Publications by authors named "Kathryn Martinez"

50 Publications

Patient Experience in Virtual Visits Hinges on Technology and the Patient-Clinician Relationship: A Large Survey Study With Open-ended Questions.

J Med Internet Res 2021 Jun 21;23(6):e18488. Epub 2021 Jun 21.

Office of Patient Experience, Clinical Transformation, Cleveland Clinic, Cleveland, OH, United States.

Background: Patient satisfaction with in-person medical visits includes patient-clinician engagement. However, communication, empathy, and other relationship-centered care measures in virtual visits have not been adequately investigated.

Objective: This study aims to comprehensively consider patient experience, including relationship-centered care measures, to assess patient satisfaction during virtual visits.

Methods: We conducted a large survey study with open-ended questions to comprehensively assess patients' experiences with virtual visits in a diverse patient population. Adults with a virtual visit between June 21, 2017, and July 12, 2017, were invited to complete a survey of 21 Likert-scale items and textboxes for comments following their visit. Factor analysis of the survey items revealed three factors: experience with technology, patient-clinician engagement, and overall satisfaction. Multivariable logistic regression was used to test the associations among the three factors and patient demographics, clinician type, and prior relationship with the clinician. Using qualitative framework analysis, we identified recurrent themes in survey comments, quantitatively coded comments, and computed descriptive statistics of the coded comments.

Results: A total of 65.7% (426/648) of the patients completed the survey; 64.1% (273/426) of the respondents were women, and the average age was 46 (range 18-86) years. The sample was geographically diverse: 70.2% (299/426) from Ohio, 6.8% (29/426) from Florida, 4.2% (18/426) from Pennsylvania, and 18.7% (80/426) from other states. With regard to insurance coverage, 57.5% (245/426) were undetermined, 23.7% (101/426) had the hospital's employee health insurance, and 18.7% (80/426) had other private insurance. Types of virtual visits and clinicians varied. Overall, 58.4% (249/426) of patients had an on-demand visit, whereas 41.5% (177/426) had a scheduled visit. A total of 41.8% (178/426) of patients had a virtual visit with a family physician, 20.9% (89/426) with an advanced practice provider, and the rest had a visit with a specialist. Most patients (393/423, 92.9%) agreed that their virtual visit clinician was interested in them as a person, and their virtual visit made it easy to get the care they needed (383/421, 90.9%). A total of 81.9% (344/420) of respondents agreed or strongly agreed that their virtual visit was as good as an in-person visit by a clinician. Having a prior relationship with their virtual visit clinician was associated with less comfort and ease with virtual technology among patients (odds ratio 0.58, 95% CI 0.35-0.98). In terms of technology, patients found the interface easy to use (392/423, 92.7%) and felt comfortable using it (401/423, 94.8%). Technical difficulties were associated with lower odds of overall satisfaction (odds ratio 0.46, 95% CI 0.28-0.76).

Conclusions: Patient-clinician engagement in virtual visits was comparable with in-person visits. This study supports the value and acceptance of virtual visits. Evaluations of virtual visits should include assessments of technology and patient-clinician engagement, as both are likely to influence patient satisfaction.
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http://dx.doi.org/10.2196/18488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277398PMC
June 2021

Change in individual physicians' screening mammography completion rates following the updated USPSTF guideline supporting shared decision making: An observational cohort study.

Patient Educ Couns 2021 May 10. Epub 2021 May 10.

Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH 44195, USA.

Objective: To understand changes in physician screening practices in response to the 2009 U.S. Preventive Services Task Force recommendation supporting shared decision making (SDM) for mammography in women aged 40-49 years.

Methods: We assessed screening completion rates for physicians in the Cleveland Clinic Health System pre-2009 (2006-2008) and post-2009 (2010-2015), and rates for physicians new to the system post-2009. We used mixed effects logistic regression to estimate the odds of a woman receiving screening post-2009. If physicians practiced SDM, we hypothesized their screening rates would change after 2009. To test this, we included each physician's pre-2009 screening rate as a predictor in the model.

Results: Among 125 physicians, the screening rate increased from 40% to 45% from pre-2009 to post-2009. For physicians new to the health system post-2009 the rate was 32%. In the mixed effects model (N = 17,007), the strongest predictor of mammography receipt among patients post-2009 was their physician's pre-2009 screening rate (aOR:3.57 per 10% increase in pre-2009 rate; 95%CI:1.69-7.50).

