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Background: Chronic pain and problematic substance use are prevalent among Veterans with homeless experience (VHE) and may contribute to a challenging primary care experience. Objective: To examine the association of chronic pain and problematic substance use with unfavorable primary care experiences among VHE and to explore the association of pain treatment utilization and unfavorable care experiences in VHE with chronic pain. Methods: We surveyed VHE (n = 3039) engaged in homeless-tailored primary care at 29 Veterans Affairs Medical Centers (VAMCs). We assessed unfavorable primary care experiences with four validated Primary Care Quality-Homeless (PCQ-H) scales: multivariable logistic regressions explored associations between unfavorable care experiences for VHE with chronic pain and problematic substance use, chronic pain alone, problematic substance use alone, or neither. We then examined the association between receipt of pain treatments and unfavorable experiences among VHE with chronic pain. Last, we identified PCQ-H items that had the greatest difference in unfavorable response rates between VHE with and without chronic pain. Results: The prevalence of unfavorable primary care experience was higher on all four scales for patients reporting chronic pain (with or without problematic substance use) (all p < 0.001), but not for problematic substance use alone, compared to VHE with neither pain nor problematic substance use. In analyses limited to VHE with chronic pain, those on long-term opioids were less likely to report an unfavorable experience (OR = 0.49, 95%CI 0.34–0.69). Receipt of occupational therapy was associated with lower odds of reporting an unfavorable experience (OR = 0.83, 95%CI 0707–0.98). PCQ-H items related to trust, relationships, and provider communication had the greatest differences in dissatisfaction ratings (all p < 0.001). Conclusions: Chronic pain is associated with unfavorable primary care experiences among VHE, potentially contributing to poor care outcomes. Strategies are needed to enhance patient-provider trust and communication and increase VHE's access to effective pain treatments. [ABSTRACT FROM AUTHOR]

Objective: To identify organizational service features associated with positive patient ratings of primary care within primary care clinics tailored to accommodate persons with ongoing and recent experiences of homelessness (PEH). Data Sources and Study Setting: PEH receiving primary care in 29 United States Veterans Health Administration homeless‐tailored clinics were surveyed about their primary care experience using the validated Primary Care Quality‐Homeless (PCQ‐H) survey. Characteristics of the clinics were assessed through surveys of clinic staff using a new organizational survey developed through literature review, site visits, statistical analysis, and consensus deliberation. Study Design: Cross‐sectional examination of patients' ratings of care based on surveys of patients, and of clinic characteristics, analyzed with Classification and Regression Tree (CART) analysis, a form of machine learning. Data Collection Methods: Patient surveys (n = 3394) were obtained from a random sample of enrolled patients by both mail and telephone by an external survey contractor. Staff (n = 52 from 29 clinics) were interviewed by telephone. Principal Findings: This analysis identified service features that impact patient experience favorably, including aspects of patient‐centeredness, team identity, strong external leadership support, and service that reach beyond traditional primary care clinic confines. Results varied according to the patient experience scale analyzed. Individual characteristics of PEH, such as degree of social support, general health, and unsheltered status, were also correlated with how they rate care. Conclusions: Organizational characteristics correlate with ratings of primary care from patients with recent and ongoing homelessness. Primary care programs serving homeless individuals can assure better care based on who they hire, how they foster team identity, what services they provide, and the strength of leadership support to protect a homeless‐focused mission. [ABSTRACT FROM AUTHOR]

Healthcare delivery is currently undergoing major structural reform, and the Learning Health System (LHS) has been proposed as an aspirational model to guide healthcare transformation. As efforts to build LHS take considerable investment from health systems, it is critical to understand their leaders' perspectives on the rationale for pursuing an LHS and the potential benefits for doing so. This paper describes the qualitative analysis of semi-structured interviews (n = 17) with health system leaders about their general perceptions of the LHS, description of key attributes and potential benefits, and perception of barriers to and facilitators for advancing the model. Participants universally endorsed the goal of the local health system aspiring to become an LHS. Participants identified many recognized attributes of LHS, though they emphasized unique attributes and potential benefits. There was also heterogeneity in participants' views on what to prioritize, how to structure the local LHS within existing initiatives, and how new initiatives should be implemented. Improving conceptual clarity of attributes of the LHS would improve its potential in guiding future reform. [ABSTRACT FROM AUTHOR]

The article presents the discussion on identifying a potential ethical conflict between the principles of beneficence and respect for patient autonomy. Topics include patients refuse to remain in an emergency department (ED) for observation after overdose reversal with naloxone; and purported conflict between beneficence and autonomy maps poorly to this situation.

