Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease

BACKGROUND

Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered.

OBJECTIVE

Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension.

DESIGN

Retrospective cohort study.

PATIENTS

Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years.

MAIN MEASURES

The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering.

KEY RESULTS

Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06).

CONCLUSIONS

Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

Overcoming Access Barriers for Veterans: Cohort Study of the Distribution and Use of Veterans Affairs' Video-Enabled Tablets Before and During the COVID-19 Pandemic

BACKGROUND

During the COVID-19 pandemic, as health care services shifted to video- and phone-based modalities for patient and provider safety, the Veterans Affairs (VA) Office of Connected Care widely expanded its video-enabled tablet program to bridge digital divides for veterans with limited video care access.

OBJECTIVE

This study aimed to characterize veterans who received and used US Department of VA-issued video-enabled tablets before versus during the COVID-19 pandemic.

METHODS

We compared sociodemographic and clinical characteristics of veterans who received VA-issued tablets during 6-month prepandemic and pandemic periods (ie, from March 11, 2019, to September 10, 2019, and from March 11, 2020, to September 10, 2020). Then, we examined characteristics associated with video visit use for primary and mental health care within 6 months after tablet shipment, stratifying models by timing of tablet receipt.

RESULTS

There was a nearly 6-fold increase in the number of veterans who received tablets in the pandemic versus prepandemic study periods (n=36,107 vs n=6784, respectively). Compared to the prepandemic period, tablet recipients during the pandemic were more likely to be older (mean age 64 vs 59 years), urban-dwelling (24,504/36,107, 67.9% vs 3766/6784, 55.5%), and have a history of housing instability (8633/36,107, 23.9% vs 1022/6784, 15.1%). Pandemic recipients were more likely to use video care (21,090/36,107, 58.4% vs 2995/6784, 44.2%) and did so more frequently (5.6 vs 2.3 average encounters) within 6 months of tablet receipt. In adjusted models, pandemic and prepandemic video care users were significantly more likely to be younger, stably housed, and have a mental health condition than nonusers.

CONCLUSIONS

Although the COVID-19 pandemic led to increased distribution of VA-issued tablets to veterans with complex clinical and social needs, tablet recipients who were older or unstably housed remained less likely to have a video visit. The VA's tablet distribution program expanded access to video-enabled devices, but interventions are needed to bridge disparities in video visit use among device recipients.

0479 Prescribing Patterns for Hypnotic Medication Among Adults Seeking CBTI Treatment: A Preliminary Report from the RESTING Study

Introduction

Use of prescription hypnotic medications is common among adults with chronic insomnia; however, little is known about prescribing patterns for hypnotic medication in middle-to-older age adults with insomnia disorder who seek to engage in cognitive behavioral therapy for insomnia (CBTI).

Methods

Participants were 235 adults aged 50 or older with insomnia disorder (mean age 63.1y [SD 7.7y], 73.6% women) enrolled in the ongoing Randomized Controlled Study on Effectiveness of Stepped-Care Sleep Therapy (RESTING). At screening, participants provided information about prescribed medications for sleep, insomnia severity (Insomnia Severity Index), daytime sleepiness (Epworth Sleepiness Scale), chronotype (Composite Morningness Questionnaire), depression (Geriatric Depression Scale) and physical and mental health (PROMIS Global-10, Physical and Mental Health Subscales).

Results

Of the 235 participants, 95 (40.4%) reported taking at least one medication prescribed to improve sleep. 26.5% were prescribed multiple medications (polypharmacy). Non-benzodiazepine receptor agonists (non-BzRAs) were the most common (prescribed to 51.6% of medication-using sample), followed by benzodiazepines (Bzs; 35.8%) and trazodone (20.0%). 25.2% of participants took a variety of other prescription medications at lower frequencies.Comparing patient characteristics for patients prescribed non-BzRAs, Bzs, and trazodone monotherapies, as well as polypharmacy, there were no significant differences in age, gender, insomnia severity or any other clinical characteristics, outside of modest associations within the PROMIS physical health scale (F[3,81]=2.78, p=.046); participants prescribed trazodone as monotherapy had significantly higher scores (better physical functioning) than participants prescribed non-BzRAs. Bzs were more likely to be prescribed as part of polypharmacy (52.9% of patients prescribed Bz) in the total medication using sample compared to those taking non-BzRAs (34.7%) or trazodone (36.8%; p<.001).

