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Background: Community health centers grapple with high no-show rates, posing challenges to patient access and primary care provider (PCP) utilization., Aim: To address these challenges, we implemented a virtual waiting room (VWR) program in April 2023 to enhance patient access and boost PCP utilization., Setting: Academic community health center in a small urban city in Massachusetts., Participants: Community health patients (n = 8706) and PCP (n = 14)., Program Description: The VWR program, initiated in April 2023, involved nurse triage of same-day visit requests for telehealth appropriateness, then placing patients in a standby pool to fill in as a telehealth visit for no-shows or last-minute cancellations in PCP schedules., Program Evaluation: Post-implementation, clinic utilization rates between July and September improved from 75.2% in 2022 to 81.2% in 2023 (p < 0.01). PCP feedback was universally positive. Patients experienced a mean wait time of 1.9 h, offering a timely and convenient alternative to urgent care or the ER., Discussion: The VWR is aligned with the quadruple aim of improving patient experience, population health, cost-effectiveness, and PCP satisfaction through improving same-day access and improving PCP schedule utilization. This innovative and reproducible approach in outpatient offices utilizing telehealth holds the potential for enhancing timely access across various medical disciplines., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background/objectives: Transitional care management (TCM) visits delivered following hospitalization have been associated with reductions in mortality, readmissions, and total costs; however, uptake remains low. We sought to describe trends in TCM visit delivery during the COVID-19 pandemic., Design: Cross-sectional study of ambulatory electronic health records from December 30, 2019 and January 3, 2021., Setting: United States., Participants: Forty four thousand six hundred and eighty-one patients receiving transitional care management services., Measurements: Weekly rates of in-person and telehealth TCM visits before COVID-19 was declared a national emergency (December 30, 2019 to March 15, 2020), during the initial pandemic period (March 16, 2020 to April 12, 2020) and later period (April 12, 2020 to January 3, 2021). Characteristics of patients receiving in-person and telehealth TCM visits were compared., Results: A total of 44,681 TCM visits occurred during the study period with the majority of patients receiving TCM visits age 65 years and older (68.0%) and female (55.0%) Prior to the COVID-19 pandemic, nearly all TCM visits were conducted in-person. In the initial pandemic, there was an immediate decline in overall TCM visits and a rise in telehealth TCM visits, accounting for 15.4% of TCM visits during this period. In the later pandemic, the average weekly number of TCM visits was 841 and 14.0% were telehealth. During the initial and later pandemic periods, 73.3% and 33.6% of COVID-19-related TCM visits were conducted by telehealth, respectively. Across periods, patterns of telehealth use for TCM visits were similar for younger and older adults., Conclusion: The study findings highlight a novel and sustained shift to providing TCM services via telehealth during the COVID-19 pandemic, which may reduce barriers to accessing a high-value service for older adults during a vulnerable transition period. Further investigations comparing outcomes of in-person and telehealth TCM visits are needed to inform innovation in ambulatory post-discharge care., (© 2021 The American Geriatrics Society.)

Background: Medically-tailored meal programs that provide home-delivered medically-appropriate food are an emerging intervention when type 2 diabetes co-occurs with food insecurity (limited or uncertain access to nutritious food owing to cost). We sought to understand the experiences of medically-tailored meal program participants., Methods: We conducted semi-structured interviews with participants in a randomized trial of medically-tailored meals (NCT02426138) until reaching content saturation. Participants were adults (age > 20 years) with type 2 diabetes in eastern Massachusetts, and the interviews were conducted from April to July 2017. Interviews were transcribed verbatim and coded by two independent reviewers. We determined emergent themes using content analysis., Results: Twenty individuals were interviewed. Their mean age was 58 (SD: 13) years, 60.0% were women, 20.0% were non-Hispanic black, and 15.0% were Hispanic. Key themes were 1) satisfaction and experience with medically-tailored meals 2) food preferences and cultural appropriateness, 3) diabetes management and awareness, and 4) suggestions for improvement and co-interventions. Within these themes, participants were generally satisfied with medically-tailored meals and emphasized the importance of receiving culturally appropriate food. Participants reported several positive effects of medically-tailored meals, including improved quality of life and ability to manage diabetes, and stress reduction. Participants suggested combining medically-tailored meals with diabetes self-management education or lifestyle interventions., Conclusions: Individuals with diabetes and food insecurity expressed satisfaction with the medically-tailored meal program, and reported that participation reduced stress and the burden of diabetes management. Suggestions to help ensure the success of medically-tailored meal programs included a strong emphasis on culturally acceptability and accommodating taste preferences for provided foods, and combining medically-tailored meals with diabetes education or lifestyle intervention., Trial Registration: ClinicalTrials.gov NCT02426138.