Surveys of underserved patient populations are needed to guide quality improvement efforts but are challenging to implement. The goal of this study was to describe recruitment and response to a national survey of Veterans with homeless experience (VHE). We randomly selected 14,340 potential participants from 26 U. S. Department of Veterans Affairs (VA) facilities. A survey contract organization verified/updated addresses from VA administrative data with a commercial address database, then attempted to recruit VHE through 4 mailings, telephone follow-up, and a $10 incentive. We used mixed-effects logistic regressions to test for differences in survey response by patient characteristics. The response rate was 40.2% (n = 5766). Addresses from VA data elicited a higher response rate than addresses from commercial sources (46.9% vs 31.2%, p <.001). Residential addresses elicited a higher response rate than business addresses (43.8% vs 26.2%, p <.001). Compared to non-respondents, respondents were older, less likely to have mental health, drug, or alcohol conditions, and had fewer VA housing and emergency service visits. Collectively, our results indicated a national mailed survey approach is feasible and successful for reaching VA patients who have recently experienced homelessness. These findings offer insight into how health systems can obtain perspectives of socially disadvantaged groups. Abbreviations: H-PACTS: Homeless-Patient Aligned Care Teams; SHEP: Survey of Healthcare Experiences of Patients; SRG: Strategic Research Group; USPS: United States Postal Service; VA: U.S. Department of Veterans Affairs; VHE: veterans with homeless experience [ABSTRACT FROM AUTHOR]

Surveys of people who experience homelessness can portray their life and healthcare experiences with a level of statistical precision; however, few have explored how the very same surveys can deliver qualitative insights as well. In responding to surveys, people experiencing homelessness can use the margins to highlight health and social concerns that investigators failed to anticipate that standard question batteries miss. This study describes the unprompted comments of a large national survey of Veterans with homeless experiences. The Primary Care Quality‐Homeless Services Tailoring (PCQ‐HOST) survey presented 85 close‐ended items to solicit social and psychological experiences, health conditions, and patient ratings of primary care. Amongst 5377 Veterans responding to the paper survey, 657 (12%) offered 1933 unprompted comments across nearly all domains queried. Using a team‐based content analysis approach, we coded and organised survey comments by survey domain, and identified emergent themes. Respondents used comments for many purposes. They noted when questions called for more nuanced responses than those allowed, especially 'sometimes' or 'not applicable' on sensitive questions, such as substance use, where recovery status was not queried. On such matters, the options of 'no' and 'yes' failed to capture important contextual and historical information that mattered to respondents, such as being in recovery. Respondents also elaborated on negative and positive care experiences, often naming specific clinics or clinicians. This study highlights the degree to which members of vulnerable populations, who participate in survey research, want researchers to know the reasons behind their responses and topics (like chronic pain and substance use disorders) that could benefit from open‐ended response options. Understanding patient perspectives can help improve care. Quantitative data from surveys can provide statistical precision but may miss key patient perspectives. The content that patients write into survey margins can highlight shortfalls of a survey and point towards future areas of inquiry. Veterans with homeless experience want to provide additional detail about their lives and care experiences in ways that transcend the boundaries of close‐ended survey questions. Questions on substance use proved especially likely to draw comments that went beyond the permitted response options, often to declare that the respondent was in recovery. Respondents frequently clarified aspects of their care experiences related to pain, pain care, transportation and experiences of homelessness. [ABSTRACT FROM AUTHOR]