Conclusions: Whether a woman received a mammogram post-2009 was highly associated with her physicians' pre-2009 screening rate, suggesting physicians are not individualizing screening decisions via SDM.

Practice Implications: Physicians may need support to effectively practice SDM.
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http://dx.doi.org/10.1016/j.pec.2021.05.011DOI Listing
May 2021

Comparison of National Data Sources to Assess Preventive Care in the US Population.

J Gen Intern Med 2021 Mar 31. Epub 2021 Mar 31.

Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s11606-021-06707-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012018PMC
March 2021

Soliciting Patients to Help Define Treatment Thresholds.

JAMA Netw Open 2021 03 1;4(3):e211181. Epub 2021 Mar 1.

Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.1181DOI Listing
March 2021

Association Between Pain, Blood Pressure, and Medication Intensification in Primary Care: an Observational Study.

J Gen Intern Med 2020 12 21;35(12):3549-3555. Epub 2020 Sep 21.

Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH, 44195, USA.

Background: Treating hypertension is important but physicians often do not intensify blood pressure (BP) treatment in the setting of pain.

Objective: To identify whether reporting pain is associated with (1) elevated BP at the same visit, (2) medication intensification, and (3) elevated BP at the subsequent visit.

Design: Retrospective cohort SETTING: Integrated health system PARTICIPANTS: Adults seen in primary care EXPOSURE: Pain status based on numerical scale: mild (1-3), moderate (4-6), or severe (≥ 7).

Main Measures: We defined elevated BP as ≥ 140/80 mmHg and medication intensification as increasing the dose or adding a new antihypertensive medication. Multilevel regression models were used to find the association between pain and (1) elevated BP at the index visit; (2) medication intensification at the index visit; and (3) elevated BP at the subsequent visit. Models adjusted for demographics, chronic conditions, and clustering within physician. In the third model, we adjusted for initial systolic BP as well.

Key Results: Our population included 56,322 patients; 3155 (6%) reported mild pain, 5050 (9%) reported moderate pain, and 4647 (8%) reported severe pain at the index visit. Compared with no pain, the adjusted odds ratios of elevated BP were 1.38 (95% CI: 1.28-1.48) for severe pain, 1.06 (95% CI: 0.99-1.14) for moderate pain, and 1.02 (95% CI: 0.93-1.12) for mild pain. Adjusted odds ratios of medication intensification at the index visit were 0.65 (95% CI: 0.54-0.80) for mild pain, 0.61 (95% CI: 0.52-0.72) for moderate pain, and 0.55 (95% CI: 0.47-0.64) for severe pain. Among patients with elevated BP at the index visit, reporting pain at the index visit was not associated with elevated BP at the subsequent visit.

Conclusions: When patients reported pain, physicians were less likely to intensify antihypertensive treatment; nevertheless, patients reporting pain were not more likely to have elevated BP at the subsequent visit.
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http://dx.doi.org/10.1007/s11606-020-06208-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728880PMC
December 2020

The Association Between Physician Race/Ethnicity and Patient Satisfaction: an Exploration in Direct to Consumer Telemedicine.

J Gen Intern Med 2020 09 6;35(9):2600-2606. Epub 2020 Jul 6.

Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA.

Background: Patient satisfaction measures have important implications for physicians. Patient bias against non-White physicians may impact physician satisfaction ratings, but this has not been widely studied.

Objective: To assess differences in patient satisfaction by physician race/ethnicity.

Design: A cross-sectional observational study.

Participants: Patients seeking care on a large nationwide direct to consumer telemedicine platform between July 2016 and July 2018 and their physicians.

Main Measures: Patient satisfaction was ascertained immediately following the encounter on scales of 1 to 5 stars and scored two ways: (1) top-box satisfaction (5 stars versus fewer) and (2) dissatisfaction (2 or fewer stars versus 3 or more). To approximate the information patients would use to make assumptions about physician race/ethnicity, four reviewers classified physicians into categories based on physician name and photo. These included White American, Black American, South Asian, Middle Eastern, Hispanic, and East Asian. Mixed effects logistic regression was used to assess differences in patient top-box satisfaction and patient dissatisfaction by physician race/ethnicity, controlling for patient characteristics, prescription receipt, physician specialty, and whether the physician trained in the USA versus internationally.