Introduction: Socioeconomically vulnerable individuals often face poor access to nutritious food and bear a disproportionate burden of diet-related chronic illness. This study tested whether a subsidized community-supported agriculture intervention could improve diet quality., Study Design: An RCT was conducted from May 2017 to December 2018 (data analyzed in 2019)., Setting/participants: Adults with a BMI >25 kg/m 2 seen at a community health center in central Massachusetts, or who lived in the surrounding county, were eligible., Intervention: Individuals were randomized to receive either subsidized community-supported agriculture membership (which provided a weekly farm produce pickup from June to November) or healthy eating information (control group). For equity, the control group received financial incentives similar to the intervention group., Main Outcome Measures: The primary outcome was the Healthy Eating Index 2010 total score (range, 0-100; higher indicates better diet quality; minimum clinically meaningful difference, 3). Healthy Eating Index was assessed using 3 24-hour recalls per participant collected each growing season. Intention-to-treat analyses compared Healthy Eating Index scores between the intervention and control group, accounting for repeated measures with generalized estimating equations., Results: There were 128 participants enrolled and 122 participants for analysis. The participants' mean age was 50.3 (SD=13.6) years; 82% were women; and 88% were white, non-Hispanic, with a similar distribution of baseline characteristics comparing the intervention and control groups. Baseline Healthy Eating Index total score was 53.9 (SD=15.3) in the control group and 55.1 (SD=15.2) in the intervention group (p=0.68). The intervention increased the mean Healthy Eating Index total score relative to the control group (4.3 points higher, 95% CI=0.5, 8.1, p=0.03). Food insecurity was lower in the intervention group (RR=0.68, 95% CI=0.48, 0.96)., Conclusions: A community-supported agriculture intervention resulted in clinically meaningful improvements in diet quality. Subsidized community-supported agriculture may be an important intervention for vulnerable individuals., Trial Registration: This study is registered at www.clinicaltrials.gov NCT03231592., Supplement Information: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Linking individuals to community resources in order to help meet health-related social needs, such as food, medications, or transportation, may improve clinical outcomes. However, little is known about the mechanisms whereby such linkage interventions might improve health. The authors conducted a mixed-methods analysis consisting of outcomes from a prospective cohort study of a linkage intervention and a qualitative analysis of case records from participants. The cohort study included intervention participants who first enrolled between December 2014 and March 2015. Participants were excluded if they could not complete the assessment because of illness or language. The authors examined changes in cost-related medication underuse (CRMU), transportation barriers, and food insecurity (FI). For the qualitative analysis, a random sample of 80 participants was selected for electronic health record review - 40 cases who showed clinical improvement (responders) and 40 cases who did not (nonresponders). Themes were extracted by 3 reviewers guided by the immersion/crystallization approach. For the cohort study, 141 individuals were included; 138 (97.9%) completed follow-up. Comparing baseline to follow-up, there were significant reductions in the prevalence of CRMU (from 44.2% to 39.1%, P  = .003) and transportation barriers (from 46.3% to 30.2%, P  = .001), but not FI (from 40.4% to 38.2%, P  = .73). For the qualitative study, emergent themes that helped differentiate responders and nonresponders included acuity of need, resource availability/access, and adequacy of the resource utilized. CRMU and transportation barriers may be important mechanisms by which linkage interventions improve health-related social needs. Patient-centered themes can help guide intervention improvements.

Importance: Whether interventions to improve food access can reduce health care use is unknown., Objective: To determine whether participation in a medically tailored meal intervention is associated with fewer subsequent hospitalizations., Design, Setting, and Participants: A retrospective cohort study was conducted using near/far matching instrumental variable analysis. Data from the 2011-2015 Massachusetts All-Payer Claims database and Community Servings, a not-for-profit organization delivering medically tailored meals (MTMs), were linked. The study was conducted from December 15, 2016, to January 16, 2019. Recipients of MTMs who had at least 360 days of preintervention claims data were matched to nonrecipients on the basis of demographic, clinical, and neighborhood characteristics., Interventions: Weekly delivery of 10 ready-to-consume meals tailored to the specific medical needs of the individual under the supervision of a registered dietitian nutritionist., Main Outcomes and Measures: Inpatient admissions were the primary outcome. Secondary outcomes were admission to a skilled nursing facility and health care costs (from medical and pharmaceutical claims)., Results: There were 807 eligible MTM recipients. After matching, there were 499 MTM recipients, matched to 521 nonrecipients for a total of 1020 study participants (mean [SD] age, 52.7 [14.5] years; 568 [55.7%] female). Prior to matching and compared with nonrecipients in the same area, health care use, health care cost, and comorbidity were all significantly higher in recipients. For example, preintervention mean (SD) inpatient admissions were 1.6 (6.5) in MTM recipients vs 0.2 (0.8) in nonrecipients (P < .001), and mean health care costs were $80 617 ($312 337) vs $16 138 ($68 738) (P < .001). Recipients compared with nonrecipients were also significantly more likely to have HIV (21.9% vs 0.7%, P < .001), cancer (37.9% vs 11.3%, P < .001), and diabetes (33.7% vs 7.0%, P < .001). In instrumental variable analyses, MTM receipt was associated with significantly fewer inpatient admissions (incidence rate ratio [IRR], 0.51; 95% CI, 0.22-0.80; risk difference, -519; 95% CI, -360 to -678 per 1000 person-years). Similarly, MTM receipt was associated with fewer skilled nursing facility admissions (IRR, 0.28; 95% CI, 0.01-0.60; risk difference, -913; 95% CI, -689 to -1457 per 1000 person-years). The models estimated that, had everyone in the matched cohort received treatment owing to the instrument (and including the cost of program participation), mean monthly costs would have been $3838 vs $4591 if no one had received treatment owing to the instrument (difference, -$753; 95% CI, -$1225 to -$280)., Conclusions and Relevance: Participation in a medically tailored meals program appears to be associated with fewer hospital and skilled nursing admissions and less overall medical spending.

Background: Electronic health record (EHR) based chronic kidney disease (CKD) registries are central to population health strategies to improve CKD care. In 2015, Partners Healthcare System (PHS), encompassing multiple academic and community hospitals and outpatient care facilities in Massachusetts, developed an EHR-based CKD registry to identify opportunities for quality improvement, defined as improvement on both process measures and outcomes measures associated with clinical care., Methods: Patients are included in the registry based on the following criteria: 1) two estimated glomerular filtration rate (eGFR) results < 60 ml/min/1.73m 2 separated by 90 days, including the most recent eGFR being < 60 ml/min/1.73m 2 ; or 2) the most recent two urine protein values > 300 mg protein/g creatinine on either urine total protein/creatinine ratio or urine albumin/creatinine ratio; or 3) an EHR problem list diagnosis of end stage renal disease (ESRD). The registry categorizes patients by CKD stage and includes rates of annual testing for eGFR and proteinuria, blood pressure control, use of angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs), nephrotoxic medication use, hepatitis B virus (HBV) immunization, vascular access placement, transplant status, CKD progression risk; number of outpatient nephrology visits, and hospitalizations., Results: The CKD registry includes 60,503 patients and has revealed several opportunities for care improvement including 1) annual proteinuria testing performed for 17% (stage 3) and 31% (stage 4) of patients; 2) ACE-I/ARB used in 41% (stage 3) and 46% (stage 4) of patients; 3) nephrotoxic medications used among 23% of stage 4 patients; and 4) 89% of stage 4 patients lack HBV immunity. For advanced CKD patients there are opportunities to improve vascular access placement, transplant referrals and outpatient nephrology contact., Conclusions: A CKD registry can identify modifiable care gaps across the spectrum of CKD care and enable population health strategy implementation. No linkage to Social Security Death Master File or US Renal Data System (USRDS) databases limits our ability to track mortality and progression to ESRD.

