Publications by authors named "Thomas D Sequist"

121 Publications

Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis.

Acad Emerg Med 2021 09;28(9):957-965

Department of Emergency Medicine, Center for Social Justice and Health Equity, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: Research regarding disparities in physical restraint use in the emergency department (ED) is limited. We evaluated the role of race, ethnicity, and preferred language on the application of physical restraint among ED patients held under a Massachusetts section 12(a) order for mandatory psychiatric evaluation.

Methods: We identified all ED patient encounters with a section 12(a) order across a large integrated 11-hospital health system from January 2018 through December 2019. Information on age, race, ethnicity, preferred language, insurance, mental illness, substance use, history of homelessness, and in-network primary care provider was obtained from the electronic health record. We evaluated for differences in physical restraint use between subgroups via a mixed-effect logistic regression with random-intercept model.

Results: We identified 32,054 encounters involving a section 12(a) order. Physical restraints were used in 2,458 (7.7%) encounters. Factors associated with physical restraint included male sex (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.28 to 1.63), Black/African American race (aOR = 1.22, 95% CI = 1.01 to 1.48), Hispanic ethnicity (aOR = 1.45, 95% CI = 1.22 to 1.73), Medicaid insurance (aOR = 1.21, 95% CI = 1.05 to 1.39), and a diagnosis of bipolar disorder or psychotic disorder (aOR = 1.51, 95% CI = 1.31 to 1.74). Across all age groups, patients who were 25 to 34 years of age were at highest risk of restraint (aOR = 2.01, 95% CI = 1.69 to 2.39). Patients with a primary care provider within our network (aOR = 0.81, 95% CI = 0.72 to 0.92) were at lower risk of restraint. No associations were found between restraint use and language, history of alcohol or substance use, or homelessness.

Conclusion: Black/African American and Hispanic patients under an involuntary mandatory emergency psychiatric evaluation hold order experience higher rates of physical restraint in the ED. Factors contributing to racial disparities in the use of physical restraint, including the potential role of structural racism and other forms of bias, merits further investigation.
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http://dx.doi.org/10.1111/acem.14327DOI Listing
September 2021

Contributors to Gender Differences in Burnout and Professional Fulfillment: A Survey of Physician Faculty.

Jt Comm J Qual Patient Saf 2021 Aug 9. Epub 2021 Aug 9.

Background: This study was conducted to describe gender differences in physician burnout and professional fulfillment and to explore their potential contributors.

Methods: This was a single-center, cross-sectional survey study of physician faculty at Brigham and Women's Hospital, an academic medical center in Boston. The population included all physician faculty who practiced clinical medicine in 2017 (n = 2,388). The study was conducted using the Stanford Physician Wellness Survey. Burnout and professional fulfillment were the main outcome measures assessed. Other variables assessed included ratings of culture of wellness, personal resilience, and efficiency of practice factors associated with physician experience.

Results: The study population consisted of 1,066 faculty, of whom 46.4% were female and 59.8% were younger than 50. Female physicians reported significantly higher rates of burnout (42.4% vs. 34.4%, p = 0.01) and lower rates of professional fulfillment (35.1% vs. 50.4%, p < 0.01) than male physicians. Female physicians reported lower ratings for self-compassion and multiple culture of wellness factors. After adjusting for demographic factors and academic rank, the study team identified multiple culture of wellness factors (perceived appreciation, schedule control, work environment diversity and inclusion) and self-compassion as attenuating the significant relationship between gender and burnout. Only perceived appreciation attenuated the significant relationship between gender and professional fulfillment.

Conclusion: This study demonstrated higher rates of burnout and lower rates of professional fulfillment among female vs. male physician faculty. Culture of wellness factors and self-compassion may contribute to gender differences in burnout and professional fulfillment and potentially represent modifiable targets for efforts seeking to eliminate gender disparities in physicians' workplace experiences.
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http://dx.doi.org/10.1016/j.jcjq.2021.08.002DOI Listing
August 2021

Comparison of measures of medication adherence from pharmacy dispensing and insurer claims data.

Health Serv Res 2021 Aug 13. Epub 2021 Aug 13.

Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.

Objective: Medication nonadherence is linked to worsened clinical outcomes and increased costs. Existing system-level adherence interventions rely on insurer claims for patient identification and outcome measurement, yet suffer from incomplete capture and lags in data acquisition. Data from pharmacies regarding prescription filling, captured in retail dispensing, may be more efficient.

Data Sources: Pharmacy fill and insurer claims data.

Study Design: We compared adherence measured using pharmacy fill data to adherence using insurer claims data, expressed as proportion of days covered (PDC) over 12 months. Agreement was evaluated using correlation/validation metrics. We also explored the relationship between adherence in both sources and disease control using prediction modeling.

Data Extraction Methods: Large pragmatic trial of cardiometabolic disease in an integrated delivery network.