Background and Objectives: Public health surveillance for overdose sometimes depends on nonfatal drug overdoses recorded in health records. However, the proportion of total overdoses identified through health record systems is unclear. Comparison of overdoses from health records to those that are self‐reported may provide insight on the proportion of nonfatal overdoses that are not identified. Methods: We conducted a cohort study linking survey data on overdose from a national survey of Veterans to United States Department of Veterans Affairs (VA) health records, including community care paid for by VA. Self‐reported overdose in the prior 3 years was compared to diagnostic codes for overdoses and substance use disorders in the same time period. Results: The sensitivity of diagnostic codes for overdose, compared to self‐report as a reference standard for this analysis, varied by substance: 28.1% for alcohol, 23.1% for sedatives, 12.0% for opioids, and 5.5% for cocaine. There was a notable concordance between substance use disorder diagnoses and self‐reported overdose (sensitivity range 17.9%–90.6%). Discussion and Conclusions: Diagnostic codes in health records may not identify a substantial proportion of drug overdoses. A health record diagnosis of substance use disorder may offer a stronger inference regarding the size of the population at risk. Alternatively, screening for self‐reported overdose in routine clinical care could enhance overdose surveillance and targeted intervention. Scientific Significance: This study suggests that diagnostic codes for overdose are insensitive. These findings support consideration of alternative approaches to overdose surveillance in public health. [ABSTRACT FROM AUTHOR]

Chronic pain commonly occurs in people living with HIV (PLWH). Many PLWH in the United States obtain opioids for chronic pain management. Whether insomnia severity and depressive symptoms are exacerbated by chronic pain and opioid use in PLWH remains to be determined. This study examined insomnia severity and depressive symptoms in 85 PLWH with chronic pain and 35 PLWH without chronic pain. Among PLWH with chronic pain, reported opioid use was examined in relation to insomnia severity and depressive symptoms. PLWH with chronic pain reported significantly greater insomnia severity (p =.033) and depressive symptoms (p =.025) than PLWH without chronic pain. Among PLWH with chronic pain who reported opioid use (n = 36), insomnia severity was greater compared to those who denied opioid use (n = 49), even after controlling for pain severity and number of comorbidities (p =.026). Greater pain severity was significantly associated with greater insomnia severity (p <.001) and depressive symptoms (p =.048) among PLWH with chronic pain who reported opioid use. These associations were not significant among those PLWH with chronic pain who denied opioid use. Findings suggest that PLWH with chronic pain are likely to experience poor sleep and depressed mood. Furthermore, poor sleep was associated with opioid use among PLWH with chronic pain. [ABSTRACT FROM AUTHOR]

Objective: Disagreement exists between rheumatology and primary care societies regarding gout management. This paper describes a formal process for gathering input from stakeholders in the planning of a trial to compare gout management strategies. Methods: We recruited patients, nurses, physician assistants, primary care clinicians, and rheumatologists to participate in a modified Delphi panel (mDP) to provide input on design of a trial focused on optimal management for primary care patients with gout. The 16 panelists received a plain‐language briefing document that discussed the rationale for the trial, key clinical issues in gout, and aspects of trial design. The panelists also received information and considerations on nine voting questions (VQs), judged to be the key design questions. Cognitive interviews with panelists ensured that the VQs were understood by the range of panelists involved in the mDP. Panelists were asked to score all VQs from 1 (definitely no) to 9 (definitely yes). Two voting rounds were conducted—round 1 by email and round 2 by video conference. Results: The VQs were modified through the cognitive interviews. The round 1 voting resulted in consensus on eight items, with consensus defined as median voting score in the same tercile (1‐3, 4‐6 or 7‐9). Re‐voting at the meeting (round 2) reached consensus on the remaining item. Conclusion: An mDP with various stakeholders facilitated consensus on the design of a trial of different management strategies for chronic gout. This method may be useful for designing trials of clinical questions with substantial disagreement across stakeholders. [ABSTRACT FROM AUTHOR]

Aims: Diabetes distress affects approximately 36% of adults with diabetes and is associated with worse diabetes self‐management and poor glycaemic control. We characterized participants' diabetes distress and studied the relationship between social support and diabetes distress. Methods: In this cross‐sectional study, we surveyed a population‐based sample of adults with type 2 diabetes covered by Alabama Medicaid. We used the Diabetes Distress Scale assessing emotional burden, physician‐related, regimen‐related and interpersonal distress. We assessed participants' level of diabetes‐specific social support and satisfaction with this support, categorized as low or moderate–high. We performed multivariable logistic regression of diabetes distress by level of and satisfaction with social support, adjusting for demographics, disease severity, self‐efficacy and depressive symptoms. Results: In all, 1147 individuals participated; 73% were women, 41% White, 58% Black and 3% Hispanic. Low level of or satisfaction with social support was reported by 11% of participants; 7% of participants had severe diabetes distress. Participants with low satisfaction with social support were statistically significantly more likely to have severe diabetes distress than those with moderate–high satisfaction, adjusted odds ratio 2.43 (95% CI 1.30, 4.54). Conclusions: Interventions addressing diabetes distress in adults with type 2 diabetes may benefit from a focus on improving diabetes‐specific social support. [ABSTRACT FROM AUTHOR]