Problem: Current regulations for internal medicine residency programs require scheduling that minimizes conflict between inpatient and outpatient responsibilities. To meet these regulations, the internal medicine residency program at Beth Israel Deaconess Medical Center implemented a unique scheduling model--the Alternating Call and Elective Scheduling (ACES) model-in July 2009., Approach: Beginning in academic year 2009-2010, the authors restructured schedules for their 95 postgraduate year 2 and 3 internal medicine residents using the ACES model. They report pre- and postimplementation housestaff responses from end-of-year program evaluation and culture-of-safety surveys, as well as residents' pre- and postintervention schedule and patient visit data., Outcomes: Prior to the intervention, 13/83 (16%) residents agreed that the structure of residency training minimized conflict between inpatient and outpatient responsibilities; after the intervention, 82/84 (98%) agreed with this statement. Before the intervention, 23/83 (28%) residents felt that the schedule promoted inpatient safety, compared with 83/84 (99%) after the intervention. Agreement that the schedule promoted outpatient safety went from 28/83 (34%) preintervention to 73/84 (87%) postintervention. Before the intervention, 45/84 (54%) residents felt that the schedule promoted a continuous healing relationship with continuity patients, compared with 67/84 (80%) after the intervention. After implementation, residents' continuity visits with their own patients increased by 14%, and total annual patient visits increased by 16%., Next Steps: Separating residents' inpatient and outpatient responsibilities may improve patient safety, the learning environment, and resident-patient relationships. Future innovations might focus on improving patient safety and decreasing stress in the outpatient environment.

Objectives: To determine whether hospital processes and hospital quality associated with the care of femoral neck fractures were significantly altered by the implementation of healthcare reform in Massachusetts., Design: Pre-post retrospective study., Setting: Massachusetts Statewide Inpatient Dataset (SID)., Patients/participants: Patients treated for femoral neck fracture (n = 23,485) in the periods prehealth (2003-06) and posthealth reform (2008-10)., Intervention: Differences in hospital processes for fracture care and quality measures were assessed for the periods before and after health reform., Outcome Measurements: Differences in hospital processes for fracture care (type of surgical intervention, length of stay, and discharge disposition) and quality metrics [mortality, complications, re-operation, and failure to rescue (FTR)] in the periods before and after health reform were assessed using regression techniques to adjust for differences in case mix and the type of surgical intervention., Results: There were no significant differences in the type of surgical intervention performed prereform and postreform (P = 0.27). After adjustment for case mix and surgical intervention, length of stay was significantly reduced {regression coefficient -0.07 [95% confidence interval (CI), -0.09 to -0.06]} as were the odds of FTR [odds ratio 0.73 (95% CI, 0.59-0.92)]. Discharges to skilled nursing facilities significantly increased in the postreform period [relative risk ratio 1.15 (95% CI, 1.03-1.30)]. Findings associated with FTR were driven by changes in the detection of surveillance sensitive complications., Conclusions: Health reform in Massachusetts led to no clinically meaningful differences in hospital processes for femoral neck fracture care. Although some differences in quality measures were noted, these cannot necessarily be attributed to health care reform.

Background: Primary care providers often fail to identify patients who are overweight or obese or discuss weight management with them. Electronic health record-based tools may help providers with the assessment and management of overweight and obesity., Purpose: We describe the design of a trial to examine the effectiveness of electronic health record-based tools for the assessment and management of overweight and obesity among adult primary care patients, as well as the challenges we encountered., Methods: We developed several new features within the electronic health record used by primary care practices affiliated with Brigham and Women's Hospital in Boston, MA. These features included (1) reminders to measure height and weight, (2) an alert asking providers to add overweight or obesity to the problem list, (3) reminders with tailored management recommendations, and (4) a Weight Management screen. We then conducted a pragmatic, cluster-randomized controlled trial in 12 primary care practices., Results: We randomized 23 clinical teams ("clinics") within the practices to the intervention group (n = 11) or the control group (n = 12). The new features were activated only for clinics in the intervention group. The intervention was implemented in two phases: the height and weight reminders went live on 15 December 2011 (Phase 1), and all of the other features went live on 11 June 2012 (Phase 2). Study enrollment went from December 2011 through December 2012, and follow-up ended in December 2013. The primary outcomes were 6-month and 12-month weight change among adult patients with body mass index ≥25 who had a visit at one of the primary care clinics during Phase 2. Secondary outcome measures included the proportion of patients with a recorded body mass index in the electronic health record, the proportion of patients with body mass index ≥25 who had a diagnosis of overweight or obesity on the electronic health record problem list, and the proportion of patients with body mass index ≥25 who had a follow-up appointment about their weight or were prescribed weight loss medication., Lessons Learned: We encountered challenges in our development of an intervention within the existing structure of an electronic health record. For example, although we decided to randomize clinics within primary care practices, this decision may have introduced contamination and led to some imbalance of patient characteristics between the intervention and control practices. Using the electronic health record as the primary data source reduced the cost of the study, but not all desired data were recorded for every participant., Conclusion: Despite the challenges, this study should provide valuable information about the effectiveness of electronic health record-based tools for addressing overweight and obesity in primary care., (© The Author(s) 2015.)

