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Background The US outbreak of coronavirus disease 2019 (COVID-19) accelerated rapidly over a short time to become a public health crisis. Objective To assess how high-risk adults’ COVID-19 knowledge, beliefs, behaviors, and sense of preparedness changed from the onset of the US outbreak (March 13–20, 2020) to the acceleration phase (March 27–April 7, 2020). Design Longitudinal, two-wave telephone survey. Participants 588 predominately older adults with ≥ 1 chronic condition recruited from 4 active, federally funded studies in Chicago. Main Measures Self-reported knowledge of COVID-19 symptoms and prevention, related beliefs, behaviors, and sense of preparedness. Key Results From the onset to the acceleration phase, participants increasingly perceived COVID-19 to be a serious public health threat, reported more changes to their daily routine and plans, and reported greater preparedness. The proportion of respondents who believed they were “not at all likely” to get the virus decreased slightly (24.9 to 22.4%; p = 0.04), but there was no significant change in the proportion of those who were unable to accurately identify ways to prevent infection (29.2 to 25.7%; p 0.14). In multivariable analyses, black adults and those with lower health literacy were more likely to report less perceived susceptibility to COVID-19 (black adults: relative risk (RR) 1.62, 95% confidence interval (CI) 1.07–2.44, p = 0.02; marginal health literacy: RR 1.96, 95% CI 1.26–3.07, p < 0.01). Individuals with low health literacy remained more likely to feel unprepared for the outbreak (RR 1.80, 95% CI 1.11–2.92, p = 0.02) and to express confidence in the federal government response (RR 2.11, 95% CI 1.49–3.00, p < 0.001) Conclusions Adults at higher risk for COVID-19 continue to lack critical knowledge about prevention. While participants reported greater changes to daily routines and plans, disparities continued to exist in perceived susceptibility to COVID-19 and in preparedness. Public health messaging to date may not be effectively reaching vulnerable communities.

IMPORTANCE: The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood. OBJECTIVE: To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. DESIGN: Retrospective analysis of overall means and clinician-level variation in performance on three new measures. SUBJECTS: Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017. MEASURES: Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication. RESULTS: Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8–54% for the PSA measure, 3–35% for the urinalysis/urine culture measure, and 13–49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively. CONCLUSIONS: Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05748-8) contains supplementary material, which is available to authorized users.

Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms.To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing.We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019.Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot.Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease.Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a "commitment nudge" that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a "justification nudge" that asked for a reason when high-risk polypharmacy was present. One practice received both.Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%).EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.

Healthcare professionals are rapidly adopting electronic health records (EHRs). Within EHRs, seemingly innocuous menu design configurations can influence provider decisions for better or worse. The purpose of this study was to examine whether the grouping of menu items systematically affects prescribing practices among primary care providers. We surveyed 166 primary care providers in a research network of practices in the greater Chicago area, of whom 84 responded (51 % response rate). Respondents and non-respondents were similar on all observable dimensions except that respondents were more likely to work in an academic setting. The questionnaire consisted of seven clinical vignettes. Each vignette described typical signs and symptoms for acute respiratory infections, and providers chose treatments from a menu of options. For each vignette, providers were randomly assigned to one of two menu partitions. For antibiotic-inappropriate vignettes, the treatment menu either listed over-the-counter (OTC) medications individually while grouping prescriptions together, or displayed the reverse partition. For antibiotic-appropriate vignettes, the treatment menu either listed narrow-spectrum antibiotics individually while grouping broad-spectrum antibiotics, or displayed the reverse partition. The main outcome was provider treatment choice. For antibiotic-inappropriate vignettes, we categorized responses as prescription drugs or OTC-only options. For antibiotic-appropriate vignettes, we categorized responses as broad- or narrow-spectrum antibiotics. Across vignettes, there was an 11.5 percentage point reduction in choosing aggressive treatment options (e.g., broad-spectrum antibiotics) when aggressive options were grouped compared to when those same options were listed individually (95 % CI: 2.9 to 20.1 %; p = .008). Provider treatment choice appears to be influenced by the grouping of menu options, suggesting that the layout of EHR order sets is not an arbitrary exercise. The careful crafting of EHR order sets can serve as an important opportunity to improve patient care without constraining physicians’ ability to prescribe what they believe is best for their patients.

The aim of this update is to briefly summarize the research articles published in 2008 that we think have the most important implications for General Internal Medicine practice. The wide breadth of General Internal Medicine practice always makes selecting articles a challenging and somewhat subjective process. In selecting articles, we relied heavily on the internal process we routinely use to do this in the Division of General Internal Medicine at Northwestern University. Each month, faculty members review an array of journals and journal aggregators (e.g., ACP Journal Club and Journal Watch General Medicine) to identify potential articles for discussion. A subgroup of the faculty then selects articles that deserve in-depth review and discussion by the entire faculty at our monthly Journal Club. If an article is judged to be particularly important and practice-changing, we then try to use this as a springboard for quality improvement efforts. For this review, we concentrate on eight articles with findings that we think should guide our practice in the future.