Conclusion

In this study, a high percentage of adults with insomnia seeking CBTI were also taking medications prescribed for sleep, including medications that are associated with increased risk (benzodiazepines, polypharmacy) or are not FDA-approved for insomnia (trazodone). Increasing prescriber knowledge about CBTI may promote adherence to the American Geriatric Society Beers Criteria for potentially inappropriate medication use in older adults. More research on how prescription patterns may differ among provider specialties could help target educational efforts to increase utilization of CBTI.

Support (If Any)

1R01AG057500

0467 Preference for Digital CBTI: Changes due to the COVID-19 Pandemic in a Randomized Controlled Trial of CBTI for Middle Aged and Older Adults

Introduction

Digital CBTI programs are effective at treating symptoms of insomnia. They also have the potential to increase treatment reach, convenience, and affordability for patients, and to reduce long wait times for behavioral sleep medicine providers. The COVID-19 pandemic has instigated an increased reliance on the use of technology for many. Thus, this study evaluates middle aged and older adults before and during the COVID-19 pandemic to assess: (1) differences in treatment modality preference (digital vs. therapist-led CBTI) and (2) sleep-related predictors of treatment modality preference.

Methods

Participants were older adults (N=229, 74% female, mean age=63.14) who were enrolled in the RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice (RESTING) study. At baseline, participants rated if they would prefer to access CBTI digitally or with a CBTI therapist, either in person or via telemedicine. After March 2020, in person was no longer listed as an option. Participants completed the Insomnia Severity Index (ISI) and a two-week sleep diary that allowed for an assessment of total sleep time (TST), sleep onset latency (SOL), and wake after sleep onset (WASO). Analyses compared responses to these items from participants completing assessments before March 2020 (Pre-Covid; n=74, 65% female, mean age=62.52) and after March 2020 (During-Covid; n=155, 78% female, mean age=63.44).

Results

Pre-Covid, 26% of participants preferred digital treatment, 47% of participants preferred a therapist-led intervention, and 27% did not express a preference. During-Covid, 35% of participants preferred digital treatment, 32% of participants preferred a therapist-led intervention, and 32% did not express a preference. This difference was statistically significant (c2=4.24, p=0.04). Responses were not significantly different between the first six months and the most recent six months of the pandemic (p=0.60). None of the sleep measures (ISI, TST, SOL, WASO) were associated with treatment modality preference in the full sample, Pre-Covid, or During-Covid.

Conclusion

The COVID-19 pandemic was associated with increased preference for digital CBTI among patients who are 50 and older, regardless of insomnia severity. Findings suggest that digital CBTI may be an acceptable treatment to many individuals with insomnia, thus increasing its dissemination potential.

Support (If Any)

R01AG057500 and T32MH019938

0468 Predictors of Response to Digital CBTI in a Randomized Controlled Trial of Middle Aged and Older Adults with Insomnia

Introduction

Digital CBTI (dCBTI) may serve as a good initial intervention in a stepped-care approach to treat insomnia. Understanding who is likely to respond to dCBTI can guide triaging of care, thus shortening wait times for those who most need to meet with an insomnia therapist. The purpose of this study was to examine baseline predictors of response to a dCBTI program after two months of access.