Introduction: There is a substantial concern among spine surgeons that healthcare reform efforts will alter the processes through which spinal care is delivered and decrease overall quality. We used the Statewide Inpatient Dataset for Massachusetts to evaluate changes in hospital processes and quality of care for patients with cervical fractures following the implementation of health reform., Methods: This was a pre-post retrospective analysis of patients (n=9,387) treated for cervical fractures in Massachusetts between 2003-2006 and 2008-2010. Changes in hospital processes (surgical intervention, length of stay (LOS) and environment of care) and quality of care (mortality, complications, reoperation and failure to rescue (FTR)) were the outcomes of interest. FTR is a quality measure that evaluates a hospital's capacity to avoid mortality following the occurrence of a sentinel complication. Patients treated between 2003 and 2006 were considered the pre-reform group. The post-reform cohort consisted of those treated from 2008 to 2010. Baseline differences between cohorts were evaluated using chi-square or Mann-Whitney U tests. Unadjusted comparisons between the dependent variables and the onset of healthcare reform were performed, followed by regression techniques that adjusted for differences in case-mix and whether a surgical intervention was performed. Multivariable logistic regression was used for categorical variables and negative binomial regression was employed for continuous variables., Results: The rates of surgical intervention remained unchanged pre- and post-reform (p=0.25). Hospital length of stay (RC: -0.18, 95% CI: -0.22, -0.14) and the FTR rate following surveillance insensitive complications (OR: 0.49, 95% CI: 0.25, 0.94) were significantly reduced following health reform. Post-reform, academic centers experienced a 22% reduction in mortality (95% CI: 0.61, 0.99) a 40% decrease in FTR (95% CI: 0.40, 0.89), a 30% decrease in surveillance insensitive complications (95% CI: 0.51, 0.96) and a 67% reduction in FTR after surveillance insensitive morbidity (95% CI: 0.11, 0.94)., Conclusions: In the period following Massachusetts healthcare reform, significant improvements were noted in hospital process and quality measures around the care of patients with cervical spine fractures. Such findings were particularly robust among academic centers. These results may forecast changes in the delivery of spine surgical care following other health reform initiatives. Level of Evidence III., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objectives: To design, implement, and assess the pilot phase of an innovative, remote case-based video-consultation program called ECHO-AGE that links experts in the management of behavior disorders in patients with dementia to nursing home care providers., Design: Pilot study involving surveying of participating long-term care sites regarding utility of recommendations and resident outcomes., Setting: Eleven long-term care sites in Massachusetts and Maine., Participants: An interprofessional specialty team at a tertiary care center and staff from 11 long-term care sites., Intervention: Long-term care sites presented challenging cases regarding residents with dementia and/or delirium related behavioral issues to specialists via video-conferencing., Methods: Baseline resident characteristics and follow-up data regarding compliance with ECHO-AGE recommendations, resident improvement, hospitalization, and mortality were collected from the long-term care sites., Results: Forty-seven residents, with a mean age of 82 years, were presented during the ECHO-AGE pilot period. Eighty-three percent of residents had a history of dementia and 44% were taking antipsychotic medications. The most common reasons for presentation were agitation, intrusiveness, and paranoia. Behavioral plans were recommended in 72.3% of patients. Suggestions for medication adjustments were also frequent. ECHO-AGE recommendations were completely or partially followed in 88.6% of residents. When recommendations were followed, sites were much more likely to report clinical improvement (74% vs 20%, P < .03). Hospitalization was also less common among residents for whom recommendations were followed., Conclusions: The results suggest that a case-based video-consultation program can be successful in improving the care of elders with dementia and/or delirium related behavioral issues by linking specialists with long-term care providers., (Published by Elsevier Inc.)

Problem: Academic medical centers (AMCs) need new approaches to delivering higher-quality care at lower costs, and engaging trainees in the work of high-functioning primary care practices., Approach: In 2012, the Harvard Medical School Center for Primary Care, in partnership with with local AMCs, established an Academic Innovations Collaborative (AIC) with the goal of transforming primary care education and practice. This novel two-year learning collaborative consisted of hospital- and community-based primary care teaching practices, committed to building highly functional teams, managing populations, and engaging patients. The AIC built on models developed by Qualis Health and the Institute for Healthcare Improvement, optimized for the local AMC context. Foundational elements included leadership engagement and development, application of rapid-cycle process improvement, and the creation of teams to care for defined patient populations. Nineteen practices across six AMCs participated, with nearly 260,000 patients and 450 resident learners. The collaborative offered three 1.5-day learning sessions each year featuring shared learning, practice coaches, and improvement measures, along with monthly data reporting, webinars, and site visits., Outcomes: Validated self-reports by transformation teams showed that practices made substantial improvement across all areas of change. Important factors for success included leadership development, practice-level resources, and engaging patients and trainees., Next Steps: The AIC model shows promise as a path for AMCs to catalyze health system transformation through primary care improvement. In addition to further evaluating the impact of practice transformation, expansion will require support from AMCs and payers, and the application of similar approaches on a broader scale.

Background: Insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of healthcare reform in Massachusetts on use of coronary revascularization procedures and in-hospital and 1-year mortality by race/ethnicity, education, and sex., Methods and Results: Using hospital claims data, we compared differences in coronary revascularization rates (coronary artery bypass grafting or percutaneous coronary intervention) and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents aged 21 to 64 years hospitalized with a principal discharge diagnosis of ischemic heart disease before (November 1, 2004, to July 31, 2006) and after (December 1, 2006, to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted logistic regression assessed 24 216 discharges before reform and 20 721 discharges after reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the prereform period. Compared with whites in the postreform period, blacks (odds ratio=0.73; 95% confidence interval, 0.63-0.84) and Hispanics (odds ratio= 0.84; 95% confidence interval, 0.74-0.97) were less likely and Asians (odds ratio=1.29; 95% confidence interval, 1.01-1.65) were more likely to receive coronary revascularization. Patients living in more educated communities, men, and persons with private insurance were more likely to receive coronary revascularization before and after reform. Compared with the prereform period, the adjusted odds of in-hospital mortality were higher in patients living in less-educated communities in the postreform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed before or after reform., Conclusions: Reducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated preexisting demographic and educational disparities in access to these procedures., (© 2014 American Heart Association, Inc.)

