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Rozenblum R, De La Cruz BA, Nolido NV, McNulty S, McManus KD, Halperin F, Block JP, Bates DW, Baer HJ. Primary care patients' and providers' perspectives about an online weight management program integrated with population health management: Post-intervention qualitative results from the PROPS study. PEC Innov 2022; 1:100057. [PMID: 37213741 PMCID: PMC10194385 DOI: 10.1016/j.pecinn.2022.100057] [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] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 05/12/2022] [Accepted: 06/07/2022] [Indexed: 05/23/2023]
Abstract
Objective To assess patients' and providers' attitudes about the online weight management program and population health management approach in the PROPS Study, which examined the effectiveness of these strategies in primary care. Methods We conducted semi-structured interviews with 22 patients and nine providers. Using thematic analysis, we analyzed transcripts of the interviews to identify key themes. Results Most patients found the online program to be well-structured and easy to use, although a few noted that the information was overwhelming or could be more personalized. Patients mentioned that the support from the population health managers was critical for their success, and several reported that they would have liked more involvement from their primary care provider or a dietitian. Providers also were satisfied with the interventions, and several stated that the population health management support was helpful because it added accountability. Providers suggested that the interventions could be improved by tailoring the information and integrating the online program with the electronic health record. Conclusion Most patients and providers were satisfied with the interventions, with several recommendations for improvements. Innovation These findings give additional information about patients' and providers' experience with this innovative approach for managing overweight and obesity in primary care.
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Affiliation(s)
- Ronen Rozenblum
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Florencia Halperin
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jason P. Block
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - David W. Bates
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Heather J. Baer
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Corresponding author at: Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont St, Boston, MA 02120, USA.
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Magny-Normilus C, Nolido NV, Borges JC, Brady M, Labonville S, Williams D, Soukup J, Lipsitz S, Hudson M, Schnipper JL. Effects of an Intensive Discharge Intervention on Medication Adherence, Glycemic Control, and Readmission Rates in Patients With Type 2 Diabetes. J Patient Saf 2021; 17:73-80. [PMID: 31009408 PMCID: PMC7647006 DOI: 10.1097/pts.0000000000000601] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Patients with diabetes are at particularly high risk for adverse outcomes after hospitalization. The goals of this study were to design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes. METHODS We randomly assigned inpatients likely to be discharged home on insulin to an intensive transitional care intervention or usual care. The primary outcome was 90-day postdischarge insulin adherence, using prescription refill information to calculate a medication possession ratio. Unadjusted analyses were conducted using Wilcoxon rank sum; adjusted analyses used multivariable linear regression and weighted propensity scoring methods, with general estimating equations to account for clustering by admitting physician. RESULTS One hundred eighty patients participated. The mean (SD) medication possession ratio to all insulin types was 84.5% (22.6) among intervention and 76.4% (25.1) among usual care patients (difference = 8.1, 95% confidence interval = -1.0 to 17.2, P = 0.06), with a smaller difference for adherence to all medications (86.3% versus 82.0%). A1c levels decreased in both groups but was larger in the intervention arm (1.09 and 0.11, respectively) (difference = -0.98, 95% confidence interval = -2.03 to -0.07, P = 0.04). Differences between study arms were not significant for rates of hypoglycemic episodes, 30-day readmissions, or emergency department visits. In adjusted/clustered analyses, the difference in A1c reduction remained statistically significant, whereas differences in all other outcomes remained nonsignificant. CONCLUSIONS The intervention was associated with improvements in glycemic control, with nonsignificant trends toward greater medication adherence. Further research is needed to optimize and successfully implement interventions to improve patient safety and health outcomes during care transitions.