Principal Findings: Among 1113 patients, adherence was higher in pharmacy fill (mean = 50.0%) versus claims data (mean = 47.4%), although they had moderately high correlation (R = 0.57, 95% CI: 0.53-0.61) with most patients (86.9%) being similarly classified as adherent or nonadherent. Sensitivity and specificity of pharmacy fill versus claims data were high (0.89, 95% CI: 0.86-0.91 and 0.80, 95% CI: 0.75-0.85). Pharmacy fill-based PDC predicted better disease control slightly more than claims-based PDC, although the difference was nonsignificant.

Conclusions: Pharmacy fill data may be an alternative to insurer claims for adherence measurement.
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http://dx.doi.org/10.1111/1475-6773.13714DOI Listing
August 2021

Association Between Cost-Saving Prescription Policy Changes and Adherence to Chronic Disease Medications: an Observational Study.

J Gen Intern Med 2021 Jul 30. Epub 2021 Jul 30.

Center for Healthcare Delivery Sciences (C4HDS) and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.

Background: Pharmacy benefit design is one tool for improving access and adherence to medications for the management of chronic disease.

Objective: We assessed the effects of pharmacy benefit design programs, including a change in pharmacy benefit manager (PBM), institution of a prescription out-of-pocket maximum, and a mandated switch to 90 days' medication supply, on adherence to chronic disease medications over time.

Design: We used a difference-in-differences design to assess changes in adherence to chronic disease medications after the transition to new prescription policies.

Subjects: We utilized claims data from adults aged 18-64, on ≥ 1 medication for chronic disease, whose insurer instituted the prescription policies (intervention group) and a propensity score-matched comparison group from the same region.

Main Measures: The outcome of interest was adherence to chronic disease medications measured by proportion of days covered (PDC) using pharmacy claims.

Key Results: There were 13,798 individuals in each group after propensity score matching. Compared to the matched control group, adherence in the intervention group decreased in the first quarter of 2015 and then increased back to pre-intervention trends. Specifically, the change in adherence compared to the last quarter of 2014 in the intervention group versus controls was - 3.6 percentage points (pp) in 2015 Q1 (p < 0.001), 0.65 pp in Q2 (p = 0.024), 1.1 pp in Q3 (p < 0.001), and 1.4 pp in Q4 (p < 0.001).

Conclusions: In this cohort of commercially insured adults on medications for chronic disease, a change in PBM accompanied by a prescription out-of-pocket maximum and change to 90 days' supply was associated with short-term disruptions in adherence followed by return to pre-intervention trends. A small improvement in adherence over the year of follow-up may not be clinically significant. These findings have important implications for employers, insurers, or health systems wishing to utilize pharmacy benefit design to improve management of chronic disease.
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http://dx.doi.org/10.1007/s11606-021-07031-wDOI Listing
July 2021

Digital disparities: lessons learned from a patient reported outcomes program during the COVID-19 pandemic.

J Am Med Inform Assoc 2021 09;28(10):2265-2268

Mass General Brigham, Somerville, Massachusetts, USA.

The collection of patient reported outcomes (PROs) allows us to incorporate the patient's voice into their care in a quantifiable, validated manner. Large-scale collection of PROs is facilitated by the electronic health record and its portal, though, historically, patients have eschewed the portal and completed patient-reported outcome measures in the clinic via tablet. Furthermore, access and use of the portal is associated with known racial inequities. Our institution oversees the largest clinical PRO program in the world, and has a long history of racially equitable PRO completion rates via tablet. However, when the COVID-19 pandemic forced us to remove tablets from clinics and rely exclusively on portal use for PRO completion, profound racial disparities resulted immediately. Our experience quantifiably demonstrates the magnitude of inequity that the portal, in its current configuration, generates and serves as a cautionary tale to other health care systems and electronic health records.
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http://dx.doi.org/10.1093/jamia/ocab138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344913PMC
September 2021

Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation.

J Am Coll Cardiol 2021 Jun 3;77(25):3171-3179. Epub 2021 May 3.

Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value.

Objectives: This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events.

Methods: Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services.

Results: Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending.

Conclusions: Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.
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http://dx.doi.org/10.1016/j.jacc.2021.04.049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8091384PMC
June 2021

Vancomycin Infusion Reaction - Moving beyond "Red Man Syndrome".

N Engl J Med 2021 04 3;384(14):1283-1286. Epub 2021 Apr 3.

From the Divisions of Allergy and Clinical Immunology and of Clinical Pharmacology (S.A.A.) and the Department of Medicine (S.M.O.), Johns Hopkins University, and the Johns Hopkins Center for Health Equity (S.M.O.) - both in Baltimore; and the Department of Medicine, Brigham and Women's Hospital (T.D.S.), Harvard Medical School (T.D.S., K.G.B.), and the Division of Rheumatology, Allergy, and Immunology (C.M.B., K.G.B.), and the Edward P. Lawrence Center for Quality and Safety (K.G.B.), Massachusetts General Hospital - all in Boston.