Methods

Participants were 173 middle aged and older adults with insomnia (M age=63.56 [SD=8.43], 76% female) who received the dCBTI SleepioTM for two months in the RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice (RESTING) study. Baseline predictors included the Epworth Sleepiness Scale (ESS), Dysfunctional Beliefs and Attitudes about Sleep (DBAS), preference for treatment (digital vs. therapist-delivered), and comfort with technology. At baseline and two-month follow-up, participants completed outcome measures, including the Insomnia Severity Index (ISI) and the PROMIS-Sleep Related Impairment (PROMIS-SRI). Multilevel modeling was used.

Results

In the full sample, no predictors were associated with change on the ISI. Among our predictors, only higher DBAS scores were associated with a smaller reduction in PROMIS-SRI scores from baseline to two-month follow-up (Beta=-0.88, SE=0.35, p=0.01 , 95% CI=-1.57, -0.19). Among those who preferred digital CBTI (n=52), none of the predictors were associated with the ISI or PROMIS-SRI. Among those who preferred therapist-led CBTI (n=66), greater comfort with technology was associated with greater reduction on the ISI (Beta=-1.77, S =0.78, p=0.02 , 95% CI=-3.30, -0.24) and higher DBAS scores were associated with a smaller reduction on the PROMIS-SRI (Beta=-1.63, S =0.56, p<0.01 , 95% CI=-2.73, -0.53).

Conclusion

The results highlight the importance of targeting dysfunctional beliefs and attitudes, which is consistent with research examining the DBAS in CBTI. Results also indicate that patient preference is an important factor to consider when triaging patients to insomnia care. While additional predictors should be examined, these preliminary findings indicate that dCBTI may be a good initial treatment option for those with high level of comfort using technology and lacking a preference for therapist-led CBTI.

Support (If Any)

R01AG057500 and T32MH019938

Factors That Influence How Providers Assess the Appropriateness of Virtual Visits: A Qualitative Investigation (Preprint)

Background

The rapid implementation of virtual care (ie, telephone or video-based clinic appointments) during the COVID-19 pandemic resulted in many providers offering virtual care with little or no formal training and without clinical guidelines and tools to assist with decision-making. As new guidelines for virtual care provision take shape, it is critical that they are informed by an in-depth understanding of how providers make decisions about virtual care in their clinical practices.

Objective

In this paper, we sought to identify the most salient factors that influence how providers decide when to offer patients video appointments instead of or in conjunction with in-person care.

Methods

We conducted semistructured interviews with 28 purposefully selected primary and specialty health care providers from the US Department of Veteran’s Affairs health care system. We used an inductive approach to identify factors that impact provider decision-making.

Results

Qualitative analysis revealed distinct clinical, patient, and provider factors that influence provider decisions to initiate or continue with virtual visits. Clinical factors include patient acuity, the need for additional tests or labs, changes in patients’ health status, and whether the patient is new or has no recent visit. Patient factors include patients’ ability to articulate symptoms or needs, availability and accessibility of technology, preferences for or against virtual visits, and access to caregiver assistance. Provider factors include provider comfort with and acceptance of virtual technology as well as virtual physical exam skills and training.

Conclusions

Providers within the US Department of Veterans Affairs health administration system consider a complex set of factors when deciding whether to offer or continue a video or telephone visit. These factors can inform the development and further refinement of decision tools, guides, and other policies to ensure that virtual care expands access to high-quality care.

Presence for racial justice: disrupting racism through physician-patient communication

