Matulis, John C.

Bulk messaging is an important population health tool used to engage patients in preventive care and chronic disease management, yet little is known about optimal formatting of the communication. One factor to consider is whether the signatory of the patient-facing communication is the patient’s own Primary Care Provider (PCP) or a generic care team signature. In this quasi-randomized, non-blinded study we compared identical generic bulk outreach messages directed toward patients with an upcoming appointment and invited them to self-schedule a Medicare Annual wellness visit prior to their scheduled PCP appointment. Twenty-eight PCPs (1582 patients) were assigned to the PCP signature group, and 22 PCPs (1289 patients) to the care team signature group. The primary outcome was patient engagement, defined as a reply to the outreach message. Demographic, utilization, and rates of reading the bulk outreach message were similar between groups. Reply rates were significantly higher in the PCP signature group compared with the care team signature group (39.2% vs. 25.2%; odds ratio 1.86; P < 0.001). These findings suggest that using a patient’s own PCP signature in bulk outreach can meaningfully increase engagement, likely leveraging the trust inherent in established PCP–patient relationships. These results may inform health system leaders and population health teams seeking to optimize digital outreach strategies.

Abstract Background: While brief duration primary care appointments may improve access, they also limit the time clinicians spend evaluating painful conditions. This study aimed to evaluate whether 15-minute primary care appointments resulted in higher rates of opioid prescribing when compared to ≥30-minute appointments. Methods: We performed a retrospective cohort study using electronic health record (EHR), pharmacy, and administrative scheduling data from five primary care practices in Minnesota. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 scheduled for 15-minute appointments were propensity score matched to those scheduled for ≥30-minutes. Sub-groups were analyzed to include patients with acute and chronic pain conditions and prior opioid exposure. Multivariate logistic regression was performed to examine the effects of appointment length on the likelihood of an opioid being prescribed, adjusting for covariates including ethnicity, race, sex, marital status, and prior ED visits and hospitalizations. Results: We identified 45,471 eligible acute primary care visits during the study period with 2.7% (N=1233) of the visits scheduled for 15 minutes and 98.2% (N=44238) scheduled for 30 minutes or longer. Rates of opioid prescribing were significantly lower for opioid naive patients with acute pain scheduled in 15-minute appointments when compared to appointments of 30 minutes of longer (OR 0.55, 95% CI 0.35-0.84). There were no significant differences in opioid prescribing among other sub-groups. Conclusions: For selected indications and for selected patients, shorter duration appointments may not result in greater rates of opioid prescribing for common painful conditions.

Colorectal cancer (CRC) is the third-most lethal cancer in the USA, and early detection through screening is crucial for improving outcomes. However, significant disparities in access and utilisation of CRC screening exist among patients with limited English proficiency. Our Quality Improvement (QI) team developed and implemented a video, featuring a Somali-speaking physician, created with input from internal medicine (IM) residents, patient education experts and community leaders to increase the rate of CRC screening uptake within a Somali-speaking population receiving primary care within an IM Residency Clinic. The baseline proportion of average-risk Somali-speaking patients who had successfully been screened for CRC was 46.3% (63/134). The proportion of patients agreeable to undergo CRC screening was assessed monthly from the beginning of video implementation (June 2022 to December 2022). We found that this intervention corresponded with a significant increase in willingness to undergo CRC screening from 36.4% to 100% during the early stages of intervention. At the end of our measurement timeframe, the proportion of the original population fully screened for CRC was 50.7% (68/134). Implementation of the video intervention was also assessed and determined to be minimally disruptive to the clinic flow.

A rigorous evaluation of the implementation of a diabetes quality measure implementation program across community healthcare clinics in Shanghai, China, where both quality measurement and primary care delivery are relatively recent but centrally supported, identified important concerns about the meaningfulness, feasibility, and accuracy of quality measures that are relevant to all quality measurement programs. These include the importance of stakeholder involvement in measure development and implementation, the need to select measures that accurately and reliably reflect care quality, the link between incentives for improved performance and data manipulation, the necessity for scientific credibility and practical feasibility of the measure, and the assurance that measure performance can be impacted by those being evaluated. In addition to elaborating on these aspects of quality measurement, we also discuss the need for quality measures that are balanced across established domains of quality, are not burdensome to participants, and are transparent, parsimonious, nimble, and oriented around continuous evaluation and improvement.

A woman in her 60s with a history of hypertension and stasis dermatitis presented to a primary care clinic with a bilateral, erythematous rash on the legs, stomach, and chest. Photosensitive rash and dermatitis may be caused by many conditions. Hydrochlorothiazide-induced dermatitis is a rare side effect of thiazide diuretics. Early identification of sulfa-sensitivity and photoallergic or phototoxic reaction is essential to accurate diagnosis and treatment of photosensitive dermatitis. Soliciting a targeted history is essential to delineating drug-induced dermatitis from stasis dermatitis. A thorough skin examination can elucidate the focal or extensive nature of the rash and is essential to making an accurate diagnosis. Immediate cessation of hydrochlorothiazide and switching drugs classes for hypertension management typically leads to resolution of symptoms.

Abstract Objective Financial impacts associated with a switch to a different electronic health record (EHR) have been documented. Less attention has been focused on the patient response to an EHR switch. The Mayo Clinic was involved in an EHR switch that occurred at 6 different locations and with 4 different “go-live” dates. We sought to understand the relationship between patient satisfaction and the transition to a new EHR. Materials and Methods We used patient satisfaction data collected by Press Ganey from July 2016 through December 2019. Our patient satisfaction measure was the percent of patients responding “very good” (top box) to survey questions. Twenty-four survey questions were summarized by Press Ganey into 6 patient satisfaction domains. Piecewise linear regression was used to model patient satisfaction before and after the EHR switch dates. Results Significant drops in patient satisfaction were associated with the EHR switch. Patient satisfaction with access (ease of getting clinic on phone, ease of scheduling appointments, etc.) was most affected (range of 6 sites absolute decline: -3.4% to -8.8%; all significant at 99% confidence interval). Satisfaction with providers was least affected (range of 6 sites absolute decline: -0.5% to -2.8%; 4 of 6 sites significant at 99% confidence interval). After 9-15 months, patient satisfaction with access climbed back to pre-EHR switch levels. Conclusions Patient satisfaction in several patient experience domains dropped significantly and stayed lower than pre–“go-live” for several months after a switch in EHR. Satisfaction with providers declined less than satisfaction with access.

Abstract Background Little is known about how practicing Internal Medicine (IM) clinicians perceive diagnostic error, and whether perceptions are in agreement with the published literature. Methods A 16-question survey was administered across two IM practices: one a referral practice providing care for patients traveling for a second opinion and the other a traditional community-based primary care practice. Our aim was to identify individual- and system-level factors contributing to diagnostic error (primary outcome) and conditions at greatest risk of diagnostic error (secondary outcome). Results Sixty-five of 125 clinicians surveyed (51%) responded. The most commonly perceived individual factors contributing to diagnostic error included atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). The most commonly cited system-level factors included cognitive burden created by the volume of data in the electronic health record (EHR) (68%), lack of time to think (64%) and systems that do not support collaboration (40%). Conditions felt to be at greatest risk of diagnostic error included cancer (46%), pulmonary embolism (43%) and infection (37%). Conclusions Inadequate clinician time and sub-optimal patient and test follow-up are perceived by IM clinicians to be persistent contributors to diagnostic error. Clinician perceptions of conditions at greatest risk of diagnostic error may differ from the published literature.