res Protoc 2021; 10:e30431. [PMID: 34435960 PMCID: PMC8430844 DOI: 10.2196/30431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 01/16/2023] Open
Abstract
Background Patient–physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient–physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters. Objective In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient–physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters. Methods We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit “patient important issue” questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient–staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes. Results The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient–clinician communication, particularly during the COVID-19 pandemic. Conclusions EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians’ work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians. Trial Registration ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512 International Registered Report Identifier (IRRID) DERR1-10.2196/30431
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Affiliation(s)
- Ming Tai-Seale
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Rebecca Rosen
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Bernice Ruo
- Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Michael Hogarth
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Christopher A Longhurst
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, United States.,School of Medicine, Department of Pediatrics, University of California San Diego, La Jolla, CA, United States
| | - Lina Lander
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Amanda L Walker
- Department of Family Medicine, University of California San Diego, La Jolla, CA, United States
| | - Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, United States.,Sutter Health Center for Health Systems Research, Palo Alto, CA, United States
| | - Albert Chan
- Sutter Health Center for Health Systems Research, Palo Alto, CA, United States.,Sutter Health Clinical Leadership Team, Sacramento, CA, United States.,Stanford Center for Biomedical Informatics Research, Stanford, CA, United States
| | - Kathleen Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States.,Meyers Primary Care Institute, University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, United States
| | - Lawrence Garber
- Meyers Primary Care Institute, University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, United States.,Reliant Medical Group, Worcester, MA, United States
| | - Marlene Millen
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, United States
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10
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Lauffenburger JC, Stults CD, Mudiganti S, Yan X, Dean-Gilley LM, He M, Tong A, Fischer MA. Impact of implementing electronic prior authorization on medication filling in an electronic health record system in a large healthcare system. J Am Med Inform Assoc 2021; 28:2233-2240. [PMID: 34279657 DOI: 10.1093/jamia/ocab119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/10/2021] [Accepted: 06/03/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Medications frequently require prior authorization from payers before filling is authorized. Obtaining prior authorization can create delays in filling prescriptions and ultimately reduce patient adherence to medication. Electronic prior authorization (ePA), embedded in the electronic health record (EHR), could remove some barriers but has not been rigorously evaluated. We sought to evaluate the impact of implementing an ePA system on prescription filling. MATERIALS AND METHODS ePA was implemented in 2 phases in September and November 2018 in a large US healthcare system. This staggered implementation enabled the later-implementing sites to be controls. Using EHR data from all prescriptions written and linked information on whether prescriptions were filled at pharmacies, we 1:1 matched ePA prescriptions with non-ePA prescriptions for the same insurance plan, medication, and site, before and after ePA implementation, to evaluate primary adherence, or the proportion of prescriptions filled within 30 days, using generalized estimating equations. We also conducted concurrent analyses across sites during the peri-implementation period (Sept-Oct 2018). RESULTS Of 74 546 eligible ePA prescriptions, 38 851 were matched with preimplementation controls. In total, 24 930 (64.2%) ePA prescriptions were filled compared with 26 731 (68.8%) control prescriptions (Adjusted Relative Risk [aRR]: 0.92, 95%CI: 0.91-0.93). Concurrent analyses revealed similar findings (64.7% for ePA vs 62.3% control prescriptions, aRR: 1.03, 95%CI: 0.98-1.09). DISCUSSION Challenges with implementation, such as misfiring and insurance fragmentation, could have undermined its effectiveness, providing implications for other health informatics interventions deployed in outpatient care. CONCLUSION Despite increasing interest in implementing ePA to improve prescription filling, adoption did not change medication adherence.