Context: Anti-Black racism is firmly rooted in US healthcare, but many clinicians do not have the tools and language to question their biases and address racism in clinical practice, eg biased communication practices such as "non-compliance" in medical documentation. Objective: Presence 5 for Racial Justice (P5RJ) leverages the Presence 5 patient-provider communication framework to identify anti-racism communication practices that support trusting relationships between physicians and Black patients and empower Black individuals in clinical care. Study design: For this multi-phased community-based participatory research (CBPR) overseen by an advisory board of clinicians and patients at four community clinics, we conducted a literature review, interviews with Black patients, clinician small-group discussions, and design thinking interviews with non-medical professionals. We mapped emergent communication practices to Presence 5 domains to create P5RJ. Setting: Four primary care clinics primarily serving Black patients in Oakland CA; Rochester NY; Leeds AL; Memphis TN. Population Studied: Total 113 participants (40 non-medical interviews, 37 Black patients interviewed, 12 advisory board members, 24 clinicians in discussion); 30 reviewed articles. Outcomes: Strategies on how providers, through communication and connection in the clinical visit, can navigate and address structural, institutional, and personally mediated forms of racism faced by Black patients. Results: P5RJ practices included: 1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address emergent bias and social determinants of health; 2) Listen intently and completely by using focused interpersonal listening without interruption and deep listening for racism impacts; give patients time and space to tell their story; 3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort, consent, and referral planning; 4) Connect with the patient's story by acknowledging socio-political factors influencing patient health and focusing on positive efforts/events to encourage patient agency; 5) Explore emotional cues by noticing and naming patient emotions and considering how racial trauma might influence these emotions. Conclusion: P5RJ practices offer strategies to reflect on clinician biases, address racism and known gaps in care for Black patients and promote health equity in their clinical care.

PPE portraits: patient and clinician experiences at a COVID-19 testing site

Context: The COVID-19 pandemic mandated personal protective equipment (PPE) in healthcare settings, obscuring clinician faces and expressions, and depersonalizing patient care experiences. PPE Portraits (affixing a clinician's photo to the front of PPE) was first introduced in 2015 during the West Africa Ebola epidemic, and has been shown to help maintain patient-provider connection at times when patients may be fearful, isolated, and unable to identify clinicians caring for them. Objective: To evaluate patient and clinician experiences with PPE Portraits. Study Design: Implementation pilot with mixed methods evaluation. Setting: A drive-thru COVID-19 testing site affiliated with a large academic medical center. Population studied: Patients (n=18) and clinicians (n=6) interviewed in March-April 2020. Clinicians were recruited through convenience sampling. Clinicians answered questions via recorded interviews or email. Patients were interviewed by phone through random sampling stratified by date of service. Patients were sent a post-visit survey. Intervention: Health workers affixed a PPE Portrait in order to connect better with individuals in their care. Outcome Measures: Patient and clinician experiences with PPE Portraits (assessed through inductive coding of qualitative data) and patient experiences with fear (assessed through survey). Results: Patient surveys indicated varying levels of fear, including mild (16%), moderate (66%), and severe (18%). Patients reported that seeing the PPE Portrait was comforting; four patients stated that it did not impact their care because they already trusted the facility. Clinicians corroborated patient sentiments, reporting that the intervention humanized both the testing experience for patients and also the interactions among patients and clinicians. They noted that patients seemed more at ease and that portraits fostered connection and trust, thereby reducing anxiety and fear and signaling to patients that they were being given holistic, optimal care. A majority of clinicians felt this intervention should be replicated, and they recommended having surplus portrait supplies on site to facilitate ad hoc portrait creation. Conclusion: PPE Portraits humanized the COVID-19 testing experiences for patients and clinicians during a time of fear. Clinicians recommended PPE Portraits for other healthcare settings that require PPE. Future research could assess how PPE Portraits promote patient-provider connection and trust.