Key Results: The sample included 119,016 encounters with 390 physicians. Sixty percent were White American, 14% South Asian, 7% Black American, 7% Hispanic, 6% Middle Eastern, and 6% East Asian. Encounters with South Asian physicians (aOR 0.70; 95% CI 0.54-0.91) and East Asian physicians (aOR 0.72; 95% CI 0.53-0.99) were significantly less likely than those with White American physicians to result in top-box satisfaction. Compared to encounters with White American physicians, those with Black American physicians (aOR 1.72; 95% CI 1.12-2.64), South Asian physicians (aOR 1.77; 95% CI 1.23-2.56), and East Asian physicians (aOR 2.10; 95% CI 1.38-3.20) were more likely to result in patient dissatisfaction.

Conclusions: In our study, patients reported lower satisfaction with some groups of non-White American physicians, which may have implications for their compensation, professional reputation, and job satisfaction.
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http://dx.doi.org/10.1007/s11606-020-06005-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459065PMC
September 2020

Use of Direct-to-Consumer Telemedicine for Attention-Deficit Hyperactivity Disorder.

J Gen Intern Med 2020 11 9;35(11):3392-3394. Epub 2020 Jun 9.

Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s11606-020-05891-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661659PMC
November 2020

The Impact of Systematic Depression Screening in Primary Care on Depression Identification and Treatment in a Large Health Care System: A Cohort Study.

J Gen Intern Med 2020 11 3;35(11):3141-3147. Epub 2020 Jun 3.

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.

Background: Unless implementation of systematic depression screening is associated with timely treatment, quality measures based on screening are unlikely to improve outcomes.

Objective: To assess the impact of integrating systematic depression screening with clinical decision support on depression identification and treatment.

Design: Retrospective pre-post study.

Participants: Adults with a primary care visit within a large integrated health system in 2016 were included. Adults diagnosed with depression in 2015 or prior to their initial primary care visit in 2016 were excluded.

Intervention: Initiation of systematic screening using the Patient Health Questionnaire (PHQ) which began in mid-2016.

Main Measures: Depression diagnosis was based on ICD codes. Treatment was defined as (1) antidepressant prescription, (2) referral, or (3) evaluation by a behavioral health specialist. We used an adjusted linear regression model to identify whether the percentage of visits with a depression diagnosis was different before versus after implementation of systematic screening. An adjusted multilevel regression model was used to evaluate the association between screening and odds of treatment.

Key Results: Our study population included 259,411 patients. After implementation, 59% of patients underwent screening. Three percent scored as having moderate to severe depression. The rate of depression diagnosis increased by 1.2% immediately after systematic screening (from 1.7 to 2.9%). The percent of patients with diagnosed depression who received treatment within 90 days increased from 64% before to 69% after implementation (p < 0.01) and the adjusted odds of treatment increased by 20% after implementation (AOR 1.20, 95% CI 1.12-1.28, p < 0.01).

Conclusions: Implementing systematic depression screening within a large health care system led to high rates of screening and increased rates of depression diagnosis and treatment.
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http://dx.doi.org/10.1007/s11606-020-05856-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661597PMC
November 2020

Corticosteroid Use for Acute Respiratory Tract Infections in Direct-to-Consumer Telemedicine.

Am J Med 2020 08 5;133(8):e399-e405. Epub 2020 Mar 5.

Center for Value-Based Care Research, Cleveland Clinic, Ohio. Electronic address:

Background: Systemic corticosteroids are not indicated for acute respiratory tract infections yet are nonetheless prescribed in outpatient care. Acute respiratory tract infections are the most common diagnosis in direct-to-consumer telemedicine. The objective of this study was to characterize use of corticosteroids for acute respiratory tract infections in this setting and to assess the association between corticosteroid receipt and patient satisfaction.

Methods: Encounters with acute respiratory tract infection patients 18 years and older on a nationwide direct-to-consumer telemedicine platform were conducted by physicians between July 2016 and July 2018. Mixed-effects logistic regression was used to assess differences in the odds of corticosteroid prescription. A second mixed-effects model assessed differences in patient satisfaction by corticosteroid or antibiotic receipt. Adjusted prescribing rates for individual physicians were estimated. Models included diagnoses, patient age and geographic region, physician specialty and geographic region, and antibiotic prescription.

Results: Of the 85,972 encounters with 465 physicians, 11% resulted in the physician prescribing corticosteroids. The median physician prescribing rate was 4.0% (range: <1%-81%). Corticosteroid receipt was associated with higher satisfaction versus receiving nothing (odds ratio: 2.54; 95% confidence interval: 2.25-2.87). Patients who received both an antibiotic and a corticosteroid reported the highest satisfaction (odd ratio: 3.91; 95% confidence interval: 3.27-4.68). There was no correlation between individual physicians' corticosteroid and antibiotic prescribing rates.