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http://dx.doi.org/10.1056/NEJMp2031891DOI Listing
April 2021

Improving the Health of the American Indian and Alaska Native Population.

Authors:
Thomas D Sequist

JAMA 2021 Mar;325(11):1035-1036

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2021.0521DOI Listing
March 2021

The essential role of population health during and beyond COVID-19.

Am J Manag Care 2021 03;27(3):123-128

Department of Quality and Safety, Brigham and Women's Hospital, One Brigham Circle, Boston, MA 02115. Email:

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.
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http://dx.doi.org/10.37765/ajmc.2021.88511DOI Listing
March 2021

Differences in the use of telephone and video telemedicine visits during the COVID-19 pandemic.

Am J Manag Care 2021 01;27(1):21-26

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA 02120. Email:

Objectives: The coronavirus disease 2019 (COVID-19) pandemic forced health systems to offer video and telephone visits as in-person visit alternatives. Although video visits offer some benefits compared with telephone visits, they require complex setup, which may disadvantage some patients due to the "digital divide." Our objective was to determine patient and neighborhood characteristics associated with visit modality.

Study Design: This was a cross-sectional study across 1652 primary care and specialty care practices of adult patients at an integrated health system from April 23 to June 1, 2020.

Methods: We used electronic health record and administrative data. Our primary outcome was visit modality (in-person, video, or telephone), which was captured using billing codes. We assessed predictors of using video vs telephone using multivariable logistic regression. We used hierarchical logistic regression to determine the contribution of patient-, physician-, and practice-level components of variance in the choice of video or telephone visits.

Results: We analyzed 231,596 visits by 162,102 patients. Sixty-five percent of the visits were virtual (31.7% telephone, 33.5% video). Patients who were older than 65 years (adjusted odds ratio [AOR], 0.41; 95% CI, 0.40-0.43), Black (AOR, 0.60; 95% CI, 0.57-0.63), Hispanic (AOR, 0.76; 95% CI, 0.73-0.80), Spanish-speaking (AOR, 0.57; 95% CI, 0.52-0.61), and from areas with low broadband access (AOR, 0.93; 95% CI, 0.88-0.98) were less likely to use video visits. Practices (38%) and clinicians (26%) drove more of the variation in video visit use than patients (9%).

Conclusions: Telemedicine access differences may compound disparities in chronic disease and COVID-19 outcomes. Institutions should monitor video visit use across demographics and equip patients, clinicians, and practices to promote telemedicine equity.
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http://dx.doi.org/10.37765/ajmc.2021.88573DOI Listing
January 2021

Rationale and design of the Novel Uses of adaptive Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) pragmatic adaptive randomized trial: a trial protocol.

Implement Sci 2021 01 7;16(1). Epub 2021 Jan 7.

Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.

Background: The prescribing of high-risk medications to older adults remains extremely common and results in potentially avoidable health consequences. Efforts to reduce prescribing have had limited success, in part because they have been sub-optimally timed, poorly designed, or not provided actionable information. Electronic health record (EHR)-based tools are commonly used but have had limited application in facilitating deprescribing in older adults. The objective is to determine whether designing EHR tools using behavioral science principles reduces inappropriate prescribing and clinical outcomes in older adults.

Methods: The Novel Uses of Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) project uses a two-stage, 16-arm adaptive randomized pragmatic trial with a "pick-the-winner" design to identify the most effective of many potential EHR tools among primary care providers and their patients ≥ 65 years chronically using benzodiazepines, sedative hypnotic ("Z-drugs"), or anticholinergics in a large integrated delivery system. In stage 1, we randomized providers and their patients to usual care (n = 81 providers) or one of 15 EHR tools (n = 8 providers per arm) designed using behavioral principles including salience, choice architecture, or defaulting. After 6 months of follow-up, we will rank order the arms based upon their impact on the trial's primary outcome (for both stages): reduction in inappropriate prescribing (via discontinuation or tapering). In stage 2, we will randomize (a) stage 1 usual care providers in a 1:1 ratio to one of the up to 5 most promising stage 1 interventions or continue usual care and (b) stage 1 providers in the unselected arms in a 1:1 ratio to one of the 5 most promising interventions or usual care. Secondary and tertiary outcomes include quantities of medication prescribed and utilized and clinically significant adverse outcomes.

Discussion: Stage 1 launched in October 2020. We plan to complete stage 2 follow-up in December 2021. These results will advance understanding about how behavioral science can optimize EHR decision support to improve prescribing and health outcomes. Adaptive trials have rarely been used in implementation science, so these findings also provide insight into how trials in this field could be more efficiently conducted.

Trial Registration: Clinicaltrials.gov ( NCT04284553 , registered: February 26, 2020).
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http://dx.doi.org/10.1186/s13012-020-01078-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792313PMC
January 2021

Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit.

JAMA Netw Open 2020 12 1;3(12):e2029891. Epub 2020 Dec 1.

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.

Importance: For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care.

Objective: To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs.