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Affiliation(s)
- Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Cheryl D Stults
- Sutter Health, Research, Development & Dissemination, Walnut Creek, California, USA
| | - Satish Mudiganti
- Sutter Health, Research, Development & Dissemination, Walnut Creek, California, USA
| | - Xiaowei Yan
- Sutter Health, Research, Development & Dissemination, Walnut Creek, California, USA
| | - Lisa M Dean-Gilley
- Sutter Health, Research, Development & Dissemination, Walnut Creek, California, USA
| | - Mengdong He
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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11
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Panattoni L, Stults CD, Chan AS, Tai-Seale M. The human resource costs of implementing autopend clinical decision support to improve health maintenance. Am J Manag Care 2020; 26:e232-e236. [PMID: 32672922 DOI: 10.37765/ajmc.2020.43766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Sutter Health developed a novel autopend, or automated laboratory test ordering, clinical decision support (CDS) tool to coordinate the patient and physician process of completing preventive services. This study estimated the costs of developing and implementing the autopend functionality within an existing electronic health maintenance (HM) reminder system. STUDY DESIGN Human resource time was measured by triangulating in-depth key informant interviews with Microsoft Outlook Calendar metadata (meetings attended) for managers and hourly data from a time-based project management tool (Project Web App) for Epic programmers. Employee time spent was multiplied by the Bureau of Labor Statistics California state hourly wages. Sutter Health is an integrated health care delivery network with more than 12,000 physicians across 100 communities serving 3 million patients. METHODS Activity-based costing methodology was used to divide the implementation into activities and the human resources required to complete them. RESULTS Developing and implementing the autopend CDS took more than 3 years, involved 6 managers and 3 Epic programmers, and cost $201,500 (2013 US$) (2670 total hours), which excluded the costs of implementing the initial HM reminder system. Managers spent 90.5% of the total costs (86.6% of total hours) integrating autopend into the health system compared with 9.5% of the total costs (13.4% of total hours) spent programming the functionality. CONCLUSIONS The autopend CDS might be similarly costly for other organizations to implement if their managers need to complete comparable activities. However, electronic health record vendors could include autopend as a standard package to reduce development costs and improve the uptake of this promising CDS tool.
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Affiliation(s)
- Laura Panattoni
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109.
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12
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Stults CD, Li J, Frosch DL, Krishnan H, Smith-McCurdy G, Jones VG, Chan AS. Assessment of Accuracy and Usability of a Fee Estimator for Ambulatory Care in an Integrated Health Care Delivery Network. JAMA Netw Open 2019; 2:e1917445. [PMID: 31834394 PMCID: PMC6991301 DOI: 10.1001/jamanetworkopen.2019.17445] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Given increased enrollment in high-deductible health insurance plans and mandates from the Patient Protection and Affordable Care Act, individualized price transparency tools are needed. OBJECTIVE To assess accuracy and initial user experience of a cost estimation tool for ambulatory procedures delivered via an online patient portal and informed by real-time data feeds from third-party payers. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study included patients aged 18 years and older at an integrated health care system in Northern California. Data from patients who used the cost estimator tool from August 21, 2018, to April 9, 2019, and who had matching explanation of benefits statements were used to assess accuracy of the tool. User experience was assessed with a brief survey completed online or via postal mail. Data were analyzed from April 15, 2019, to October 11, 2019. MAIN OUTCOMES AND MEASURES Tool accuracy and user experience and satisfaction. RESULTS As of April 30, 2019, 4610 estimates (3569 [77.4%] via internet; 1041 [22.6%] via telephone) were produced using the cost estimator tool. Among 342 individuals who had an estimate and a matching explanation of benefits statement, 287 estimates (83.9%) were accurate. All 342 individuals with an estimate and an explanation of benefits statement were invited to participate in a user survey, and 125 individuals completed the survey (36.5% response rate). Survey respondents included 92 (73.6%) women, 72 (57.6%) non-Hispanic white participants , 91 participants (72.8%) with a college degree or higher, and 55 participants (44.0%) with an income of $100 000 per year or higher. Mean (SD) age was 46.8 (13.1) years. Ninety-nine participants (79.2%) found the tool easy to use, 109 participants (87.2%) would use it again, and 100 participants (80.0%) would recommend it to others. Seven participants (5.6%) reported contacting a clinician about the estimate, and 12 participants (9.6%) changed their decision based on the estimate. CONCLUSIONS AND RELEVANCE This quality improvement study is the first report of an online cost estimator in an integrated health care delivery network. The findings suggest that the tool, informed by real-time data feeds from third-party payers, was easy to use and provided accurate results. Increasing the number of searchable services and sharing best practices with other health care systems who share the same portal platform are the next steps for the tool.