Black patient perceptions of COVID-19 vaccine, treatment, and testing

Context: The Presence for Racial Justice project leverages the Stanford Presence 5 framework to present anti-racism communication practices that promote clinician trust-building for Black patients in primary care. With the racial/ethnic disparities in COVID-19 infection rates, an assessment of Black patients' perspectives around COVID-19 care is required to promote health equity in current and future health crises. Objective: To compile clinician communication strategies for promotion of patient understanding and agency concerning Black patients' perceptions of COVID-19 vaccine, treatment and testing. Study design: Qualitative study employing inductive and deductive thematic analysis. Setting: Four primary care clinics primarily serving Black patients in Oakland, CA; Rochester, NY; Leeds, AL; and Memphis, TN. Population Studied: 37 Black patients, recruited through convenience sampling by their primary care clinician for 45-minute semi-structured audio-recorded interviews. Outcome Measures: Emergent themes around Black patient perceptions and motivations for seeking/delaying COVID-19 vaccine, treatment, and testing, and their ideal medical guidance on COVID-19 care. Results: Due to historic mistreatment of Black patients within the healthcare system, medicine, and research, there is a high prevalence of mistrust amongst the Black patient interviewees towards the safety, efficacy, and equitable distribution of the COVID-19 vaccine compared to existing vaccines. Patients feared racial discriminatory treatment and intended to wait for the general population, authority figures, and White patients to receive the vaccine first. Many patients believed personal protective behaviors (e.g., mask wearing, staying home, taking supplements) would be more effective than receiving the COVID-19 vaccine. They expressed a preference for receiving COVID-19 medical care in the comfort of their homes due to high costs and risks of maltreatment, death, and loneliness. Conclusion: Black patients hinged their vaccination decisions on having enough time to observe vaccine rollout and discussion with their clinicians. Relating new medical interventions (ie., COVID-19 vaccine) to accept medical approaches (ie., Flu vaccine) and being aware of historical distrust in medicine can inform clinician efforts to empower and provide excellent care for Black patients moving forward.

Presence 5 for Racial Justice Workshop: Fostering Dialogue Across Medical Education to Disrupt Anti-Black Racism in Clinical Encounters

INTRODUCTION

Anti-Black racism has strong roots in American health care and medical education. While curricula on social determinants of health are increasingly common in medical training, curricula directly addressing anti-Black racism are limited. Existing frameworks like the Presence 5 framework for humanism in medicine can be adapted to develop a novel workshop that promotes anti-racism communication.

METHODS

We performed a literature review of anti-racism collections and categorized anti-racism communication practices using the Presence 5 framework to develop the Presence 5 for Racial Justice Workshop. Implementation included an introductory didactic, a small-group discussion, and a large-group debrief. Participants evaluated the workshop via an online survey, and we analyzed the resulting qualitative feedback.

RESULTS

A total of 17 participants took part in two workshops, with nine of the participants responding to the evaluation survey. Themes that emerged from survey responses included strengths of and improvements for the workshop structure (protected time for anti-racism discussion, dialogue between learners and faculty) and content (specific phrases and language, practicing self-reflection).

DISCUSSION

The workshop provides participants with a semistructured discussion around the five anti-racism communication practices. Barriers to implementation include incorporating the workshop into existing curricula and ensuring diverse learners. Barriers to evaluating the workshop include the low survey response rate. Recommendations to improve the workshop include using case-based discussion and varying the workshop structure according to institutional needs. Next steps include an implementation study to evaluate the acceptability, feasibility, and effectiveness of the workshop.

A Web-Based Self-Management Intervention for Veterans With Chronic Conditions and Their Caregivers: A Pilot Study

Web-based Self-management Using Collaborative Coping Enhancement in Diseases (Web-SUCCEED) is a dyadic intervention for patients and their caregivers designed to improve self-management through improving dyadic stress coping, dyadic relationships, and positive emotions. Veterans Affairs (VA) patients with one or more chronic conditions and positive screen for self-management distress were recruited with their informal caregiver from VA Palo Alto. Of the 17 patients and 16 caregivers recruited (62.3% of eligible), 8 patients and 8 caregivers (48.5%) completed the intervention and assessments. Twelve participants withdrew mostly citing the stress of the pandemic as their reason; 5 did not respond to multiple outreach efforts. Veterans were 66□18 y and caregivers were 58□16 y. Veterans and caregivers who completed the program rated it high on usability and acceptability. Pre-post t-tests across a psychosocial battery did not reveal significant differences; results were limited by incomplete post-intervention data. Further testing with modified retention strategies is recommended.