Design, Setting, And Participants: Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020.

Exposure: Receipt of a given test within 1 week before or after the AWV.

Main Outcomes And Measures: Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed.

Results: Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests.

Conclusions And Relevance: In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.29891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733154PMC
December 2020

Digital triage: Novel strategies for population health management in response to the COVID-19 pandemic.

Healthc (Amst) 2020 Dec 26;8(4):100493. Epub 2020 Oct 26.

Brigham Digital Innovation Hub, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA; Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, 450 Brookline Avenue, Boston, MA, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA, USA. Electronic address:

The COVID-19 pandemic has created unique challenges for the U.S. healthcare system due to the staggering mismatch between healthcare system capacity and patient demand. The healthcare industry has been a relatively slow adopter of digital innovation due to the conventional belief that humans need to be at the center of healthcare delivery tasks. However, in the setting of the COVID-19 pandemic, artificial intelligence (AI) may be used to carry out specific tasks such as pre-hospital triage and enable clinicians to deliver care at scale. Recognizing that the majority of COVID-19 cases are mild and do not require hospitalization, Partners HealthCare (now Mass General Brigham) implemented a digitally-automated pre-hospital triage solution to direct patients to the appropriate care setting before they showed up at the emergency department and clinics, which would otherwise consume resources, expose other patients and staff to potential viral transmission, and further exacerbate supply-and-demand mismatching. Although the use of AI has been well-established in other industries to optimize supply and demand matching, the introduction of AI to perform tasks remotely that were traditionally performed in-person by clinical staff represents a significant milestone in healthcare operations strategy.
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http://dx.doi.org/10.1016/j.hjdsi.2020.100493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586929PMC
December 2020

Practice pattern of use of high sensitivity troponin in the outpatient settings.

Clin Cardiol 2020 Dec 22;43(12):1573-1578. Epub 2020 Oct 22.

Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: High-sensitivity troponin assays (hs-Tn) detect lower serum concentrations than prior-generation assays and help guide acute coronary syndrome (ACS) evaluation in emergency departments. Outpatient hs-Tn utilization is not well described.

Hypothesis: Outpatient providers use hs-TnT to triage patients with suspected ACS.

Methods: We compared the volume of outpatient prior-generation troponin tests in the pre-hsTn implementation period (January 2015-March 2018) with outpatient hs-TnT volume in the post-implementation period (April 2018-January 2020). Triage patterns were compared between patients with hs-TnT≥99th vs <99th percentile, using two-sample t tests. In patients triaged home, adverse events were compared between patients with hs-TnT≥99th vs <99th percentile, using log-rank tests.

Results: Across a large tertiary healthcare system, a mean of 80 prior-generation tests/month were ordered during the pre-hsTn implementation period compared with 12 hs-TnT tests/month in the post-implementation period. Prior-generation orders rose by 1.72 tests/month during pre-implementation, vs a decline of 2.74 hs-TnT tests/month during post-implementation (P < .001). Among 129 hs-TnT orders, most were placed by cardiologists (54%) and primary care providers (32%). Patient symptoms at the time of troponin ordering included dyspnea (34%) and chest pain (33%), although 25% were asymptomatic. Among symptomatic patients (n = 74), those with hs-TnT > 99th percentile were more likely to be sent to the ED (RR, 3.36; 95% CI, 1.22-9.25; P = .002). Among patients sent home (n = 66), those with hs-TnT > 99th percentile had more adverse events by 6 months (3.3% vs 22.2% RR, 6.67; 95% CI, 1.04-42.9; P = .026).

Conclusions: In this healthcare system, outpatient troponin utilization significantly declined since hs-TnT implementation. Some providers use hs-TnT to triage patients with suspected ACS to the ED; others test asymptomatic patients and some send patients home despite high hs-TnT values.
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http://dx.doi.org/10.1002/clc.23482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724219PMC
December 2020

Patient and Visit Characteristics Associated With Use of Direct Scheduling in Primary Care Practices.

JAMA Netw Open 2020 08 3;3(8):e209637. Epub 2020 Aug 3.

Harvard Medical School, Boston, Massachusetts.

Importance: Medical practices increasingly allow patients to schedule their own visits through online patient portals, yet little is known about who adopts direct scheduling or how this service is used.

Objective: To determine patient and visit characteristics associated with direct scheduling, visit patterns, and potential implications for access and continuity in the primary care setting.

Design, Setting, And Participants: This cross-sectional study used electronic health record (EHR) data from 17 adult primary care practices in a large academic medical center in the Boston, Massachusetts, area. Participants included patients 18 years or older who were attributed in the EHR to an active primary care physician at 1 of the included primary care practices, were enrolled in the patient portal, and had at least 1 visit to 1 of these practices between March 1, 2018, and March 1, 2019, the period of analysis. Data were analyzed from October 25, 2019, to April 14, 2020.