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Affiliation(s)
- Cherlie Magny-Normilus
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Yale School of Nursing, West Haven, Connecticut
| | - Nyryan V. Nolido
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jorge C. Borges
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Maureen Brady
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stephanie Labonville
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Deborah Williams
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jane Soukup
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stuart Lipsitz
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Margo Hudson
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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3
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Baer HJ, Rozenblum R, De La Cruz BA, Orav EJ, Wien M, Nolido NV, Metzler K, McManus KD, Halperin F, Aronne LJ, Minero G, Block JP, Bates DW. Effect of an Online Weight Management Program Integrated With Population Health Management on Weight Change: A Randomized Clinical Trial. JAMA 2020; 324:1737-1746. [PMID: 33141209 PMCID: PMC7610192 DOI: 10.1001/jama.2020.18977] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 12/29/2022]
Abstract
IMPORTANCE Online programs may help with weight loss but have not been widely implemented in routine primary care. OBJECTIVE To compare the effectiveness of a combined intervention, including an online weight management program plus population health management, with the online program only and with usual care. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized trial with enrollment from July 19, 2016, through August 10, 2017, at 15 primary care practices in the US. Eligible participants had a scheduled primary care visit and were aged 20 to 70 years, had a body mass index between 27 and less than 40, and had a diagnosis of hypertension or type 2 diabetes. Follow-up ended on May 8, 2019. INTERVENTIONS Participants in the usual care group (n = 326) were mailed general information about weight management. Participants in the online program only group (n = 216) and the combined intervention group (n = 298) were registered for the online program. The participants in the combined intervention group also received weight-related population health management, which included additional support from nonclinical staff who monitored their progress in the online program and conducted periodic outreach. MAIN OUTCOMES AND MEASURES The primary outcome was weight change at 12 months based on measured weights recorded in the electronic health record. Weight change at 18 months was a secondary outcome. RESULTS Among the 840 participants who enrolled (mean age, 59.3 years [SD, 8.6 years]; 60% female; 76.8% White), 732 (87.1%) had a recorded weight at 12 months and the missing weights for the remaining participants were imputed. There was a significant difference in weight change at 12 months by group with a mean weight change of -1.2 kg (95% CI, -2.1 to -0.3 kg) in the usual care group, -1.9 kg (95% CI, -2.6 to -1.1 kg) in the online program only group, and -3.1 kg (95% CI, -3.7 to -2.5 kg) in the combined intervention group (P < .001). The difference in weight change between the combined intervention group and the usual care group was -1.9 kg (97.5% CI, -2.9 to -0.9 kg; P < .001) and the difference between the combined intervention group and the online program only group was -1.2 kg (95% CI, -2.2 to -0.3 kg; P = .01). At 18 months, the mean weight change was -1.9 kg (95% CI, -2.8 to -1.0 kg) in the usual care group, -1.1 kg (95% CI, -2.0 to -0.3 kg) in the online program only group, and -2.8 kg (95% CI, -3.5 to -2.0 kg) in the combined intervention group (P < .001). CONCLUSIONS AND RELEVANCE Among primary care patients with overweight or obesity and hypertension or type 2 diabetes, combining population health management with an online program resulted in a small but statistically significant greater weight loss at 12 months compared with usual care or the online program only. Further research is needed to understand the generalizability, scalability, and durability of these findings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02656693.
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Affiliation(s)
- Heather J. Baer
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Ronen Rozenblum
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Barbara A. De La Cruz
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Matthew Wien
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nyryan V. Nolido
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kristina Metzler
- Center for Clinical Investigation, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Florencia Halperin
- Harvard Medical School, Harvard University, Boston, Massachusetts
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Louis J. Aronne
- Intellihealth Inc, San Francisco, California
- Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine, New York, New York
| | | | - Jason P. Block
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - David W. Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
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4
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Baer HJ, De La Cruz BA, Rozenblum R, Nolido NV, Orav EJ, Metzler K, Block JP, Halperin F, McManus KD, Aronne LJ, Minero G, Bates DW. Integrating an online weight management program with population health management in primary care: Design, methods, and baseline data from the PROPS randomized controlled trial (Partnerships for Reducing Overweight and Obesity with Patient-centered Strategies). Contemp Clin Trials 2020; 95:106026. [PMID: 32428586 DOI: 10.1016/j.cct.2020.106026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 01/24/2020] [Revised: 04/24/2020] [Accepted: 05/09/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Scalable, low-cost weight management strategies are needed in primary care. We conducted a pragmatic, cluster-randomized controlled trial to examine the effectiveness of an online weight management program integrated with population health management support. METHODS We adapted an online weight management program and integrated it with population health management support in 15 primary care practices (24 clinics). We randomized the 24 clinics to usual care (UC), online program alone (OP), or combined intervention (CI). Eligible participants had to be ages 20 to 70 and have a recent primary care visit, body mass index (BMI) ≥ 27 and < 40 kg/m2, and a diagnosis of hypertension or type 2 diabetes. Participants attended routine visits and completed surveys over 18 months. The primary outcome is absolute weight change at 12 months (± 90 days) after enrollment, calculated from weights measured at primary care visits and recorded in the electronic health record. RESULTS We enrolled 840 participants between July 2016 and August 2017 (326 UC, 216 OP, and 298 CI.) At enrollment, participants' mean age was 59.3 years, their mean weight was 203.1 pounds, and their mean BMI was 32.5 kg/m2; 60% of participants were female, 76.8% were white, 96.4% had hypertension, and 24.4% had type 2 diabetes. CONCLUSION It is feasible to adapt an online weight management program and integrate it with population health management support in primary care. The results of this trial will provide valuable information about the effectiveness of these strategies in primary care settings. ClinicalTrials.govregistration number:NCT02656693.