Conclusions: Corticosteroid receipt was associated with patient satisfaction. Most physicians rarely prescribed corticosteroids, yet a small number prescribed them frequently. Identification of high-prescribing physicians for educational interventions could reduce use of corticosteroids for acute respiratory tract infections.
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http://dx.doi.org/10.1016/j.amjmed.2020.02.014DOI Listing
August 2020

Response to requests for contraception in one direct-to-consumer telemedicine service.

Contraception 2020 05 12;101(5):350-352. Epub 2020 Feb 12.

Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid, Ave, G10, Cleveland, OH 44195, United States. Electronic address:

Objective: To describe real-world care seeking and contraception provision in one direct to consumer telemedicine platform.

Study Design: We described encounters with reproductive age female patients between July 2016 and July 2018 seeking contraception on the American Well telemedicine platform.

Results: Of 126,712 total encounters with reproductive age women, 682 were with women seeking contraception, and 83% received it. The mean encounter length was 4.4 min versus 5.0 min for non-contraceptive visits. Insurance information was provided for 78% of contraceptive encounters versus 85% of non-contraceptive encounters, p < 0.001. Of the 27 encounters in which the patient requested emergency contraception, three did not result in such a prescription.

Conclusion: Direct to consumer telemedicine may increase access to contraceptives, yet overall use was uncommon. Most women seeking contraception via direct to consumer telemedicine on this platform received it. Three women who requested emergency contraception did not receive it, yet reasons for this are unknown.
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http://dx.doi.org/10.1016/j.contraception.2020.01.017DOI Listing
May 2020

Influenza Management via Direct to Consumer Telemedicine: an Observational Study.

J Gen Intern Med 2020 10 9;35(10):3111-3113. Epub 2020 Jan 9.

Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 99150, USA.

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http://dx.doi.org/10.1007/s11606-020-05640-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573037PMC
October 2020

Management of Urinary Tract Infections in Direct to Consumer Telemedicine.

J Gen Intern Med 2020 03 30;35(3):643-648. Epub 2019 Oct 30.

Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA.

Background: Urinary tract infections (UTI) are a common reason for seeking care via direct to consumer (DTC) telemedicine, yet patterns of care, including antibiotic prescribing, have not been reported.

Objective: To describe management of UTI in a large nationwide DTC telemedicine platform.

Design: Cross-sectional observational study.

Participants: Patients seeking care for or diagnosed with UTI via DTC telemedicine between July 2016 and July 2018.

Main Measures: Patient measures included age, sex, geographic region, satisfaction with care, and patient-reported call reason. High-risk patients were defined as males, patients over 65 years, or those diagnosed with pyelonephritis. Physician measures included specialty and geographic region. Antibiotic prescription was assessed overall and by antibiotic type. Variation in antibiotic prescriptions was assessed by patient and physician factors, including geographic region of both parties.

Key Results: Of the 20,600 patients diagnosed with a UTI during the study period, 96% were female. Most (84%) stated their call reason was a UTI. Overall, 94% of UTI patients received an antibiotic; 56% got nitrofurantoin, 29% got trimethoprim-sulfamethoxazole, and 10% got a quinolone. Receipt of an antibiotic was associated with higher satisfaction with care (p < 0.001). While nitrofurantoin was the most common antibiotic for all physician regions, antibiotic type varied by physician region. Of the 6% of the study population defined as high risk, 69% received an antibiotic: 72% of males, 91% of women over 65, and 21% of patients diagnosed with pyelonephritis.

Conclusions: Management of UTI via DTC telemedicine appears to be appropriate for average-risk patients, and most are able to self-diagnose. Most patients received guideline-concordant care, but over half of high-risk patients received antibiotics. DTC telemedicine offers convenient, low-cost care that is generally appropriate. Efforts should be made to ensure high-risk patients get proper follow-up.
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http://dx.doi.org/10.1007/s11606-019-05415-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080949PMC
March 2020

Impact of a system-wide quality improvement initiative on blood pressure control: a cohort analysis.

BMJ Qual Saf 2020 03 31;29(3):225-231. Epub 2019 Aug 31.

Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA.

Objective: To assess the impact of a quality improvement programme on blood pressure (BP) control and determine whether medication intensification or repeated measurement improved control.

Design: Retrospective cohort comparing visits in 2015 to visits in 2016 (when the programme started).

Subjects: Adults with ≥1 primary care visit between January and June in 2015 and 2016 and a diagnosis of hypertension in a large integrated health system.