Main Outcomes And Measures: Adoption of direct scheduling, defined as at least 1 use during the study period. Usual scheduling was defined as scheduling with clinic staff by telephone or in person.

Results: We examined 134 225 completed visits by 62 080 patients (mean [SD] age, 51.1 [16.4] years, 37 793 [60.9%] women) attributed to 140 primary care physicians at 17 primary care practices. A total of 5020 patients (8.1% [95% CI, 7.9%-8.3%]) adopted direct scheduling, with an age range of 18 to 95 years. Compared with nonadopters in the same practices, adopters were younger (adjusted odds ratio [AOR] per additional year, 0.98 [95% CI, 0.98-0.99]) and were more likely to be White (AOR, 1.09 [95% CI, 1.01-1.17]) and commercially insured (AOR vs uninsured, 1.40 [95% CI, 1.11-1.76]) and to have more comorbidities (AOR per additional comorbidity, 1.07 [95% CI, 1.04-1.11]). Compared with usually scheduled visits, directly scheduled visits were more likely to be for general medical examinations (1979 visits [36.7%] vs 26 519 visits [21.9%]; P < .001) and with one's own primary care physician (5267 visits [95.2%] vs 94 634 visits [73.5%]; P < .001).

Conclusions And Relevance: These findings suggest that direct scheduling was associated with greater primary care continuity. Early adopters were more likely to be young, White, and commercially insured, and to the extent these differences persist as direct scheduling is used more widely, this service may widen socioeconomic disparities in primary care access.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.9637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453311PMC
August 2020

Changes in hospital admissions for urgent conditions during COVID-19 pandemic.

Am J Manag Care 2020 08;26(8):327-328

Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Email:

Objectives: To determine whether patients are deferring necessary care for urgent conditions during the coronavirus disease 2019 (COVID-19) pandemic and, if so, to what extent.

Study Design: Cross-sectional study.

Methods: Using billing data from 8 acute care hospitals, we identified 9 principal medical diagnoses from International Classification of Diseases, Tenth Revision codes across 4 medical specialties (cardiology, gastroenterology, neurology, and urology). In addition, we defined a combined obstetrical falsification end point. We compared daily admission rates during the pandemic period (3/1/2020-4/30/2020) with the same dates in 2019 (3/1/2019-4/30/2019). As a reference, we also compared a prepandemic period in the same years (1/1/2019-2/28/2019 and 1/1/2020-2/29/2020). We compared admission rates between years using t tests.

Results: There were 3219 admissions for the conditions of interest during the study period in 2019 and 2661 in 2020. There was no difference in prepandemic daily admission rates in 2020 compared with 2019 (29.04 vs 27.63 admissions per day; -4.9%; P = .50). During the pandemic period, there was a 33.7% decrease in admission rates for all conditions combined in 2020 compared with 2019 (24.68 vs 16.37; -33.7%; P = .03). By specialty, the combined gastroenterology (10.22 vs 7.20; -29.6%; P = .02) and cardiovascular (2.34 vs 1.29; -44.7%; P = .05) end points demonstrated reduction in daily admission rates.

Conclusions: Daily admission rates during the COVID-19 pandemic were lower for these acute medical conditions. Public awareness campaigns are urgently needed to reassure the public about the safety of presenting for care.
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http://dx.doi.org/10.37765/ajmc.2020.43837DOI Listing
August 2020

Comparison of a new 3-item self-reported measure of adherence to medication with pharmacy claims data in patients with cardiometabolic disease.

Am Heart J 2020 10 24;228:36-43. Epub 2020 Jun 24.

Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.

Background: Less than half of patients with cardiometabolic disease consistently take prescribed medications. While health insurers and some delivery organizations use claims to measure adherence, most clinicians do not have access during routine interactions. Self-reported scales exist, but their practical utility is often limited by length or cost. By contrast, the accuracy of a new 3-item self-reported measure has been demonstrated in individuals with HIV. We evaluated its concordance with claims-based adherence measures in cardiometabolic disease.

Methods: We used data from a recently-completed pragmatic trial of patients with cardiometabolic conditions. After 12 months of follow-up, intervention subjects were mailed a survey with the 3-item measure that queries about medication use in the prior 30 days. Responses were linearly transformed and averaged. Adherence was also measured in claims in month 12 and months 1-12 of the trial using proportion of days covered (PDC) metrics. We compared validation metrics for non-adherence for self-report (average <0.80) compared with claims (PDC <0.80).

Results: Of 459 patients returning the survey (response rate: 43.5%), 50.1% were non-adherent in claims in month 12 while 20.9% were non-adherent based on the survey. Specificity of the 3-item metric for non-adherence was high (month 12: 0.83). Sensitivity was relatively poor (month 12: 0.25). Month 12 positive and negative predictive values were 0.59 and 0.52, respectively.

Conclusions: A 3-item self-reported measure has high specificity but poor sensitivity for non-adherence versus claims in cardiometabolic disease. Despite this, the tool could help target those needing adherence support, particularly in the absence of claims data.
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http://dx.doi.org/10.1016/j.ahj.2020.06.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508975PMC
October 2020

Impact of Clinical Process Improvement Training in an Integrated Delivery System.