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Affiliation(s)
- Heather J Baer
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.
| | - Barbara A De La Cruz
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Ronen Rozenblum
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Nyryan V Nolido
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States of America
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Kristina Metzler
- Department of Nutrition, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Jason P Block
- Harvard Medical School, Boston, MA, United States of America; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Florencia Halperin
- Harvard Medical School, Boston, MA, United States of America; Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Katherine D McManus
- Department of Nutrition, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Louis J Aronne
- BMIQ Professionals Program, Intellihealth/BMIQ, United States of America; Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine, New York, NY, United States of America
| | - Guadalupe Minero
- BMIQ Professionals Program, Intellihealth/BMIQ, United States of America
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
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5
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Mixon AS, Kripalani S, Stein J, Wetterneck TB, Kaboli P, Mueller S, Burdick E, Nolido NV, Labonville S, Minahan JA, Orav EJ, Goldstein J, Schnipper JL. An On-Treatment Analysis of the MARQUIS Study: Interventions to Improve Inpatient Medication Reconciliation. J Hosp Med 2019; 14:614-617. [PMID: 31433768 PMCID: PMC6817307 DOI: 10.12788/jhm.3308] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/24/2019] [Accepted: 05/30/2019] [Indexed: 11/20/2022]
Abstract
It is unclear which medication reconciliation interventions are most effective at reducing inpatient medication discrepancies. Five United States hospitals' interdisciplinary quality improvement (QI) teams were virtually mentored by QI-trained physicians. Sites implemented one to seven evidence-based interventions in 791 patients during the 25-month implementation period. Three interventions were associated with significant decreases in potentially harmful discrepancy rates: (1) defining clinical roles and responsibilities, (2) training, and (3) hiring staff to perform discharge medication reconciliation. Two interventions were associated with significant increases in potentially harmful discrepancy rates: training staff to take medication histories and implementing a new electronic health record (EHR). Hospitals should focus first on hiring and training pharmacy staff to assist with medication reconciliation at discharge and delineating roles and responsibilities of clinical staff. We caution hospitals implementing a large vendor EHR, as medication discrepancies may increase. Finally, the effect of medication history training on discrepancies needs further study.
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Affiliation(s)
- Amanda S Mixon
- GRECC, VA Tennessee Valley Healthcare System, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jason Stein
- Section of Hospital Medicine, Emory University School of Medicine, Atlanta,
Georgia, and 1Unit, Atlanta,
Georgia
| | - Tosha B Wetterneck
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Peter Kaboli
- Center for Access Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, Iowa, and Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Stephanie Mueller
- Hospital Medicine Unit, Brigham Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Elisabeth Burdick
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nyryan V Nolido
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Jacquelyn A Minahan
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- University of Kansas, Lawrence, Kansas
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Jeffrey L Schnipper
- Hospital Medicine Unit, Brigham Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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6
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Schnipper JL, Mixon A, Stein J, Wetterneck TB, Kaboli PJ, Mueller S, Labonville S, Minahan JA, Burdick E, Orav EJ, Goldstein J, Nolido NV, Kripalani S. Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. BMJ Qual Saf 2018; 27:954-964. [PMID: 30126891 DOI: 10.1136/bmjqs-2018-008233] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [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: 04/23/2018] [Revised: 07/09/2018] [Accepted: 07/17/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Unintentional discrepancies across care settings are a common form of medication error and can contribute to patient harm. Medication reconciliation can reduce discrepancies; however, effective implementation in real-world settings is challenging. METHODS We conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The intervention consisted of local implementation of medication reconciliation best practices, utilising an evidence-based toolkit with 11 intervention components. Trained QI mentors conducted monthly site phone calls and two site visits during the intervention, which lasted from December 2011 through June 2014. The primary outcome was number of potentially harmful unintentional medication discrepancies per patient; secondary outcome was total discrepancies regardless of potential for harm. Time series analysis used multivariable Poisson regression. RESULTS Across five sites, 1648 patients were sampled: 613 during baseline and 1035 during the implementation period. Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month (95% CI 0.86 to 1.08), p=0.53. The intervention was associated with a reduction in total medication discrepancies, IRR 0.92 per month (95% CI 0.87 to 0.97), p=0.002. Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR. CONCLUSIONS Mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. The effect of EHR implementation on medication discrepancies warrants further study. TRIAL REGISTRATION NUMBER NCT01337063.