Background: There is substantial variation in the practice of preoperative medical evaluation (PME) and limited evidence for its benefit, which raises concerns about overuse. Surgeons have a unique role in this multidisciplinary practice. The objective of this qualitative study was to explore surgeons' practices and their beliefs about PME. Methods: We conducted of semi-structured interviews with 18 surgeons in Baltimore, Maryland. Surgeons were purposively sampled to maximize diversity in terms of practice type (academic vs. private practice), surgical specialty, gender, and experience level. General topics included surgeons' current PME practices, perceived benefits and harms of PME, the surgical risk assessment, and potential improvements and barriers to change. Interviews were audio-recorded and transcribed. Transcripts were analyzed using content analysis to identify themes, which are presented as assertions. Transcripts were re-analyzed to identify supporting and opposing instances of each assertion. Results: A total of 15 themes emerged. There was wide variation in surgeons' described PME practices. Surgeons believed that PME improves surgical outcomes, but not all patients benefit. Surgeons were cognizant of the financial cost of the current system and the potential inconvenience that additional tests and office visits pose to patients. Surgeons believed that PME has minimal to no risk and that a normal PME is reassuring to them and patients. Surgeons were confident in their ability to assess surgical risk, and risk assessment by non-surgeons rarely affected their surgical decision-making. Hospital and anesthesiology requirements were a major driver of surgeons' PME practices. Surgeons did not receive much training on PME but perceived their practices to be similar to their colleagues. Surgeons believed that PME provides malpractice protection, welcomed standardization, and perceived there to be inadequate evidence to significantly change their current practice. Conclusions: Views of surgeons should be considered in future research on and reforms to the PME process. [ABSTRACT FROM AUTHOR]

Background: A challenge to reducing overuse of health services is communicating recommendations against unnecessary health services to patients. The predominant approach has been to highlight the limited benefit and potential harm of such services for that patient, but the prudent use of health resources can also benefit others. Whether appealing to patient altruism can reduce overuse is unknown.Objective: To determine whether altruistic appeals reduce hypothetical requests for overused services and affect physician ratings.Design: Experimental survey using hypothetical vignettes describing three overused health services (antibiotics for acute sinusitis, imaging for acute low back pain, and annual exams for healthy adults).Participants: U.S. adults recruited from Research Now, an online panel of individuals compensated for performing academic and marketing research surveys.Interventions: In the control version of the vignettes, the physician's rationale for recommending against the service was the minimal benefit and potential for harm. In the altruism version, the rationale additionally included potential benefit to others by forgoing that service.Main Measures: Differences in requests for overused services and physician ratings between participants randomized to the control and altruism versions of the vignettes.Key Results: A total of 1001 participants were included in the final analyses. There were no significant differences in requests for overused services for any of the clinical scenarios (P values ranged from 0.183 to 0.547). Physician ratings were lower in the altruism version for the acute sinusitis (6.68 vs. 7.03, P = 0.012) and back pain scenarios (6.14 vs. 6.83, P < 0.001), and marginally lower for the healthy adult scenario (5.27 vs. 5.57, P = 0.084).Conclusions: In this experimental survey, altruistic appeals delivered by physicians did not reduce requests for overused services, and resulted in more negative physician ratings. Further studies are warranted to determine whether alternative methods of appealing to patient altruism can reduce overuse. [ABSTRACT FROM AUTHOR]