Am J Med Qual 2021 May-Jun 01;36(3):156-162

Massachusetts General Hospital, Boston, MA Harvard Medical School, Boston, MA Partners HealthCare, Boston, MA Dana-Farber Cancer Institute, Boston, MA Brigham and Women's Hospital, Boston, MA.

Multiple integrated health systems use frontline staff training in quality and process improvement, although the optimal method to determine training success remains unknown. The authors assessed the Partners Clinical Process Improvement Leadership Program's short-term impact by evaluating data in project presentations during 14 courses between 2010 and 2016. Long-term impact was assessed via a graduate survey. Among 262 interprofessional teams, 180 (69%) achieved short-term improvement, including 78 (30%) achieving and 102 (39%) demonstrating improvement toward their project goal. Projects implementing ≥2 interventions were more likely to succeed. Of 231 graduates surveyed, 79% reported the ability to lead and 67% reported actual work on additional quality improvement projects. Ninety-seven percent of alumni reported a positive career impact. Hospital leadership support of clinical process improvement training meets short-term improvement needs and promotes long-term capacity for learning health systems.
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http://dx.doi.org/10.1177/1062860620943960DOI Listing
August 2020

A multi-center analysis of cumulative inpatient opioid use in colorectal surgery patients.

Am J Surg 2020 11 2;220(5):1160-1166. Epub 2020 Jul 2.

Colorectal Surgery Center, Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, USA. Electronic address:

Background: There are little data on risk factors for increased inpatient opioid use and its relationship with persistent opioid use after colorectal surgery.

Methods: We identified colorectal surgery patients across five collaborating institutions. Patient comorbidities, surgery data, and outcomes were captured in the American College of Surgeons National Surgical Quality Improvement Program. We recorded preoperative opioid exposure, inpatient opioid use, and persistent use 90-180 days after surgery.

Results: 1646 patients were analyzed. Patients receiving ≥250 MMEs (top quartile) were included in the high use group. On multivariable analysis, age <65, emergent surgery, inflammatory bowel disease, and postoperative complications, but not prior opioid exposure, were predictive of high opioid use. Patients in the top quartile of use had an increased risk of persistent opioid use (19.8% vs. 9.7%, p < 0.001), which persisted on multivariable analysis (OR 1.48; p = 0.037).

Conclusions: We identified risk factors for high inpatient use that can be used to identify patients that may benefit from opioid sparing strategies. Furthermore, high postoperative inpatient use was associated with an increased risk of persistent opioid use.
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http://dx.doi.org/10.1016/j.amjsurg.2020.06.038DOI Listing
November 2020

Improving Allergy Documentation: A Retrospective Electronic Health Record System-Wide Patient Safety Initiative.

J Patient Saf 2020 Jun 1. Epub 2020 Jun 1.

From the Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital.

Objectives: Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been reported. The goal of this initiative was to systematically reduce free-text allergen entries in the EHR allergy module.

Methods: We assessed free-text allergy entries in a commercial EHR used at a multihospital integrated health care system in the greater Boston area. Using both manual and automated methods, a multidisciplinary consensus group prioritized high-risk and frequently used free-text allergens for conversion to coded entries, added new allergen entries, and deleted duplicate allergen entries. Environmental allergies were moved to the patient problem list.

Results: We identified 242,330 free-text entries, which included a variety of environmental allergies (42%), food allergies (18%), contrast media allergies (13%), "no known allergy" (12%), drug allergies (2%), and "no contrast allergy" (2%). Most free-text entries were entered by medical assistants in ambulatory settings (34%) and registered nurses in perioperative settings (20%). We remediated a total of 52,206 free-text entries with automated methods and 79,578 free-text entries with manual methods.

Conclusions: Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety. Additional strategies are required to completely eliminate free-text allergy entry, and establish systematic, consistent, and safe guidelines for documenting allergies.
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http://dx.doi.org/10.1097/PTS.0000000000000711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704710PMC
June 2020

Factors Associated With Increased Collection of Patient-Reported Outcomes Within a Large Health Care System.

JAMA Netw Open 2020 04 1;3(4):e202764. Epub 2020 Apr 1.

Partners Healthcare, Somerville, Massachusetts.

Importance: The collection of patient-reported outcomes (PROs) has garnered intense interest, but dissemination of PRO programs has been limited, as have analyses of the factors associated with successful programs.

Objective: To identify factors associated with improving PRO collection rates within a large health care system using a centralized PRO infrastructure.

Design, Setting, And Participants: This cohort study included 205 medical and surgical clinics in the Partners Healthcare system in Massachusetts that implemented a PRO program between March 15, 2014, and December 31, 2018, using a standardized centralized infrastructure. Data were analyzed from March to April 2019.