Background: Bariatric or weight loss surgery (WLS) may alter alcohol metabolism resulting in a higher prevalence of problem drinking postoperatively. Few studies distinguish those who report improvements in drinking from those who report worsening behavior after surgery. The objective of this study was to characterize high-risk alcohol use before and after WLS and according to surgery type., Methods: We interviewed patients before and annually after WLS. High-risk alcohol use as assessed via a modified version of the Alcohol Use Disorders Identification Test-Consumption., Results: Of 541 participants who underwent WLS, 375 (69% retention) completed the 1-year interview and 328 (63% retention) completed the 2-year interview. At 1 year, 13% reported high-risk drinking compared to 17% at baseline, P = .10; at year 2, 13% reported high-risk drinking compared to 15% at baseline, P = .39; 7% and 6% of patients, respectively, reported new high-risk drinking at 1- and 2-year follow-up. At both follow-up time points, more than half of those who reported high-risk drinking at baseline no longer did so. A larger proportion of gastric bypass patients (71%) reported amelioration in high-risk drinking than gastric banding (48%) at year 1, but this difference did not reach statistical significance (P = .07); the difference largely dissipated by year 2 (50% versus 57%) ., Conclusion: Although 7% of patients report new high-risk alcohol use 1 year after WLS, more than half who reported high-risk alcohol use before surgery discontinued high-risk drinking., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Physicians are under increased pressure to help control rising health care costs, though they lack information regarding cost implications of patient care decisions., Objective: To evaluate the impact of real-time display of laboratory costs on primary care physician ordering of common laboratory tests in the outpatient setting., Design: Interrupted time series analysis with a parallel control group., Participants: Two hundred and fifteen primary care physicians (153 intervention and 62 control) using a common electronic health record between April 2010 and November 2011. The setting was an alliance of five multispecialty group practices in Massachusetts., Intervention: The average Medicare reimbursement rate for 27 laboratory tests was displayed within an electronic health record at the time of ordering, including 21 lower cost tests (< $40.00) and six higher cost tests (> $40.00)., Main Measures: We compared the change-in-slope of the monthly laboratory ordering rate between intervention and control physicians for 12 months pre-intervention and 6 months post-intervention. We surveyed all intervention and control physicians at 6 months post-intervention to assess attitudes regarding costs and cost displays., Key Results: Among 27 laboratory tests, intervention physicians demonstrated a significant decrease in ordering rates compared to control physicians for five (19%) tests. This included a significant relative decrease in ordering rates for four of 21 (19%) lower cost laboratory tests and one of six (17%) higher cost laboratory tests. A majority (81%) of physicians reported that the intervention improved their knowledge of the relative costs of laboratory tests., Conclusions: Real-time display of cost information in an electronic health record can lead to a modest reduction in ordering of laboratory tests, and is well received. Our study demonstrates that electronic health records can serve as a tool to promote cost transparency and reduce laboratory test use.

Objectives: To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high-risk medications., Design: Pre-post interventional trial., Setting: Large academic medical center., Participants: Individuals aged 70 and older (n = 19,949) admitted between May 1, 2008, September 30, 2011. Individuals aged 80 and older admitted after April 26, 2010, received the intervention, those aged 80 and older admitted before were primary controls, and those aged 70 to 79 were concurrent controls., Intervention: The intervention uses a checklist promoting delirium prevention, recognition and management, and modifies the computerized provider order entry system to provide care focused on elderly adults., Measurements: Frequency of orders for activating the rapid response team for altered mental status, frequency of orders for haloperidol in excess of 0.5 mg or intravenous (IV) morphine in excess of 2 mg, and discharge disposition., Results: Participants receiving the intervention had a mean age of 86.1 ± 4.6; 58.2% were female. The number of orders to activate the rapid response team for altered mental status increased in participants receiving the bundle and in controls (odds ratio (OR) for the difference of differences = 1.23 (95% confidence interval (CI) = 0.68-2.24, P = .49)). Participants receiving the bundle were less likely to receive more than 0.5 mg of IV, intramuscular, or oral haloperidol (OR = 0.60, 95% CI = 0.39-0.91, P = .02) and more than 2 mg of IV morphine (OR = 0.52, 95% CI = 0.42-0.63, P < .001). Participants who received the bundle were more likely to be discharged home than to extended care facilities (OR = 1.18, 95% CI = 1.04-1.35, P = .01)., Conclusion: An intervention focused on delirium prevention and recognition by bedside staff combined with computerized decision support facilitates safer prescribing of high-risk medications and possibly results in less need for extended care., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Background: Bariatric surgery is one of few obesity treatments to produce substantial weight loss but only a small proportion of medically-eligible patients, especially men and racial minorities, undergo bariatric surgery., Objective: To describe primary care patients' consideration of bariatric surgery, potential variation by sex and race, and factors that underlie any variation., Design, Setting, and Patients: Telephone interview of 337 patients with a body mass index or BMI > 35 kg/m(2) seen at four diverse primary care practices in Greater-Boston., Measurements: Patients' consideration of bariatric surgery., Results: Of 325 patients who had heard of bariatric surgery, 34 % had seriously considered surgery. Men were less likely than women and African Americans were less likely than Caucasian patients to have considered surgery after adjustment for sociodemographics and BMI. Comorbid conditions did not explain sex and racial differences but racial differences dissipated after adjustment for quality of life (QOL), which tended to be higher among African American than Caucasian patients. Physician recommendation of bariatric surgery was independently associated with serious consideration for surgery [OR 4.95 (95 % CI 2.81-8.70)], but did not explain variation in consideration of surgery across sex and race. However, if recommended by their doctor, men were as willing and African American and Hispanic patients were more willing to consider bariatric surgery than their respective counterparts after adjustment. Nevertheless, only 20 % of patients reported being recommended bariatric surgery by their doctor and African Americans and men were less likely to receive this recommendation; racial differences in being recommended surgery were also largely explained by differences in QOL. High perceived risk to bariatric surgery was the most commonly cited barrier; financial concerns were uncommonly cited., Limitations: Single geographic region; examined consideration and not who eventually proceeded with bariatric surgery., Conclusion: African Americans and men were less likely to have considered bariatric surgery and were less likely to have been recommended surgery by their doctors. Differences in how obesity affects QOL appear to account for some of these variations. High perceived risk rather than financial barrier was the major deterrent for patients.