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Affiliation(s)
- Cheryl D. Stults
- Sutter Health Center for Health Systems Research, Palo Alto, California
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
| | - Jiang Li
- Sutter Health Center for Health Systems Research, Palo Alto, California
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
| | - Dominick L. Frosch
- Sutter Health Center for Health Systems Research, Palo Alto, California
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
| | - Hari Krishnan
- Sutter Health Office of Patient Experience, Sacramento, California
| | | | - Veena G. Jones
- Sutter Health Office of Patient Experience, Sacramento, California
| | - Albert S. Chan
- Sutter Health Office of Patient Experience, Sacramento, California
- Stanford Center for Biomedical Informatics Research, Stanford, California
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13
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Meehan A, Bundorf MK, Klimke R, Stults CD, Chan AS, Pun T, Tai-Seale M. Online Consent Enables a Randomized, Controlled Trial Testing a Patient-Centered Online Decision-Aid for Medicare Beneficiaries to Meet Recruitment Goal in Short Time Frame. J Patient Exp 2019; 7:12-15. [PMID: 32128365 PMCID: PMC7036687 DOI: 10.1177/2374373519827029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Online consenting allows potential participants of research projects to deliberate their participation at their own pace and may be more cost-effective than conventional approaches. Yet, online consenting is not widespread in health services research due partly to concerns about security, confidentiality, and lack of established processes. We report our use of online consenting to successfully enroll over 1185 Medicare beneficiaries in a short 9-week time frame for a research study.
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Affiliation(s)
- Amy Meehan
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Mary Kate Bundorf
- Department of Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Roman Klimke
- Department of Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Albert S Chan
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA.,Sutter Health, San Carlos, CA, USA
| | - Ting Pun
- Patient-Centered Outcomes Research Institute Patient Advisory Council, Portola Valley, CA, USA
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA.,University of California San Diego School of Medicine, La Jolla, CA, USA
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14
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Stults CD, Fattahi S, Meehan A, Bundorf MK, Chan AS, Pun T, Tai-Seale M. Comparative Usability Study of a Newly Created Patient-Centered Tool and Medicare.gov Plan Finder to Help Medicare Beneficiaries Choose Prescription Drug Plans. J Patient Exp 2018; 6:81-86. [PMID: 31236456 PMCID: PMC6572936 DOI: 10.1177/2374373518778343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: In response to reported difficulties in selecting a Medicare Part D prescription drug plan, we designed a patient-centered online Part D plan selection tool (CHOICE1.0) to simplify the selection process and to provide personalized, expert recommendations. Methods: This ethnographic comparative usability study observed 44 patients using the first version of the tool during Medicare 2016 Open Enrollment. Participants were observed as they chose their drug plan using Medicare.gov and 1 of 3 versions of CHOICE1.0 that varied in amount of expert guidance. Descriptive statistics were used to analyze exit survey data. The observations were video-recorded, and field notes were analyzed thematically. Results: Participants were significantly more satisfied with CHOICE1.0 for choosing a plan, understanding information, and ease of use compared to Medicare.gov. Those using expert versions of CHOICE1.0 were more likely to indicate their intention to switch plans than those using Medicare.gov, though they wanted to know the source and content. Conclusion: The more patient-centered prescription drug choice tool improved user experience and enabled users to choose plans more consistent with expert recommendations.
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Affiliation(s)
- Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | | | - Amy Meehan
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | - M Kate Bundorf
- Department of Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Albert S Chan
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA.,Sutter Health, San Carlos, CA, USA
| | - Ting Pun
- Patient-Centered Outcomes Research Institute Patient Advisory Council, Portola Valley, CA, USA
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA.,University of California San Diego School of Medicine, La Jolla, CA, USA
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15
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Abstract
INTRODUCTION Medicare beneficiaries often report that the process of choosing a prescription drug plan is frustrating and confusing and many do not enroll in the plan that covers their drugs at the lowest cost. METHODS We conducted 4 focus groups to understand beneficiaries' experiences in selecting a drug plan to identify what resources and factors were most important to them. Participants were patients served by a multispecialty delivery system and were primarily affluent and Caucasian. RESULTS While low cost was essential to many, other characteristics like having the same plan as a partner, company reputation, convenience, and anticipation of possible future health problems were sometimes more important. Although some used resources including insurance brokers, counselors, and websites beyond Medicare.gov, many expressed a desire for greater assistance with and greater simplicity in the choice process. CONCLUSION Although older adults would likely benefit from greater assistance in choosing Medicare Part D prescription drug plans, more research is necessary to understand how to help with decision-making in this context.