Importance Drug coupons are widely used, but their effects are not well understood. Objective To quantify the effect of coupons on statin use and expenditures. Design Retrospective cohort analysis of IMS Health LRx LifeLink database. Setting U.S. retail pharmacy transactions. Participants Incident statin users who initiated branded atorvastatin or rosuvastatin between June 2006 and February 2013. Main Outcomes and Measures Monthly statin utilization (pill-days of therapy), switching (filling a different statin), termination (failure to refill statin for 6 mo), and out-of-pocket and total costs. Results Of 1.1 million incident atorvastatin and rosuvastatin users, 2% used a coupon for at least one statin fill. At 1 year, compared with noncoupon users, those who used a statin coupon on their first fill were dispensed an equal number of monthly pill-days (23.7 vs 23.8), were less likely to switch statins (14.4% vs 16.3%), and were less likely to have terminated statin therapy (31.3% vs 39.2%). At 4 years, coupon users were more likely to have switched (45.5% vs 40.8%) and less likely to have terminated statin therapy (50.6% vs 61.1%) compared with noncoupon users. Those who used greater numbers of coupons were substantially less likely to switch and terminate statin therapies. Monthly out-of-pocket costs were lower among coupon than noncoupon users at 1 year ($9.7 vs $15.1), but total monthly costs were qualitatively similar ($115.5 vs $116.9). At 4 years, monthly out-of-pocket costs among coupon users remained lower ($14.3 vs $16.6) compared with noncoupon users. Sensitivity analyses supported the main results. Conclusions Coupons for branded statins are associated with higher utilization and lower rates of discontinuation and short-term switching to other statin products. [ABSTRACT FROM AUTHOR]

Background Studies have shown that publication of work during medical school and residency is associated with higher numbers of later publications and citations of published research. However, it is unknown whether this association exists for non-PhD physician-scientists and whether the association persists later into their careers. Methods We extracted publication records from the curricula vitae (CVs) of 102 corresponding authors of articles published in 2008 in the New England Journal of Medicine and JAMA, and obtained those authors' citation records from Web of Science. We used regression models to examine the association between time of first publication and later publication and citation rates for the entire postgraduate career and a recent 2-year period. Results After adjusting for time since medical school graduation, sex, location of medical school (United States or not United States), and additional non-PhD degrees, we found that authors who first published before graduating from medical school had a greater mean number of publications after medical school and during the period from 2006 to 2007 (164 and 28, respectively) than those who first published during the 5 years afterward (111 and 19, respectively) and those who first published more than 5 years after graduation (59 and 13, respectively). Similarly, authors who first published before graduating from medical school had a greater mean number of citations of their published work since graduation and of publications from 2006 to 2007 (4634 and 333, respectively) than those who first published during the 5 years afterward (2936 and 183, respectively) and those who first published more than 5 years after graduation (1512 and 143, respectively). Conclusions Early publication is associated with higher numbers of publications and more citations of published research among non-PhD physician-scientists. This association persists well into a researcher's career. [ABSTRACT FROM AUTHOR]

The authors discusses the dual agency problem of physicians in the stewardship aspect of providing marginal beneficial care. The authors suggest that obligations of physicians in providing marginal beneficial intervention should be reconceptualized to address the dual agency crisis. Also discussed are the Choosing Wisely initiative, the moral significance of healthcare interventions and conceptual framework for dual agency.

Objective: To describe patterns of care use for adult Medicaid beneficiaries with diabetes and the association between primary care utilization and Ambulatory Care Sensitive (ACS) diabetes hospitalizations. Methods: This retrospective cohort study analyzes Alabama Medicaid claims data from January 2010 to April 2018 for 52,549 covered adults ages 19 to 64 with diabetes. Individuals were characterized by demographics, comorbidities, and health care use including primary, specialty, mental health, pharmaceutical, laboratory and hospital care. Characteristics of those with and without any ACS diabetes hospitalization are reported. A set of 118,758 observations was created, pairing information on primary care use in one year with ACS hospitalizations in the following year. Logistic regression analysis was used to assess the impact of primary care use in one year on the occurrence of an ACS hospitalization in the following year. Results: One third of the cohort had at least one ACS diabetes hospitalization over their observed periods; hospital users tended to have multiple ACS hospitalizations. Hospital users had more comorbidities and pharmaceutical and other types of care use than those with no ACS hospitalizations. Controlling for other types of care use, comorbidities and demographics, having a primary care visit in one year was significantly associated with a reduced likelihood of ACS hospitalization in the following year (adjusted odds ratio comparing 1-2 primary care visits versus none 0.79, 95% confidence interval 0.73-0.85). Conclusions: Program and population health interventions that increase access to primary care can have a beneficial effect of reducing excess inpatient hospital use for Medicaid covered adults with diabetes. Disclosure: J.M. Bronstein: None. L. Huang: None. A.A. Agne: None. F.L. Mondesir: None. C.A. Presley: None. K.R. Riggs: None. M. Pisu: None. E.B. Levitan: Consultant; Self; Novartis Pharmaceuticals Corporation. Research Support; Self; Amgen Inc. A. Cherrington: None. Funding: National Institute of Diabetes and Digestive and Kidney Diseases [ABSTRACT FROM AUTHOR]