Background: The "hidden curriculum" and role models for responding to medical errors might play a central role in influencing residents' attitudes about disclosure. We sought to compare surgical and nonsurgical residents' exposure to role modeling for responding to medical errors and their attitudes about error disclosure., Study Design: We conducted a cross-sectional, electronic survey of surgical and nonsurgical residents at 2 large academic medical centers. The questionnaire asked respondents about personal experience with medical errors; training for responding to errors; frequency of exposure to role modeling related to disclosure; and attitudes about disclosure. Descriptive statistics were used to describe frequencies. Chi-square and Fisher's exact test were used to compare proportions between surgical and nonsurgical trainees., Results: The response rate was 58% (253 of 435). Surgical residents reported more frequently observing a colleague be treated harshly (eg, humiliated or verbally abused) for an error than nonsurgical residents (sometimes or often, 39% [26 of 66] vs 20% [37 of 187]; p = 0.002). Surgical residents were more likely than nonsurgical residents to believe they would be treated harshly by others if they acknowledged making a medical error (35% [23 of 66] vs 12% [23 of 187]; p < 0.001) and believe they have to compromise their own values when dealing with medical errors at their institution (11% [7 of 66] vs 2% [4 of 187]; p = 0.008). Surgical residents were less likely than nonsurgical residents to feel free to express concerns to other members of the team about medical errors in patient care (70% [46 of 66] vs 83% [115 of 187]; p = 0.02)., Conclusions: The punitive response to error by senior members of the health care team might be an impediment to the transparent disclosure of errors among residents that might disproportionally affect surgical training programs., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the impact on smoking status documentation of a payer-sponsored pay-for-performance (P4P) incentive that targeted a minority of an integrated healthcare delivery system's patients., Study Design: Three commercial insurers simultaneously adopted P4P incentives to document smoking status of their members with 3 chronic diseases. The healthcare system responded by adding a smoking status reminder to all patients' electronic health records (EHRs). We measured change in smoking status documentation before (2008-2009) and after (2010-2011) P4P implementation by patient P4P eligibility., Methods: The P4P-eligible patients were compared primarily with a subset of non-P4P-eligible patients who resembled P4P-eligible patients and also with all non-P4P-eligible patients. Multivariate models adjusted for patient and provider characteristics and accounted for provider-level clustering and preimplementation trends., Results: Documentation increased from 48% of 207,471 patients before P4P to 71% of 227,574 patients after P4P. Improvement from 56% to 83% occurred among P4P-eligible patients (adjusted odds ratio [AOR], 3.6; 95% confidence interval [CI], 2.9-4.5) and from 56% to 80% among the comparable subset of non-P4P-eligible patients (AOR, 3.0; 95% CI, 2.3-3.9). The difference in improvement between groups was significant (AOR, 1.3; 95% CI, 1.1-1.4; P = .009)., Conclusions: A P4P incentive targeting a minority of a healthcare system's patients stimulated adoption of a system wide EHR reminder and improved smoking status documentation overall. Combining a P4P incentive with an EHR reminder might help healthcare systems improve treatment delivery for smokers and meet "meaningful use" standards for EHRs.

Background: It is unknown whether there exist certain subsets of patients outside of the intensive care unit in whom the risk of nosocomial gastrointestinal bleeding is high enough that prophylactic use of acid-suppressive medication may be warranted., Objective: To identify risk factors for nosocomial gastrointestinal bleeding in a cohort of non-critically ill hospitalized patients, develop a risk scoring system, and use this system to identify patients most likely to benefit from acid suppression., Design: Cohort study., Patients: Adult patients admitted to an academic medical center from 2004 through 2007. Admissions with a principal diagnosis of gastrointestinal bleeding or a principal procedure code for cardiac catheterization were excluded., Main Measures: Medication, laboratory, and other clinical data were obtained through electronic data repositories maintained at the medical center. The main outcome measure-nosocomial gastrointestinal bleeding occurring outside of the intensive care unit-was ascertained via ICD-9-CM coding and confirmed by chart review., Key Results: Of 75,723 admissions (median age = 56 years; 40 % men), nosocomial gastrointestinal bleeding occurred in 203 (0.27 %). Independent risk factors for bleeding included age > 60 years, male sex, liver disease, acute renal failure, sepsis, being on a medicine service, prophylactic anticoagulants, and coagulopathy. Risk of bleeding increased as clinical risk score derived from these factors increased. Acid-suppressive medication was utilized in > 50 % of patients in each risk stratum. Our risk scoring system identified a high risk group in whom the number-needed-to-treat with acid-suppressive medication to prevent one bleeding event was < 100., Conclusions: In this large cohort of non-critically ill hospitalized patients, we identified several independent risk factors for nosocomial gastrointestinal bleeding. With further validation at other medical centers, the risk model derived from these factors may help clinicians to direct acid-suppressive medication to those most likely to benefit.

Objective: To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety., Design: From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating 'eJournals' that enabled rapid updating of medication lists during subsequent clinical visits., Measurements: A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies., Results: Among 121,046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04)., Conclusions: When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider's medical record., Trial Registration Number: This study was registered at ClinicalTrials.gov (NCT00251875).

Objectives: To identify factors that influence the breast cancer treatment decisions of women aged 80 and older., Design: Medical record review., Setting: One academic primary care clinic and two community health centers in Boston., Participants: Sixty-five women aged 80 and older diagnosed with breast cancer between 1994 and 2004 and followed through June 30, 2010., Measurements: Data were abstracted on breast cancer characteristics, comorbidities, treatments received, and outcomes. Notes from primary care physicians, oncologists, and breast surgeons were reviewed to determine factors involved in treatment decision-making., Results: Median age at diagnosis was 84.0 (interquartile range 82.0-86.3), 55 (84.6%) were non-Hispanic white, and 40 (61.5%) had at least one comorbidity. Nine women were diagnosed with ductal carcinoma in situ, 42 with a new primary invasive breast cancer, eight with a second primary, and six with a breast cancer recurrence. Sixty-three (96.9%) received some type of treatment. Fifty-six (86.2%) had at least one detailed physician note on treatment decision-making in their charts. The main categories found to influence participant, family, and physician treatment decision-making were tumor characteristics, ratio of treatment benefits to risks, logistics (e.g., transportation, finances), and participant age, health (including a concurrent diagnosis), and psychosocial characteristics. Family was involved in treatment discussions for 46 (70.8%) participants., Conclusion: The quality of physician documentation about decision-making in these women was high. A great amount of thoughtful and complex decision-making involving patients, family, and physicians occurs after a woman aged 80 and older is diagnosed with breast cancer., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Background: Medical residents are often responsible for leading and performing cardiopulmonary resuscitation; however, their levels of expertise and comfort as leaders of advanced cardiovascular life support (ACLS) teams vary widely. While the current American Heart Association ACLS course provides education in recommended resuscitative protocols, training in leadership skills is insufficient. In this article, we describe the design and implementation in our institution of a formative curriculum aimed at improving residents' readiness for being leaders of ACLS teams using human patient simulation. Human patient simulation refers to a variety of technologies using mannequins with realistic features, which allows learners to practice through scenarios without putting patients at risk. We discuss the limitations of the program and the challenges encountered in implementation. We also provide a description of the initiation and organization of the program. Case scenarios and assessment tools are provided., Description of the Institutional Training Program: Our simulation-based training curriculum consists of 8 simulated patient scenarios during four 1-hour sessions. Postgraduate year-2 and 3 internal medicine residents participate in this program in teams of 4. Assessment tools are utilized only for formative evaluation. Debriefing is used as a teaching strategy for the individual resident leader of the ACLS team to facilitate learning and improve performance. To evaluate the impact of the curriculum, we administered a survey before and after the intervention. The survey consisted of 10 questions answered on a 5-point Likert scale, which addressed residents' confidence in leading ACLS teams, management of the equipment, and management of cardiac rhythms. Respondents' mean presimulation (ie, baseline) and postsimulation (ie, outcome) scores were compared using a 2-sample t test. Residents' overall confidence score improved from 2.8 to 3.9 (P < 0.001; mean improvement, 1.1; 95% confidence interval, 0.7-1.6). The average score for performing and leading ACLS teams improved from 2.8 to 4 (P < 0.001; mean difference, 1.2; 95% confidence interval, 0.7-1.7). There was a uniform increase in the residents' self-confidence in their role as effective leaders of ACLS teams, and residents valued this simulation-based training program.