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Affiliation(s)
- Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | | | - M Kate Bundorf
- Department of Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
- School of Medicine, University of California San Diego, CA, USA
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16
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Dillon EC, Stults CD, Wilson C, Chuang J, Meehan A, Li M, Elwyn G, Frosch DL, Yu E, Tai-Seale M. An evaluation of two interventions to enhance patient-physician communication using the observer OPTION 5 measure of shared decision making. Patient Educ Couns 2017; 100:1910-1917. [PMID: 28532861 DOI: 10.1016/j.pec.2017.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 02/15/2017] [Accepted: 04/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Evaluate interventions to enhance patient-physician communication and shared decision making (SDM). METHODS We used Observer OPTION5 to evaluate primary care visits within a cluster randomized controlled trial in a California delivery organization. Trial interventions included Open Communication (OpenComm), combining patient activation and physician coaching, and AskShareKnow, a patient activation tool, and were compared to a usual care arm. Scores were analyzed with descriptive statistics and generalized estimating equation analysis for 40 visits containing 200 decision topics. RESULTS The mean overall OPTION5 score was 26.5 out of 100 (s.d.=15.2). Compared to visits in the usual care arm, OpenComm visits had higher mean item scores (0-4 scale) for eliciting (mean=1.0 vs 0.8) and integrating patient preferences (mean=1.0 vs 0.8). OpenComm and AskShareKnow visits had higher scores for presenting options (mean=1.5, 1.5 vs 1.3). AskShareKnow visits had higher scores for discussing pros/cons (mean=1.5 vs 1.1). Lower patient education attainment was associated with lower scores. CONCLUSIONS OpenComm and AskShareKnow were associated with improved SDM relative to usual care. PRACTICE IMPLICATIONS Results suggest targeting patient and physician behaviors promotes SDM better than patient activation only. Improving SDM for less educated patients is crucial.
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Affiliation(s)
- Ellis C Dillon
- Palo Alto Medical Foundation Research Institute, Mountain View, USA.
| | - Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Mountain View, USA.
| | | | - Judith Chuang
- Palo Alto Medical Foundation Research Institute, Mountain View, USA.
| | - Amy Meehan
- Palo Alto Medical Foundation Research Institute, Mountain View, USA.
| | - Martina Li
- Palo Alto Medical Foundation Research Institute, Mountain View, USA.
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, USA.
| | - Dominick L Frosch
- Palo Alto Medical Foundation Research Institute, Mountain View, USA; Department of Medicine, University of California, Los Angeles, USA.
| | - Edward Yu
- Palo Alto Medical Foundation, Mountain View, USA.
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Mountain View, USA.
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17
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Forcino RC, Barr PJ, O'Malley AJ, Arend R, Castaldo MG, Ozanne EM, Percac-Lima S, Stults CD, Tai-Seale M, Thompson R, Elwyn G. Using CollaboRATE, a brief patient-reported measure of shared decision making: Results from three clinical settings in the United States. Health Expect 2017; 21:82-89. [PMID: 28678426 PMCID: PMC5750739 DOI: 10.1111/hex.12588] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2017] [Indexed: 12/30/2022] Open
Abstract
Introduction CollaboRATE is a brief patient survey focused on shared decision making. This paper aims to (i) provide insight on facilitators and challenges to implementing a real‐time patient survey and (ii) evaluate CollaboRATE scores and response rates across multiple clinical settings with varied patient populations. Method All adult patients at three United States primary care practices were eligible to complete CollaboRATE post‐visit. To inform key learnings, we aggregated all mentions of unanticipated decisions, problems and administration errors from field notes and email communications. Mixed‐effects logistic regression evaluated the impact of site, clinician, patient age and patient gender on the CollaboRATE score. Results While CollaboRATE score increased only slightly with increasing patient age (OR 1.018, 95% CI 1.014‐1.021), female patient gender was associated with significantly higher CollaboRATE scores (OR 1.224, 95% CI 1.073‐1.397). Clinician also predicts CollaboRATE score (random effect variance 0.146). Site‐specific factors such as clinical workflow and checkout procedures play a key role in successful in‐clinic implementation and are significantly related to CollaboRATE scores, with Site 3 scoring significantly higher than Site 1 (OR 1.759, 95% CI 1.216 to 2.545) or Site 2 (z=−2.71, 95% CI −1.114 to −0.178). Discussion This study demonstrates that CollaboRATE can be used in diverse primary care settings. A clinic's workflow plays a crucial role in implementation. Patient experience measurement risks becoming a burden to both patients and administrators. Episodic use of short measurement tools could reduce this burden.