Measures: Elevated BP was defined as a BP ≥140/90 mm Hg. Physician response was defined as: nothing; BP recheck within 30 days; or medication intensification within 30 days. Our outcome was BP control (<140/90 mm Hg) at the last visit of the year. We used a multilevel logistic regression model (adjusted for demographic and clinical variables) to identify the effect of the programme on the odds of BP control.

Results: Our cohort included 111 867 adults. Control increased from 72% in 2015 to 79% in 2016 (p<0.01). The average percentage of visits with elevated blood pressure was 31% in 2015 and 25% in 2016 (p<0.01). During visits with an elevated BP, physicians were more likely to intensify medication in 2016 than in 2015 (43% vs 40%, p<0.01) and slightly more likely to obtain a BP recheck (15% vs 14%, p<0.01). Among patients with ≥1 elevated BP who attained control by the last visit in the year, there was 6% increase from 2015 to 2016 in the percentage of patients who received at least one medication intensification during the year and a 1% increase in BP rechecks. The adjusted odds of the last BP reading being categorised as controlled was 59% higher in 2016 than in 2015 (95% CI 1.54 to 1.64).

Conclusion: A system-wide initiative can improve BP control, primarily through medication intensification.
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http://dx.doi.org/10.1136/bmjqs-2018-009032DOI Listing
March 2020

Patient Satisfaction and Antibiotic Prescribing for Respiratory Infections by Telemedicine.

Pediatrics 2019 09 1;144(3). Epub 2019 Aug 1.

Center for Value-Based Care Research, and

Background And Objectives: Respiratory tract infections (RTIs) are a common reason for direct-to-consumer (DTC) telemedicine consultation. Antibiotic prescribing during video-only DTC telemedicine encounters was explored for pediatric RTIs.

Methods: Encounter data were obtained from a nationwide DTC telemedicine platform. Mixed-effects regression was used to assess variation in antibiotic receipt by patient and physician factors as well as the association between antibiotic receipt and visit length or patient satisfaction.

Results: Of 12 842 RTI encounters with 560 physicians, antibiotics were prescribed in 55%. The provider was more likely to receive a 5-star rating from the parent when an antibiotic was prescribed (93.4% vs 80.8%). A 5-star rating was associated with a prescription for an antibiotic (odds ratio [OR] 3.38; 95% confidence interval [CI] 2.84 to 4.02), an antiviral (OR 2.56; 95% CI 1.81 to 3.64), or a nonantibiotic (OR 1.93; 95% CI 1.58 to 2.36). Visit length was associated with higher odds of a 5-star rating only when no antibiotic was prescribed (OR 1.03 per 6 seconds; 95% CI 1.01 to 1.06). Compared with nonpediatricians, pediatric providers were less likely to prescribe antibiotics (OR 0.44; 95% CI 0.29 to 0.68); however, pediatricians received higher encounter satisfaction ratings (OR 1.50; 95% CI 1.11 to 2.03).

Conclusions: During DTC telemedicine consultations for RTIs, pediatric patients were frequently prescribed antibiotics, which correlated with visit satisfaction. Although pediatricians prescribed antibiotics at a lower rate than other physicians, their satisfaction scores were higher. Further work is required to ensure that antibiotic use during DTC telemedicine encounters is guideline concordant.
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http://dx.doi.org/10.1542/peds.2019-0844DOI Listing
September 2019

Physician Empathy and Diabetes Outcomes.

J Gen Intern Med 2019 10;34(10):1967

Center for Value-Based Care Research , Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s11606-019-05188-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816582PMC
October 2019

Antibiotic Prescribing for Respiratory Tract Infections and Encounter Length.

Ann Intern Med 2019 07;171(2):150

Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio (K.A.M., M.B.R.).

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http://dx.doi.org/10.7326/L19-0264DOI Listing
July 2019

Balance Between Best Practice and Patient Satisfaction: Antimicrobial Stewardship in Telemedicine-Reply.

JAMA Intern Med 2019 04;179(4):589-590

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jamainternmed.2018.8772DOI Listing
April 2019

Cultural and Generational Considerations in RN Retention.

J Nurs Adm 2019 Apr;49(4):201-207

Author Affiliations: Associate Professor (Dr Dols), Assistant Professor (Dr Chargualaf), and Graduate Research Assistant (Ms Martinez), School of Nursing & Health Professions, University of the Incarnate Word, San Antonio, Texas.

Objective: The aim of this study was to identify evolving cultural and generational factors influencing nurse retention.