Background: In Massachusetts, physician groups' performance on validated surveys of patient experience has been publicly reported since 2006. Groups also receive detailed reports of their own performance, but little is known about how physician groups have responded to these reports., Objective: To examine whether and how physician groups are using patient experience data to improve patient care., Design and Participants: During 2008, we conducted semi-structured interviews with the leaders of 72 participating physician groups (out of 117 groups receiving patient experience reports). Based on leaders' responses, we identified three levels of engagement with patient experience reporting: no efforts to improve (level 1), efforts to improve only the performance of low-scoring physicians or practice sites (level 2), and efforts to improve group-wide performance (level 3)., Main Measures: Groups' level of engagement and specific efforts to improve patient care., Key Results: Forty-four group leaders (61%) reported group-wide improvement efforts (level 3), 16 (22%) reported efforts to improve only the performance of low-scoring physicians or practice sites (level 2), and 12 (17%) reported no performance improvement efforts (level 1). Level 3 groups were more likely than others to have an integrated medical group organizational model (84% vs. 31% at level 2 and 33% at level 1; P < 0.005) and to employ the majority of their physicians (69% vs. 25% and 20%; P < 0.05). Among level 3 groups, the most common targets for improvement were access, communication with patients, and customer service. The most commonly reported improvement initiatives were changing office workflow, providing additional training for nonclinical staff, and adopting or enhancing an electronic health record., Conclusions: Despite statewide public reporting, physician groups' use of patient experience data varied widely. Integrated organizational models were associated with greater engagement, and efforts to enhance clinicians' interpersonal skills were uncommon, with groups predominantly focusing on office workflow and support staff.

Background: Performance reporting is increasingly focused on physician practice sites and individual physicians., Objective: To assess the reliability of performance measurement for practice sites and individual physicians., Research Design: We used data collected across multiple payers as part of a statewide measurement collaborative to evaluate the observed measure reliability and sample size requirements to achieve acceptable reliability of 4 Health Care Effectiveness Data and Information Set measures of preventive care and 10 Health Care Effectiveness Data and Information Set measures of chronic care across 334 practice sites. We conducted a parallel set of physician-level analyses using data across 118 primary physicians practicing within a large multispecialty group., Measures: Observed reliabilities and estimated sample size requirements to achieve reliability ≥0.70., Results: At the practice site level, sample sizes required to achieve a reliability of 0.70 were less than 200 patients per site for all 4 measures of preventive care, all 4 process measures of diabetes care, and 2 outcomes measures of diabetes care. Larger samples were required to achieve reliability for cholesterol screening in the presence of cardiovascular disease (n = 249) and use of appropriate asthma medications (n = 351). At the physician level, less than 200 patients were required for all 4 measures of preventive care, but for many chronic care measures the samples of patients available per physician were not sufficient to achieve a reliability of 0.70., Conclusion: In a multipayer collaborative, sample sizes were adequate to reliably assess clinical process and outcome measures at the practice site level. For individual physicians, sample sizes proved adequate to reliably measure preventive care, but may not be feasible for chronic care assessment.

Objective: To examine whether the Acute Respiratory Infection (ARI) Quality Dashboard, an electronic health record (EHR)-based feedback system, changed antibiotic prescribing., Study Design: Cluster randomized, controlled trial., Methods: We randomly assigned 27 primary care practices to receive the ARI Quality Dashboard or usual care. The primary outcome was the intent-to-intervene antibiotic prescribing rate for ARI visits. We also compared antibiotic prescribing between ARI Quality Dashboard users and nonusers., Results: During the 9-month intervention, there was no difference between intervention and control practices in antibiotic prescribing for all ARI visits (47% vs 47%; P = .87), antibiotic-appropriate ARI visits (65% vs 64%; P = .68), or non–antibiotic-appropriate ARI visits (38% vs 40%; P = .70). Among the 258 intervention clinicians, 72 (28%) used the ARI Quality Dashboard at least once. These clinicians had a lower overall ARI antibiotic prescribing rate (42% vs 50% for nonusers; P = .02). This difference was due to less antibiotic prescribing for non-antibiotic-appropriate ARIs (32% vs 43%; P = .004), including nonstreptococcal pharyngitis (31% vs 41%; P = .01) and nonspecific upper respiratory infections (19% vs 34%; P = .01)., Conclusions: The ARI Quality Dashboard was not associated with an overall change in antibiotic prescribing for ARIs, although when used, it was associated with improved antibiotic prescribing. EHR-based quality reporting, as part of "meaningful use," may not improve care in the absence of other changes to primary care practice.