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Affiliation(s)
- Rachel C Forcino
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
| | - Paul J Barr
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
| | - Roger Arend
- Dartmouth-Hitchcock Patient and Family Advisory Council, Lebanon, NH, USA
| | - Molly G Castaldo
- Dartmouth Master of Health Care Delivery Science Program, Hanover, NH, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Chelsea HealthCare Center, Chelsea, MA, USA
| | - Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Rachel Thompson
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
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18
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Tai-Seale M, Hatfield LA, Wilson CJ, Stults CD, McGuire TG, Diamond LC, Frankel RM, MacLean L, Stone A, Elston Lafata J. Periodic health examinations and missed opportunities among patients likely needing mental health care. Am J Manag Care 2016; 22:e350-e357. [PMID: 28557520 PMCID: PMC5558789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Periodic health examinations (PHEs) are the most common reason adults see primary care providers. It is unknown if PHEs serve as a "safe portal" for patients with mental health needs to initiate care. We examined how physician communication styles impact mental health service delivery in PHEs. STUDY DESIGN Retrospective observational study using audio-recordings of 255 PHEs with patients likely to need mental health care. METHODS Mixed-methods examined the timing of a mental health discussion (MHD), its quality, and the relationship between MHD quality and physician practice styles. MHD quality was measured against evidence-based practices as a 3-level variable (evidence-based, perfunctory, or absent). Physician practice styles were measured by: visit length, verbal dominance, and elicitation of a patient's agenda. A generalized ordered logit model was used. RESULTS Many patients came with mental health concerns, as over 50% of the MHDs occurred in the first 5 minutes of the visit. One-third of the 255 patients had an evidence-based MHD, another third had a perfunctory MHD, and the remaining had no MHD. MHD quality was significantly associated with physician communication styles. Visits with physicians who tend to spend more time with patients, fully elicit patients' agendas, and let patients talk (instead of being verbally dominant) were more likely to deliver evidence-based MHD. CONCLUSIONS If done well, PHEs could be a safe portal for patients to seek mental health care, but most PHEs fell short. Improving PHE quality may require reimbursement for longer visits and coaching for physicians to more fully elicit patients' agendas and to listen more attentively.
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Affiliation(s)
- Ming Tai-Seale
- 2350 W El Camino Real, Rm 446, Mountain View, CA 94301. E-mail:
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19
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Madrid S, Tuzzio L, Stults CD, Wright LA, Napolitano G, Dillon E, Tabano H, Greene SM. Sharing Experiences and Expertise: The Health Care Systems Research Network Workshop on Patient Engagement in Research. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Tai-Seale M, Hatfield L, Wilson C, Stults CD, McGuire T, Diamond L, Frankel R, MacLean L, Stone A, Elston Lafata J. Evidence-Based Mental Health Discussions During Periodic Health Exams: The Cup Is 1/3 Full. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Stults CD, Baskin A, Tai-Seale M, Bundorf MK. Patient Experiences in Selecting a Medicare Part D Prescription Drug Plan. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Dillon EC, Stults CD, Wilson C, Meehan A, Chuang J, Li M, Elwyn G, Frosch D, Tai-Seale M. Evaluating Shared Decision-Making Across Clinical Topics in Primary Care: An Exploratory Study Using the OPTION<sup>5</sup> Observer Measure. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Stults CD, McCuistion MH, Frosch DL, Hung DY, Cheng PH, Tai-Seale M. Shared Medical Appointments: A Promising Innovation to Improve Patient Engagement and Ease the Primary Care Provider Shortage. Popul Health Manag 2016; 19:11-6. [DOI: 10.1089/pop.2015.0008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cheryl D. Stults
- Palo Alto Medical Foundation, Research Institute, Mountain View, California
| | | | | | - Dorothy Y. Hung
- Palo Alto Medical Foundation, Research Institute, Mountain View, California
| | - Peter H. Cheng
- Palo Alto Medical Foundation, The Guzik Center for the Advancement of Geriatrics and Palliative Care, Palo Alto, California
| | - Ming Tai-Seale
- Palo Alto Medical Foundation, Research Institute, Mountain View, California