Background: Multigenerational/culturally diverse workforces challenge the nurse leader's understanding of nurse satisfaction.

Methods: A survey was designed to identify the RN's career intentions, desired leadership traits, and practice environment appraisal.

Results: While generally satisfied with their current position, generational differences in the average number of years nurses intend to stay at their current employer exist with Millennials anticipating staying 3.03 years; Generation X, 5.83 years; and Boomers, 8.25 years. Perceived inability to meet patient needs, which varied by generation, was significantly related to nurse satisfaction (P < .01). Factors identified by the nurses that may improve retention, regardless of generation, were pay, staffing, and nursing leadership support. Preferred leader traits varied by generation and ethnicity. Hispanic nurses value hardworking, honest leaders, whereas non-Hispanic nurses value dependability.

Conclusion: Nurse leaders must individualize efforts to retain an ethnically diverse and multigenerational nursing workforce.
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http://dx.doi.org/10.1097/NNA.0000000000000738DOI Listing
April 2019

Coding Bias in Respiratory Tract Infections May Obscure Inappropriate Antibiotic Use.

J Gen Intern Med 2019 06;34(6):806-808

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s11606-018-4823-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544729PMC
June 2019

Physician Empathy Is Not Associated with Laboratory Outcomes in Diabetes: a Cross-sectional Study.

J Gen Intern Med 2019 01 7;34(1):75-81. Epub 2018 Nov 7.

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.

Background: One widely cited study suggested a link between physician empathy and laboratory outcomes in patients with diabetes, but its findings have not been replicated. While empathy has a positive impact on patient experience, its impact on other outcomes remains unclear.

Objective: To assess associations between physician empathy and glycosylated hemoglobin (HgbA1c) as well as low-density lipoprotein (LDL) levels in patients with diabetes.

Design: Retrospective cross-sectional study.

Participants: Patients with diabetes who received care at a large integrated health system in the USA between January 1, 2011, and May 31, 2014, and their primary care physicians.

Main Measures: The main independent measure was physician empathy, as measured by the Jefferson Scale of Empathy (JSE). The JSE is scored on a scale of 20-140, with higher scores indicating greater empathy. Dependent measures included patient HgbA1c and LDL. Mixed-effects linear regression models adjusting for patient sociodemographic characteristics, comorbidity index, and physician characteristics were used to assess the association between physician JSE scores and their patients' HgbA1c and LDL.

Key Results: The sample included 4176 primary care patients who received care with one of 51 primary care physicians. Mean physician JSE score was 118.4 (standard deviation (SD) = 12). Median patient HgbA1c was 6.7% (interquartile range (IQR) = 6.2-7.5) and median LDL concentration was 83 (IQR = 66-104). In adjusted analyses, there was no association between JSE scores and HgbA1c (β = - 0.01, 95%CI = - 0.04, 0.02, p = 0.47) or LDL (β = 0.41, 95%CI = - 0.47, 1.29, p = 0.35).

Conclusion: Physician empathy was not associated with HgbA1c or LDL. While interventions to increase physician empathy may result in more patient-centered care, they may not improve clinical outcomes in patients with diabetes.
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http://dx.doi.org/10.1007/s11606-018-4731-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6318196PMC
January 2019

Antibiotic Prescribing for Respiratory Tract Infections and Encounter Length: An Observational Study of Telemedicine.

Ann Intern Med 2019 02 2;170(4):275-277. Epub 2018 Oct 2.

Cleveland Clinic, Cleveland, Ohio (K.A.M., M.R., N.J., A.B., M.B.R.).

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http://dx.doi.org/10.7326/M18-2042DOI Listing
February 2019

Patterns of Use and Correlates of Patient Satisfaction with a Large Nationwide Direct to Consumer Telemedicine Service.

J Gen Intern Med 2018 10 15;33(10):1768-1773. Epub 2018 Aug 15.

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.

Background: Despite its rapid expansion, little is known about use of direct to consumer (DTC) telemedicine.

Objective: To characterize telemedicine patients and physicians and correlates of patient satisfaction DESIGN: Cross-sectional study PARTICIPANTS: Patients and physicians of a large nationwide DTC telemedicine service MAIN MEASURES: Patient characteristics included demographics and whether or not they reported insurance information. Physician characteristics included specialty, board certification, and domestic versus international medical training. Encounter characteristics included time of day, wait time, length, coupon use for free or reduced-cost care, diagnostic outcome, prescription receipt, and patient/physician geographic concordance. Patients rated satisfaction with physicians on scales of 0 to 5 stars and reported where they would have sought care had they not used telemedicine. Logistic regression was used to assess factors associated with 5-star physician ratings.