Limited health literacy may influence patients' ability to identify medications taken; a serious concern for ambulatory safety and quality.To assess the relationship between health literacy, patient recall of antihypertensive medications, and reconciliation between patient self-report and the medical record.In-person interviews, literacy assessment, medical records abstraction.Adults with hypertension at three community health centers.We measured health literacy using the short-form Test of Functional Health Literacy in Adults. Patients were asked about the medications they took for blood pressure. Their responses were compared with the medical record.Of 119 participants, 37 (31%) had inadequate health literacy. Patients with inadequate health literacy were less able to name any of their antihypertensive medications compared to those with adequate health literacy (40.5% vs 68.3%, p = 0.005). After adjusting for age and income, this difference remained (adjusted odds ratio [OR] = 2.9, 95% confidence interval [95%CI] = 1.3-6.7). Agreement between patient reported medications and the medical record was low: 64.9% of patients with inadequate and 37.8% with adequate literacy had no medications common to both lists.Limited health literacy was associated with a greater number of unreconciled medications. Future studies should investigate how this may impact safety and hypertension control.

To determine whether outpatient cholesterol management varies by gender or race among patients with atherosclerosis, and assess factors related to subsequent cholesterol control.Retrospective cohort study.Primary care clinics affiliated with an academic medical center.Two hundred forty-three patients with coronary heart disease, cerebrovascular disease, or peripheral vascular disease and low-density lipoprotein cholesterol (LDL-C)130 mg/dl.The primary process of care assessed for 1,082 office visits was cholesterol management (medication intensification or LDL-C monitoring). Cholesterol management occurred at 31.2% of women's and 38.5% of men's visits (P=.01), and 37.3% of black and 31.7% of white patients' visits (P=.09). Independent predictors of cholesterol management included female gender (adjusted risk ratio [ARR], 0.77; 95% confidence interval [CI], 0.60 to 0.97), seeing a primary care clinician other than the patient's primary care physician (ARR, 0.23; 95% CI, 0.11 to 0.45), and having a new clinical problem addressed (ARR, 0.60; 95% CI, 0.48 to 0.74). After 1 year, LDL-C130 mg/dl occurred less often for women than men (41% vs 61%; P=.003), black than white patients (39% vs 58%; P=.01), and patients with only Medicare insurance than with commercial insurance (37% vs 58%; P=.008). Adjustment for clinical characteristics and management attenuated the relationship between achieving an LDL-C130 mg/dl and gender.In this high-risk population with uncontrolled cholesterol, cholesterol management was less intensive for women than men but similar for black and white patients. Less intense cholesterol management accounted for some of the disparity in cholesterol control between women and men but not between black and white patients.

Modifications to the National Cholesterol Education Program (NCEP) guidelines lowered optional low-density lipoprotein cholesterol (LDL-C) treatment goals.We evaluated the implications of widely adopting these optional goals in clinical practice.We performed a cross-sectional study using 1999 to 2002 data from 3,281 U.S. adults aged 20 to 79 years participating the National Health and Nutrition Examination Survey.The primary outcomes were the proportions of adults whose fasting LDL-C levels exceeded NCEP recommended and optional targets from 2001 and 2004. We used survey weights to estimate the size of the U.S. population exceeding targets. We examined outcomes for 4 coronary disease risk subgroups described by the NCEP.Low-density lipoprotein cholesterol values exceeded 2001 NCEP goals for 30.0% of adults, and 35.8% had levels above optional 2004 goals. An estimated 24,900,000 individuals (14.2%) exceeded 2001 thresholds for drug therapy, 46,200,000 (26.3%) exceeded optional 2001 thresholds for drug therapy, and 56,500,000 (32.2%) were above the optional 2004 thresholds for drug therapy. For lower, moderate, moderately high, and high-risk groups, 13.4%, 44.2%, 58.8%, and 71.8%, respectively, exceeded 2001 NCEP goals; 13.4%, 15.7%, 87.4%, and 96.0% of these groups exceeded optional 2004 thresholds for drug therapy.In 1999 to 2002, LDL-C levels commonly exceeded 2001 NCEP goals, especially for moderately high and high-risk individuals, and cholesterol-lowering medications were underused. Optional goals promulgated by the NCEP in 2001 and 2004 moderately increased the number of adults with LDL-C above their goal, and greatly increased the number of low, moderately high, and high-risk adults who exceeded LDL-C thresholds, for cholesterol-lowering medication.