Exposures: Relevant clinical characteristics were recorded for each clinic launching a PRO program.

Main Outcomes And Measures: The primary outcome was the mean PRO collection rate during each clinic's most recent 6 months of collection prior to January 2019. Data were analyzed using a linear regression model with the 6-month PRO collection rate as the dependent variable and clinic characteristics as independent variables. Secondary analysis used a logistic regression model to assess clinical factors associated with successful clinics, defined as those that collected PROs at a rate greater than 50%.

Results: Between March 2014 and December 2018, 205 Partners Healthcare clinics were available for analysis, and 4 061 205 PRO measures from 745 028 encounters were collected. Among these, 103 clinics (50.2%) collected at a rate greater than 50%. Increased collection rates were associated with more than 50% of physicians in a clinic trained on PROs (change, 19.6% [95% CI, 9.9%-29.4%]; P < .001), routine administrative oversight of collection rates (change, 16.0% [95% CI, 6.6%-25.5%]; P = .001), previous collection of PROs on paper (change, 12.5% [95% CI, 4.7%-20.3%]; P = .002), presence of a clinical champion (change, 11.2% [95% CI, 2.5%-20.0%]; P = .01) and payer incentive (change, 10.5% [95% CI, 2.0%-18.9%]; P = .02).

Conclusions And Relevance: These findings suggest that training physicians on the use of PROs, administrative surveillance of collection rates, and the presence of a local clinical champion may be promising interventions for increasing PRO collection. Clinics that have previously collected PROs may have greater success in increasing collections. Payer incentive for collection was associated with improved collections, but not associated with successful programs.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.2764DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156989PMC
April 2020

Investing in the Health of American Indians and Alaska Natives.

JAMA Intern Med 2020 05;180(5):633-634

Division of General Internal Medicine, Department of Health Care Policy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2020.0189DOI Listing
May 2020

Prevalence and Impact of Having Multiple Barriers to Medication Adherence in Nonadherent Patients With Poorly Controlled Cardiometabolic Disease.

Am J Cardiol 2020 02 7;125(3):376-382. Epub 2019 Nov 7.

Department of Medicine, Center for Healthcare Delivery Sciences (C4HDS), Brigham and Women's Hospital (BWH) and Harvard Medical School, Boston, Massachusetts; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

Adherence to medications remains poor despite numerous efforts to identify and intervene upon nonadherence. One potential explanation is the limited focus of many interventions on one barrier. Little is known about the prevalence and impact of having multiple barriers in contemporary practice. Our objective was to quantify adherence barriers for patients with poorly controlled cardiometabolic condition, identify patient characteristics associated with having multiple barriers, and determine its impact on adherence. We used a linked electronic health records and insurer claims dataset from a large health system from a recent pragmatic trial. Barriers to medication taking before the start of the intervention were elicited by clinical pharmacists using structured interviews. We used multivariable modified Poisson regression models to examine the association between patient factors and multiple barriers and multivariable linear regression to evaluate the relation between multiple barriers and claims-based adherence. Of the 1,069 patients (mean: 61 years of age) in this study, 25.1% had multiple barriers to adherence; the most common co-occurring barriers were forgetfulness and health beliefs (31%, n = 268). Patients with multiple barriers were more likely to be non-white (relative risk [RR] 1.57, 95% confidence interval [CI] 1.21 to 1.74), be single/unpartnered (RR 1.36, 95% CI 1.06 to 1.74), use tobacco (RR 1.54, 95% CI 1.13 to 2.11), and have poor glycemic control (RR 1.77, 95% CI 1.31 to 2.39) versus those with 0 or 1 barrier. Each additional barrier worsened average adherence by 3.1% (95% CI -4.6%, -1.5%). In conclusion, >25% of nonadherent patients present with multiple barriers to optimal use, leading to meaningful differences in adherence. These findings should inform quality improvement interventions aimed at nonadherence.
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http://dx.doi.org/10.1016/j.amjcard.2019.10.043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957723PMC
February 2020

Cascades of Care After Incidental Findings in a US National Survey of Physicians.

JAMA Netw Open 2019 10 2;2(10):e1913325. Epub 2019 Oct 2.

Harvard Medical School, Boston, Massachusetts.

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally.

Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians.

Design, Setting, And Participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019.

Main Outcomes And Measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades.

Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions.

Conclusions And Relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.13325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806665PMC
October 2019

Envisioning health equity for American Indian/Alaska Natives: a unique HIT opportunity.

J Am Med Inform Assoc 2019 08;26(8-9):891-894

Office of the Chief Technology Officer, U.S. Department of Health and Human Services, Washington, DC, USA.