Key Results: The analysis included 28,222 encounters between 24,040 patients and 277 physicians completed between January 2013 and August 2016. Sixty-five percent of patients were under 40 years and 32% did not report insurance information. Family medicine was the most common physician specialty (47%) and 16% trained at a non-US medical school. Coupons were used in 24% of encounters. Respiratory infections were diagnosed in 35% of encounters and 69% resulted in a prescription. Had they not used telemedicine, 43% of patients reported they would have used urgent care/retail clinic, 29% would have gone to the doctor's office, 15% would have done nothing, and 6% would have gone to the emergency department. Eighty-five percent of patients rated their physician 5 stars. High satisfaction was positively correlated with prescription receipt (OR 2.98; 95%CI 2.74-3.23) and coupon use (OR 1.47; 95%CI 1.33-1.62).

Conclusions: Patients were largely satisfied with DTC telemedicine, yet satisfaction varied by coupon use and prescription receipt. The impact of telemedicine on primary care and emergency department use is likely to be small under present usage patterns.
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http://dx.doi.org/10.1007/s11606-018-4621-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153236PMC
October 2018

Correlates and Outcomes of Physician Burnout-Reply.

JAMA Intern Med 2018 07;178(7):1000

Medicine Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jamainternmed.2018.2403DOI Listing
July 2018

Thromboembolic and Major Bleeding Events With Rivaroxaban Versus Warfarin Use in a Real-World Setting.

Ann Pharmacother 2018 Jan 23;52(1):19-25. Epub 2017 Aug 23.

1 Cleveland Clinic Health System, Cleveland, OH, USA.

Background: Although randomized trials demonstrate the noninferiority of rivaroxaban compared with warfarin in the context of nonvalvular atrial fibrillation (AF), little is known about how these drugs compare in practice.

Objective: To assess the relative effectiveness and safety of rivaroxaban versus warfarin in a large health system and to evaluate this association by time in therapeutic range (TTR).

Methods: We conducted a retrospective cohort study with propensity matching in the Cleveland Clinic Health System. The study included patients initiated on warfarin or rivaroxaban for thromboembolic prevention in nonvalvular AF between January 2012 and July 2016. The main outcomes were thromboembolic events and major bleeds. Analyses were stratified by warfarin patients' TTR.

Results: The cohort consisted of 472 propensity-matched pairs. The mean age was 73.6 years (SD = 11.7), and the mean CHADS score was 1.8. The median TTR for warfarin patients was 64%. In the propensity-matched analysis, there was no significant difference in thromboembolic or major bleeding events between groups. Among warfarin patients with a TTR <64% and their matched rivaroxaban pairs, there was also no significant difference in thromboembolic or major bleeding events.

Conclusions: Under real-world conditions, warfarin and rivaroxaban were associated with similar safety and effectiveness, even among those with suboptimal therapeutic control. Individualized decision making, taking into account the nontherapeutic tradeoffs associated with these medications (eg, monitoring, half-life, cost) is warranted.
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http://dx.doi.org/10.1177/1060028017727290DOI Listing
January 2018

Are Providers Prepared to Engage Younger Women in Shared Decision-Making for Mammography?

J Womens Health (Larchmt) 2018 01 28;27(1):24-31. Epub 2017 Jun 28.

1 Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio.

Background: The U.S. Preventive Services Task Force recommends providers engage women aged 40-49 years in shared decision-making (SDM) for mammography. This requires mammography knowledge, adequate time to discuss screening, and self-confidence in doing so. Yet, to date, no studies have assessed provider readiness to engage younger women in SDM.

Methods: An online survey of primary care providers was conducted in Cleveland in 2015. It inquired about knowledge of screening benefits and harms, including the impact of screening on mortality, risk of additional imaging, biopsy, overtreatment following screening, and likelihood of a true-positive result. Key knowledge was defined as accurate estimation of the impact of screening on mortality and risk of overtreatment. Respondents reported time typically spent with patients discussing mammography, self-assessed competence in engaging patients in screening discussions, and perspectives on SDM for mammography.

Results: Of 612 providers invited, 220 completed the survey (response rate: 36%). Knowledge of harms was low: 90% and 82% underestimated the risk of additional imaging or breast biopsy, respectively. Sixty-two percent correctly estimated screening's impact on mortality. The majority (83%) believed in SDM for mammography, yet, most (77%) spent less than 5 minutes with patients discussing screening. Of those who believed in SDM, only 10% had key mammography knowledge and also felt highly competent at engaging women in screening discussions.