Association Between Mental Health Conditions and Care Fragmentation: A National Study of High-Risk Older Veterans

Fragmented healthcare causes information loss, duplicative tests, and unwieldy self-care regimens. These challenges may be amplified among older, high-risk patients with co-occurring mental health conditions (MHC). We compared healthcare fragmentation for chronic physical conditions among Veterans with and without MHC (depression, PTSD, schizophrenia, bipolar disorder, anxiety, personality disorder, or psychosis based on ICD-9 codes). Sample included Veterans who were □65y, at high risk for 1-year hospitalization, and had □4 non-MHC visits during FY14. Visits were covered by Veterans Affairs (VA), VA-purchased care (both from VA Corporate Data Warehouse), or Medicare Parts A/B (claims data from VA Information Resource Center). Outcomes were two fragmentation measures calculated in FY15: 1) non-mental health provider count, where a higher number indicates more fragmentation, and 2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen provider, where a higher number indicates less fragmentation. We used Poisson regression and GLM with binomial distribution and logit link to test the association between MHC status and fragmentation, controlling for sociodemographic characteristics (e.g., age), medical comorbidity, and driving distance to VA. Of the 125,481 Veterans included, 47.3% had 1+ MHC. Compared to older, high-risk Veterans without MHC, those with MHC saw fewer providers (pseudo R2 = 0.02) and had a higher UPC (more concentrated care; OR = 1.07). Within the VA, older, high-risk Veterans with MHC do not experience greater healthcare fragmentation. Further research is needed to determine if this is due to different needs, underuse, or appropriate use of healthcare across the groups.

Use of Video-Enabled Tablet for Virtual Care Among Older Veterans

With the proliferation of virtual care, healthcare systems are exploring ways to bridge the digital divide among vulnerable patients. Department of Veterans Affairs (VA) is distributing devices for qualifying Veterans to enable video visits with medical providers at home, yet their use among older patients is unknown. This retrospective cohort study used administrative data to characterize the use of VA-loaned iPads among older Veterans compared to younger Veterans and identify demographic predictors of utilization. Among 16,385 patients who were shipped a VA-loaned iPad in 2014-2019, 33.66% (n=5,516) were over 65 years old, and 3.1% (n=503) were over the age of 85. Two thirds (n=6799) of younger patients had a video visit (mean=3 visits) with provider using iPad in the 6 months since shipment, compared to 50% (n=253) of 85+ year-olds (mean=1.8 visits). Most common types of virtual visits for the oldest old patients were for geriatrics or home-based primary care, compared to mental health visits among younger patients. Logistic regression identified characteristics of older patients who were more likely to use iPads, such a marital status, urban location, and lower disease burden, which is similar to their younger counterparts. While older age groups used VA-loaned tablets less frequently, those who engaged with the devices were similar in demographics as their younger counterparts. Older patients used iPads differently, with higher engagement in geriatric and primary care services. Providing devices for virtual care may allow health systems to more easily reach older patients in the comfort of their home.

"It's a disease of families": Neurologists' insights on how to improve communication and quality of life for families of Parkinson's disease patients

OBJECTIVES

Parkinson's disease presents an evolving challenge for patients and families due to an unpredictable disease trajectory and symptoms that complicate social interactions. In this study, we explore neurologists' perspectives on the challenges Parkinson's disease presents for families and the strategies they use to improve communication and quality of life.

METHODS

We conducted hour-long semi-structured interviews with 16 neurologists at 4 care delivery institutions in the San Francisco Bay Area, focusing on techniques neurologists use to support families through the Parkinson's disease journey.

RESULTS

Neurologists identified strategies for addressing caregiver-patient disagreements around symptom accuracy and negotiating driving safety. Family education is needed to contextualize patient symptoms and to identify psychosocial support resources. Unmet caregiver needs remain, particularly in the form of psychosocial support, respite care and support for unequal gender dynamics in the Parkinson's disease caregiving experience.

DISCUSSION

Family members of Parkinson's disease patients face unique caregiving and interpersonal challenges due to the nature of the disease. Targeted education and structural support are needed to alleviate current burdens and allow for improved patient- and family-centered care.