The Indian Health Service provides care to remote and under-resourced communities in the United States. American Indian/Alaska Native patients have some of the highest morbidity and mortality among any ethnic group in the United States. Starting in the 1980s, the IHS implemented the Resource and Patient Management System health information technology (HIT) platform to improve efficiency and quality to address these disparities. The IHS is currently assessing the Resource and Patient Management System to ensure that changing health information needs are met. HIT assessments have traditionally focused on cost, reimbursement opportunities, infrastructure, required or desired functionality, and the ability to meet provider needs. Little information exists on frameworks that assess HIT legacy systems to determine solutions for an integrated rural healthcare system whose end goal is health equity. This search for a next-generation HIT solution for a historically underserved population presents a unique opportunity to envision and redefine HIT that supports health equity as its core mission.
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http://dx.doi.org/10.1093/jamia/ocz052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6696492PMC
August 2019

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer.

Jt Comm J Qual Patient Saf 2019 08 6;45(8):552-557. Epub 2019 Jul 6.

Background: An ambulatory safety net (ASN) is an innovative organizational intervention for addressing patient safety related to missed and delayed diagnoses of abnormal test results. ASNs consist of a set of tools, reports and registries, and associated work flows to create a high-reliability system for abnormal test result management.

Methods: Two ASNs implemented at an academic medical center are described, one focusing on colon cancer and the other on lung cancer. Data from electronic registries and chart reviews were used to evaluate the effectiveness of the ASNs, which were defined as follows: colon cancer-the proportion of patients who were scheduled for or completed a colonoscopy following safety net team outreach to the patient; lung cancer-the proportion of patients for whom the safety net was able to identify and implement appropriate follow-up, as defined by scheduled or completed chest CT.

Results: The effectiveness of the colon cancer ASN was 44.0%, and the effectiveness of the lung cancer ASN was 56.9%. The ASNs led to the development of registries to address patient safety, fostered collaboration among interdisciplinary teams of clinicians and administrative staff, and created new work flows for patient outreach and tracking.

Conclusion: Two ASNs were successfully implemented at an academic medical center to address missed and delayed recognition of abnormal test results related to colon cancer and lung cancer. The ASNs are providing a framework for development of additional safety nets in the organization.
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http://dx.doi.org/10.1016/j.jcjq.2019.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545363PMC
August 2019

Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities.

JAMA Dermatol 2019 Aug;155(8):899-905

Division of General Internal Medicine, Massachusetts General Hospital, Boston.

Importance: Understanding geographic and financial barriers to health care is an important step toward creating more accessible health care systems. Yet, the barriers to dermatological care access for American Indian populations in rural areas have not been studied extensively.

Objective: To evaluate the driving distances and insurance coverage for dermatological care and the current availability of teledermatological programs within the Indian Health Service (IHS) or tribal hospitals system.

Design, Setting, And Participants: This mixed-methods study was conducted from May 7, 2018, to September 1, 2018, and did not take place in any IHS or tribal health care facility in the continental United States. The study design involved a geographic analysis and a cross-sectional telephone survey with brick-and-mortar dermatology clinics (n = 27) and teledermatological programs (n = 49). Brick-and-mortar clinics were selected for their proximity to a rural IHS or tribal hospital.

Main Outcomes And Measures: Mean driving distance from rural IHS or tribal hospital to nearest dermatology clinic, number of dermatology clinics within a 35-mile or 90-mile radius of IHS or tribal hospitals, insurance and referral types accepted by dermatology clinics, and number of teledermatological programs collaborating with IHS or tribal hospitals or health centers.

Results: In total, 27 brick-and-mortar dermatology clinics and 49 teledermatological programs were identified and contacted for the survey. The median (interquartile range [IQR]) driving distance between rural IHS or tribal hospitals and the nearest dermatology clinic was 68 (30-104) miles. Of the 27 dermatology clinics in closest proximity to rural IHS or tribal hospitals (median [IQR] driving distance, 82.4 [31-114] miles), 25 (93%) responded to the survey, 6 (22%) did not accept patients with Medicaid, and 6 (22%) did not accept IHS referrals for patients without insurance. Of the 49 teledermatological programs, 45 (92%) responded and 14 (29%) were no longer active. Ten (20%) teledermatology programs were currently partnering (n = 6), previously partnered (n = 2), or were setting up services (n = 2) with an IHS or tribal site. Only 9% (n = 27) of the 303 rural IHS or facility in the continental United States reported receiving teledermatological services.

Conclusions And Relevance: Substantial geographic and insurance coverage barriers to dermatological care exist for American Indian individuals in rural communities; teledermatological innovations could represent an important step toward minimizing the disparities in dermatological care access and outcomes.
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http://dx.doi.org/10.1001/jamadermatol.2019.0872DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6584892PMC
August 2019

Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries.

JAMA Intern Med 2019 Sep;179(9):1211-1219

Department of Medicine, Harvard Medical School, Boston, Massachusetts.

Importance: Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.

Objective: To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.

Design, Setting, And Participants: Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019.

Exposures: Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG.

Main Outcomes And Measures: Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade.

Results: Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade.

Conclusions And Relevance: Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.
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http://dx.doi.org/10.1001/jamainternmed.2019.1739DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547245PMC
September 2019
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