Background: Diabetes distress affects up to 45% of adults with diabetes and is associated with reduced treatment adherence and poor glycemic control. We evaluated diabetes distress and the relationship between social support and diabetes distress in adults with Medicaid. Methods: We surveyed a population-based sample of adults, aged 19 to 64 years old, covered by Alabama Medicaid, and diagnosed with type 2 diabetes. Diabetes distress was measured with the 17-item Diabetes Distress Scale (DDS) assessing emotional burden, physician-related distress, regimen-related distress, and interpersonal distress. A score of <2 indicates little/no distress, 2-2.9 moderate distress, and ≥3 high distress. Social support was assessed by the question "How much support do you get for dealing with your diabetes?" and responses were categorized as low, moderate, or high social support. We performed multivariate logistic regression of diabetes distress by social support, adjusting for demographics, disease severity, self-efficacy, and depressive symptoms. Results: In total, 541 individuals participated; 72% were female, 40% white, 58% black, and 3% Hispanic. Mean diabetes distress score was 1.7 (SD 0.88); 72.8% of participants had little/no diabetes distress, 16.8% moderate distress, and 10.4% high distress. Most participants (56.9%) reported high social support, but 13.5% reported low and 29.6% moderate social support. Participants who reported low and moderate social support were significantly more likely to have high diabetes distress (≥3) than those who reported high social support, adjusted odds ratio 14.3 (95% CI 5.2, 39.1) and 4.2 (95% CI 1.6, 10.7), respectively. This relationship was present for each diabetes distress domain, with particularly strong relationships between low social support and high interpersonal and regimen-related distress. Conclusions: Interventions seeking to reduce diabetes distress in adults with type 2 diabetes may benefit from a focus on improving social support. Disclosure: C.A. Presley: None. F.L. Mondesir: None. A.A. Agne: None. K.R. Riggs: None. M. Pisu: None. E.B. Levitan: Consultant; Self; Novartis Pharmaceuticals Corporation. Research Support; Self; Amgen Inc. J.M. Bronstein: None. A. Cherrington: None. Funding: National Institute of Diabetes and Digestive and Kidney Diseases [ABSTRACT FROM AUTHOR]

The article offers insights on potential ethical tensions inherent to the concept of high-value care education. Topics covered include the different ways to increase value, the need to navigate tension between physicians' commitment to providing cost-effective care while maintaining the primacy of patient welfare and the implications of instilling a primary commitment to patient welfare in cultivating professional identity.

A response by Doctors Kevin R. Riggs, Eun Ji Shin, and Jodi B. Segal to a letter to the editor about their article "Prevalence and cost of office visits prior to colonoscopy for colon cancer screening" in a 2016 issue is presented.

A letter to the editor is presented concerning prevalence and cost of office visits prior to colonoscopy for colon cancer screening.

A response from the authors of the article "Providing price displays for physicians: Which price is right?," is presented.

The authors discuss the price transparency in health care. Topics discussed include the price transparency as one way to address the cost crisis in the U.S. health care system, sources to consider for displaying the price of certain tests for physicians and the authors' suggestion to consider some ethical issues to guide the design and implementation of providing price displays to physicians.

The article presents a case study related to discordant thymectomy in identical twins concordant for myasthenia gravis. It states that the pathologic examination of one twin showed thymic tissue with increased lymphoid nodules and five months the second twin sister developed initial symptoms of myasthenia gravis. The study concludes that as no immunosuppressive agent was given to second twin the clinical observation could not be ethically replicated in randomized clinical trial.