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Stults CD, McClellan S, Panattoni L, Mazza MC, Tai-Seale M. Estimating the Human Resource Costs of Developing and Implementing Shared Medical Appointments in Primary Care. J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Stults CD, Dillon EC, Meehan A, Chuang J, Tai-Seale M. Engaging Patients as Stakeholders to Foster More Open Communication With Primary Care Providers. J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Stults CD, Elston Lafata J, Diamond L, MacLean L, Stone AL, Wunderlich T, Frankel RM, Tai-Seale M. How do primary care physicians respond when patients cry during routine ambulatory visits? ACTA ACUST UNITED AC 2014. [DOI: 10.1179/1753807614y.0000000044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Tai-Seale M, Foo PK, Stults CD. Patients with mental health needs are engaged in asking questions, but physicians' responses vary. Health Aff (Millwood) 2013; 32:259-67. [PMID: 23381518 DOI: 10.1377/hlthaff.2012.0962] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Increased patient engagement is of particular interest regarding patients with mental health needs, given the high burden of mental illness in the United States and the potential for greater patient engagement to improve health outcomes. Little is known about the extent to which these patients ask questions of their physicians; how physicians respond; and what the relationship is between patients' questions and visit outcomes. We conducted in-depth mixed-method analyses of 322 audio recordings of primary care visits by people with mental health needs. We found that patients asked many questions-a median of fifteen per visit-but that they were more likely to ask about biomedical topics, such as diabetes, than about mental health topics. Patients received highly varied responses from physicians. Our findings suggest that efforts aimed at improving patient engagement should move beyond simply encouraging patients to ask questions. The goal should also be to support physicians in recognizing patients' concerns and providing the most responsive answers, as well as promoting strong relationships to undergird communication among all members of the care team.
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Affiliation(s)
- Ming Tai-Seale
- Department of Health Policy Research, Palo Alto Medical Foundation Research Institute, California, USA.
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McCuistion MH, Stults CD, Dohan D, Frosch DL, Hung DY, Tai-Seale M. Overcoming challenges to adoption of shared medical appointments. Popul Health Manag 2013; 17:100-5. [PMID: 24156662 DOI: 10.1089/pop.2013.0035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although research has shown many benefits of Shared Medical Appointments (SMAs) or group visits, uptake by physicians has been quite limited. The objective of this study was to explore the facilitators and barriers to implementing SMAs in a large multispecialty medical group. This was a comparative analysis of SMAs at 3 geographically distinct, semiautonomous divisions of the medical group based on qualitative themes identified in audio recorded key informant interviews with medical and administrative staff (n=12) involved with the implementation of SMAs. Data were collected by conducting key informant interviews focusing on the SMA implementation process, including motivations, history, barriers, and facilitators. Uptake at the 3 divisions was predicated by differing motivations, facilitators, and barriers. Divisions 1 and 2 allocated necessary resources including management support, a physician champion, expert consults, and support staff. These divisions also overcame physician reluctance and financial sustainability challenges. Despite early interest, Division 3 did not devote the time or resources to overcome initial resistance. Without the impetus of management mandate or a champion's enthusiasm, early attempts of SMA implementation faltered and were abandoned. In these cases, a physician champion, management support, and financial sustainability were judged to be the primary enablers of successful implementations of SMAs. Without these enablers and other contributing factors, implementing SMAs was challenging.
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Stone AL, Tai-Seale M, Stults CD, Luiz JM, Frankel RM. Three types of ambiguity in coding empathic interactions in primary care visits: implications for research and practice. Patient Educ Couns 2012; 89:63-68. [PMID: 22809831 PMCID: PMC3462251 DOI: 10.1016/j.pec.2012.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 05/17/2012] [Accepted: 06/14/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To describe three methodological challenges experienced in studying patients' expressions of emotion in a sample of periodic health exams, and the research and practice implications of these challenges. METHODS Qualitative analysis of empathic cues in audio-taped and transcribed periodic health examinations of adult patients (n=322) in an integrated delivery system. The empathic and potential empathic opportunities methodology was used. RESULTS Identifying emotional cues that constitute "empathic opportunities" is a complex task. Three types of ambiguity made this task particularly challenging: 1) presentations of emotional cues can be "fuzzy" and varied; 2) expressions of illness can be emotionally laden in the absence of explicit "emotion words"; and 3) empathic opportunities vary in length and intensity. CONCLUSION Interactional ambiguities pose a challenge to researchers attempting to document emotional cues with a binary coding scheme that indicates only whether an empathic opportunity is present or absent. Additional efforts to refine the methodological approach for studying empathy in medical interactions are needed. PRACTICE IMPLICATIONS The challenges discussed likely represent the same types of situations physicians find themselves in when talking with patients. Highlighting these ambiguities may aid physicians in better recognizing and meeting the emotional needs of their patients.
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