Conclusions: Most providers in our sample were inadequately equipped to engage women in SDM for mammography. Broad-based efforts are needed to increase the capacity of providers to engage younger women in decision-making.
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http://dx.doi.org/10.1089/jwh.2016.6047DOI Listing
January 2018

Treatment experiences of Latinas after diagnosis of breast cancer.

Cancer 2017 Aug 11;123(16):3022-3030. Epub 2017 Apr 11.

Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan.

Background: The authors examined racial/ethnic differences in patient perspectives regarding their breast cancer treatment experiences.

Methods: A weighted random sample of women newly diagnosed with breast cancer between 2013 and 2015 in Los Angeles County and Georgia were sent surveys 2 months after undergoing surgery (5080 women; 70% response rate). The analytic sample was limited to patients residing in Los Angeles County (2397 women).

Results: The pattern of visits with different specialists before surgery was found to be similar across racial/ethnic groups. Low acculturated Latinas (Latinas-LA) were less likely to report high clinician communication quality for both surgeons and medical oncologists (<69% vs >72% for all other groups; P<.05). The percentage of patients who reported high satisfaction regarding how physicians worked together was similar across racial/ethnic groups. Latinas-LA were more likely to have a low autonomy decision style (48% vs 24%-50% for all other groups; P<.001) and were more likely to report receiving too much information versus other ethnic groups (20% vs <16% for other groups; P<.001). Patients who reported a low autonomy decision style were more likely to rate the amount of information they received for the surgery decision as "too much" (16% vs 9%; P<.001).

Conclusions: There appears to be moderate disparity in breast cancer treatment communication and decision-making experiences reported by Latinas-LA versus other groups. The approach to treatment decision making by Latinas-LA represents an important challenge to health care providers. Initiatives are needed to improve patient engagement in decision making and increase clinician awareness of these challenges in this patient population. Cancer 2017;123:3022-30. © 2017 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5544545PMC
August 2017

Divergent Responses to Mammography and Prostate-Specific Antigen Recommendations.

Am J Prev Med 2017 10 15;53(4):533-536. Epub 2017 Mar 15.

Cleveland Clinic, Center for Value-Based Care Research, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.amepre.2017.01.035DOI Listing
October 2017

Factors Associated with Routine Recommendation of Mammography for Women Aged 40-49: Provider Characteristics and Screening Influences.

South Med J 2017 02;110(2):129-135

From the Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio, the Department of Internal Medicine, University of Michigan, Ann Arbor, the Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth Medical Center, Cleveland, and the Division of General Internal Medicine, MetroHealth Medical Center, Cleveland, Ohio.

Objectives: Despite the US Preventive Services Task Force recommendation against screening mammography in women younger than 50 years, rates remain high, suggesting that screening recommendations may be motivated by other factors. The objective of this study was to understand provider-reported influences on screening recommendations for women 40 to 49 years old at average risk for breast cancer.

Methods: An online survey of primary care providers was conducted at four health centers in Cleveland, Ohio in 2015. Provider-reported routine recommendation of mammography for women aged 40 to 49 at average risk for breast cancer was the primary outcome. The independent measures included influence of electronic health records, national guidelines, institutional policy, patient preferences, concerns about overtreatment, concerns about false-positives, and interest in early detection on screening recommendations. We used multivariable logistic regression to estimate the odds of recommending screening by potential influences, controlling for provider characteristics and provider-assessed balance of harms and benefits of screening in this age group.

Results: Of 612 providers invited, 220 completed the survey (response rate 36%); 69% routinely recommended screening and 24% believed that the harms of screening in younger women outweighed the benefits. Being influenced by institutional policy was associated with higher odds of recommending screening (odds ratio [OR] 4.19, 95% confidence interval [CI] 1.35-12.9), as was interest in early detection (OR 4.19, 95% CI 1.31-12.9). Conversely, strong influence of national guidelines was associated with a lower odds of recommending screening (OR 0.25, 95% CI 0.09-0.71). The influence of patient preferences was not associated with screening recommendation.

Conclusions: Providers face competing influences on screening recommendations for younger patients, some of which may be at odds with their beliefs. Institutional policy change allowing individually tailored screening discussions may improve patient-centered care.
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http://dx.doi.org/10.14423/SMJ.0000000000000598DOI Listing
February 2017
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