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Affiliation(s)
- Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Amanda Mixon
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Jason Stein
- Internal Medicine, Emory University Hospital, Atlanta, Georgia, USA
| | - Tosha B Wetterneck
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter J Kaboli
- Internal Medicine, Iowa City VAMC and University of Iowa, Iowa City, Iowa, USA
| | - Stephanie Mueller
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie Labonville
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jacquelyn A Minahan
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Elisabeth Burdick
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Endel John Orav
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Jenna Goldstein
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Nyryan V Nolido
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sunil Kripalani
- Department of Medicine and Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee, USA
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7
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Dalal AK, Schaffer A, Gershanik EF, Papanna R, Eibensteiner K, Nolido NV, Yoon CS, Williams D, Lipsitz SR, Roy CL, Schnipper JL. The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial. J Gen Intern Med 2018; 33:1043-1051. [PMID: 29532297 PMCID: PMC6025668 DOI: 10.1007/s11606-018-4393-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/03/2018] [Accepted: 02/01/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up. KEY RESULTS Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03). CONCLUSIONS Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern. CLINICAL TRIALS IDENTIFIER NCT01153451.
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Affiliation(s)
- Anuj K Dalal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Adam Schaffer
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, MA, USA
| | - Esteban F Gershanik
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ranganath Papanna
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katyuska Eibensteiner
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Nyryan V Nolido
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Cathy S Yoon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Deborah Williams
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Partners HealthCare, Inc., Boston, MA, USA
| | - Stuart R Lipsitz
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christopher L Roy
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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8
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Abstract
BACKGROUND Although Axis I hypochondriasis is closely related to certain personality characteristics, the nature and extent of personality dysfunction in these patients still needs clarification. This study assessed the prevalence of personality disorders observed in hypochondriacal patients, described the types and comorbidity of personality disorders, and compared the psychological distress of patients with and without the most common comorbid personality disorder. METHOD One hundred fifteen patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for hypochondriasis completed self-administered assessments, including the Personality Diagnostic Questionnaire-4+ (PDQ-4+), the Hopkins Symptom Checklist-90-Revised (SCL-90-R), the Whiteley Index, and the Somatic Symptom Inventory. These data were taken from a study conducted between September 1997 and November 2001. RESULTS Eighty-eight patients (76.5%) had 1 or more personality disorders, whereas 27 patients (23.5%) had no personality disorders. Fifty-one patients (44.3%) had more than 3 personality disorders. The most common personality disorder in the hypochondriacal patients was obsessive-compulsive personality disorder (OCPD; 55.7%), followed by avoidant personality disorder (40.9%). The comorbidity of OCPD and avoidant personality disorder was 53.1% (34 of 64 patients with OCPD). The total PDQ-4+ score of the 64 patients with OCPD was significantly higher than that of the 51 patients without OCPD. On the SCL-90-R, the 64 patients with OCPD showed significantly higher scores on all of 3 global indices and 7 of 10 primary symptom dimensions (paranoid ideation, depression, anxiety, phobic anxiety, obsessive-compulsive, interpersonal sensitivity, and psychoticism) on the SCL-90-R compared to the 51 patients without OCPD. CONCLUSIONS The high prevalence of personality disorders, particularly OCPD, among patients with hypochondriasis suggests that consideration of personality features is important in assessment and therapeutic interventions for hypochondriasis.
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Affiliation(s)
- Reiko Sakai
- Department of Psychiatry, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
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