The genealogy of teaching clinical reasoning and diagnostic skill: the GEL Study

The genealogy of graduate medical education in America begins at the bedside. However, today's graduate medical trainees work in a training environment that is vastly different from medical training a century ago. The goal of the Graduate Medical Education Laboratory (GEL) Study, supported by the American Medical Association's (AMA) "Reimagining Residency" initiative, is to determine the factors in the training environment that most contribute to resident well-being and developing diagnostic skills. We believe that increasing time at the bedside will improve clinical skill, increase professional fulfillment, and reduce workplace burnout. Our graduate medical education laboratory will test these ideas to understand which interventions can be shared among all training programs. Through the GEL Study, we aim to ensure resident readiness for practice as we understand, then optimize, the learning environment for trainees and staff.

Neurologist Strategies for Optimizing the Parkinson's Disease Clinical Encounter

OBJECTIVE

For patients with Parkinson's disease (PD), effective communication during neurology encounters is critical to ensuring the treatment plan maximizes quality of life. However, few research studies have engaged neurologists as key experts in identifying opportunities to optimize the clinical encounter. In this study, 16 neurologists from 4 clinic sites participated in hour-long semistructured interviews targeting opportunities to better address patients' quality of life needs.

MAIN FINDINGS

Neurologists identified opportunities to meet needs across 4 domains: (1) PD patient education materials and self-management tools to facilitate clinical communication; (2) techniques for improving clinical communication, including strategies for eliciting nonmotor symptoms and contextualizing symptoms to better meet patient quality of life needs; (3) addressing system-level barriers, including time constraints and the lack of an identified specialist referral network; and (4) training in how to lead difficult conversations.

PRINCIPAL CONCLUSIONS

Neurologists identified specific barriers, and proposed solutions, to improving care delivery for patients with PD. Integrating practice tools to address quality of life needs, training neurologists in communication around end-of-life care, and strengthening referral networks for rehabilitation and psychosocial support hold promise for improving quality of life for patients with PD.

Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study

OBJECTIVE

To examine associations between clinics' extent of patient-centered medical home (PCMH) implementation and improvements in chronic illness care quality.

DATA SOURCE

Data from 808 Veterans Health Administration (VHA) primary care clinics nationwide implementing the Patient Aligned Care Teams (PACT) PCMH initiative, begun in 2010.

DESIGN

Clinic-level longitudinal observational study of clinics that received training and resources to implement PACT. Clinics varied in the extent they had PACT components in place by 2012.

DATA COLLECTION

Clinical care quality measures reflecting intermediate outcomes and care processes related to coronary artery disease (CAD), diabetes, and hypertension care were collected by manual chart review at each VHA facility from 2009 to 2013.

FINDINGS

In adjusted models containing 808 clinics, the 77 clinics with the most PACT components in place had significantly larger improvements in five of seven chronic disease intermediate outcome measures (e.g., BP < 160/100 in diabetes), ranging from 1.3 percent to 5.2 percent of the patient population meeting measures, and two of eight process measures (HbA1c measurement, LDL measurement in CAD) than the 69 clinics with the least PACT components. Clinics with moderate levels of PACT components showed few significantly larger improvements than the lowest PACT clinics.

CONCLUSIONS

Veterans Health Administration primary care clinics with the most PCMH components in place in 2012 had greater improvements in several chronic disease quality measures in 2009-2013 than the lowest PCMH clinics.

Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions: A Systematic Review

IMPORTANCE

Determining innovative approaches that better align health needs to the appropriate setting of care remains a key priority for the transformation of US health care; however, to our knowledge, no comprehensive assessment exists of alternative management strategies to hospital admission for acute medical conditions.

OBJECTIVE

To examine the effectiveness, safety, and cost of managing acute medical conditions in settings outside of a hospital inpatient unit.

EVIDENCE REVIEW

MEDLINE, Scopus, CINAHL, and the Cochrane Database of Systematic Reviews (January 1995 to February 2016) were searched for English-language systematic reviews that evaluated alternative management strategies to hospital admission. Two investigators extracted data independently on trial design, eligibility criteria, clinical outcomes, patient experience, and health care costs. The quality of each review was assessed using the revised AMSTAR tool (R-AMSTAR) and the strength of evidence from primary studies was graded according to the Oxford Centre for Evidence-Based Medicine.

FINDINGS

Twenty-five systematic reviews (representing 123 primary studies) met inclusion criteria. For outpatient management strategies, several acute medical conditions had no significant difference in mortality, disease-specific outcomes, or patient satisfaction compared with inpatient admission. For quick diagnostic units, the evidence was more limited but did demonstrate low mortality rates and high patient satisfaction. For hospital-at-home, a variety of acute medical conditions had mortality rates, disease-specific outcomes, and patient and caregiver satisfaction that were either improved or no different compared with inpatient admission. For observation units, several acute medical conditions were found to have no difference in mortality, a decreased length of stay, and improved patient satisfaction compared to inpatient admission; results for some conditions were more limited. Across all alternative management strategies, cost data were heterogeneous but showed near-universal savings when assessed.

CONCLUSIONS AND RELEVANCE

For low-risk patients with a range of acute medical conditions, evidence suggests that alternative management strategies to inpatient care can achieve comparable clinical outcomes and patient satisfaction at lower costs. Further study and application of such opportunities for health system redesign is warranted.

Association Between Acute Medical Exacerbations and Consuming or Producing Web-Based Health Information: Analysis From Pew Survey Data

Background

The Internet is an increasingly important resource for individuals who seek information from both health professionals and peers. While the demographic and health characteristics of persons who use health information technology has been well described, less is known about the relationship between these health characteristics and level of engagement with health information technology. Even less is known about whether persons who produce Web-based health information differ in health status from persons who consume such content.

Objective

We explored the health characteristics of persons who engage with the Internet for the purposes of consuming or producing Web-based health information, and specifically, whether healthier versus sicker persons engage with health information technology in different ways.

Methods

We analyzed data from the 2012 Pew Health survey, a landline and cell phone survey of 3104 adults in the United States. Using multiple logistic regression with sampling weights, we examined the association between sociodemographic and health characteristics and the consumption or production of Web-based health information. Sociodemographic variables included age, sex, race, and education. Health characteristics included self-reported health status, presence of chronic condition(s), and having an acute medical exacerbation. Acute medical exacerbations were defined as an emergency department visit, hospitalization, or other serious medical emergency in the last 12 months.

Results

The majority of the sample reported good or excellent health (79.7%), although 50.3% reported having at least one chronic condition. About a fifth (20.2%) of the sample experienced an acute medical exacerbation in the past year. Education was the sociodemographic characteristic most strongly associated with consuming Web-based health information. The strongest health-related predictors of consuming Web-based health information were an acute medical exacerbation (OR 2.39, P<.001) and having a chronic condition (OR 1.54, P=.007). Having an acute medical exacerbation was the only predictor of producing Web-based health information (OR 1.97, P=.003). All participants, regardless of health status, were most interested in Web-based health information regarding diseases or medical problems. However, persons with acute medical exacerbations were more likely to seek Web-based health information regarding medical tests, procedures, and drugs compared to persons without acute medical exacerbations.

Conclusions

Producers of Web-based health information differ from consumers of this information in important health characteristics that could skew the content of peer-generated Web-based health information and overrepresent the experiences of persons with acute medical exacerbations. Providers may have a role to play in directing patients towards high-quality, easy-to-understand online information, especially information regarding treatments and procedures.

UCLA mobile clinic project

We report on a man seeking care at the UCLA mobile clinic, illustrating and then discussing the challenges of caring for people who are homeless (especially mental illness and potential distrust of providers). Student-run free clinics can be beneficial but further research must examine how well such clinics meet homeless patients' needs.