Objective: To evaluate whether a new documentation-based clinical decision support system (CDSS) is effective in addressing deficiencies in the care of patients with coronary artery disease (CAD) and diabetes mellitus (DM)., Study Design: Controlled trial randomized by physician., Methods: We assigned primary care physicians (PCPs) in 10 ambulatory practices to usual care or the CAD/DM Smart Form for 9 months. The primary outcome was the proportion of deficiencies in care that were addressed within 30 days after a patient visit., Results: The Smart Form was used for 5.6% of eligible patients. In the intention-to-treat analysis, patients of intervention PCPs had a greater proportion of deficiencies addressed within 30 days of a visit compared with controls (11.4% vs 10.1%, adjusted and clustered odds ratio =1.14; 95% confidence interval, 1.02-1.28; P = .02). Differences were more pronounced in the "on-treatment" analysis: 17.0% of deficiencies were addressed after visits in which the Smart Form was used compared with 10.6% of deficiencies after visits in which it was not used (P <.001). Measures that improved included documentation of smoking status and prescription of antiplatelet agents when appropriate., Conclusions: Overall use of the CAD/DM Smart Form was low, and improvements in management were modest. When used, documentation-based decision support shows promise, and future studies should focus on refining such tools, integrating them into current electronic health record platforms, and promoting their use, perhaps through organizational changes to primary care practices.

Background: Electronic health records (EHRs) are widely viewed as useful tools for supporting the provision of high quality healthcare. However, evidence regarding their effectiveness for this purpose is mixed, and existing studies have generally considered EHR usage a binary factor and have not considered the availability and use of specific EHR features., Objective: To assess the relationship between the use of an EHR and the use of specific EHR features with quality of care., Research Design: A statewide mail survey of physicians in Massachusetts conducted in 2005. The results of the survey were linked with Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, and generalized linear regression models were estimated to examine the associations between the use of EHRs and specific EHR features with quality measures, adjusting for physician practice characteristics., Subjects: A stratified random sample of 1884 licensed physicians in Massachusetts, 1345 of whom responded. Of these, 507 had HEDIS measures available and were included in the analysis (measures are only available for primary care providers)., Measure: Performance on HEDIS quality measures., Results: The survey had a response rate of 71%. There was no statistically significant association between use of an EHR as a binary factor and performance on any of the HEDIS measure groups. However, there were statistically significant associations between the use of many, but not all, specific EHR features and HEDIS measure group scores. The associations were strongest for the problem list, visit note and radiology test result EHR features and for quality measures relating to women's health, colon cancer screening, and cancer prevention. For example, users of problem list functionality performed better on women's health, depression, colon cancer screening, and cancer prevention measures, with problem list users outperforming nonusers by 3.3% to 9.6% points on HEDIS measure group scores (all significant at the P < 0.05 level). However, these associations were not universal., Conclusions: Consistent with past studies, there was no significant relationship between use of EHR as a binary factor and performance on quality measures. However, availability and use of specific EHR features by primary care physicians was associated with higher performance on certain quality measures. These results suggest that, to maximize health care quality, developers, implementers and certifiers of EHRs should focus on increasing the adoption of robust EHR systems and increasing the use of specific features rather than simply aiming to deploy an EHR regardless of functionality.

Background: Increasing clinician awareness of racial disparities and improving communication may enhance diabetes care among black patients., Objective: To evaluate the effect of cultural competency training and performance feedback for primary care clinicians on diabetes care for black patients., Design: Cluster randomized, controlled trial conducted between June 2007 and May 2008. (ClinicalTrials.gov registration number: NCT00436176) SETTING: 8 ambulatory health centers in eastern Massachusetts., Participants: 124 primary care clinicians caring for 2699 (36%) black and 4858 (64%) white diabetic patients., Intervention: INTERVENTION clinicians received cultural competency training and monthly race-stratified performance reports that highlighted racial differences in control of hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein (LDL) cholesterol levels and blood pressure., Measurements: Clinician awareness of racial differences in diabetes care and rates of achieving clinical control targets among black patients at 12 months., Results: White and black patients differed significantly in baseline rates of achieving an HbA(1c) level less than 7% (46% vs. 40%), an LDL cholesterol level less than 2.59 mmol/L (<100 mg/dL) (55% vs. 43%), and blood pressure less than 130/80 mm Hg (32% vs. 24%) (all P < 0.050). At study completion, intervention clinicians were significantly more likely than control clinicians to acknowledge the presence of racial disparities in the 8 health centers as a whole (82% vs. 59%; P = 0.003), within their local health center (70% vs. 51%; P = 0.020), and among their own patients (63% vs. 43%; P = 0.037). Black patients of clinicians in the intervention and control groups did not differ at 12 months in rates of controlling HbA(1c) level (48% vs. 45%; P = 0.24), LDL cholesterol level (48% vs. 49%; P = 0.40), or blood pressure (23% vs. 25%; P = 0.47)., Limitation: 11% of primary care teams did not attend cultural competency training sessions., Conclusion: The combination of cultural competency training and race-stratified performance reports increased clinician awareness of racial disparities in diabetes care but did not improve clinical outcomes among black patients.

Background: To improve the documentation and treatment of tobacco use in primary care, we developed and implemented a 3-part electronic health record enhancement: (1)smoking status icons, (2) tobacco treatment reminders, and (3) a Tobacco Smart Form that facilitated the ordering of medication and fax and e-mail counseling referrals., Methods: We performed a cluster-randomized controlled trial of the enhancement in 26 primary care practices between December 19, 2006, and September 30, 2007. The primary outcome was the proportion of documented smokers who made contact with a smoking cessation counselor. Secondary outcomes included coded smoking status documentation and medication prescribing., Results: During the 9-month study period, 132 630 patients made 315 962 visits to study practices. Coded documentation of smoking status increased from 37% of patients to 54% (+17%) in intervention practices and from 35% of patients to 46% (+11%) in control practices (P < .001 for the difference in differences). Among the 9589 patients who were documented smokers at the start of the study, more patients in the intervention practices were recorded as nonsmokers by the end of the study (5.3% vs 1.9% in control practices; P < .001). Among 12 207 documented smokers, more patients in the intervention practices made contact with a cessation counselor (3.9% vs 0.3% in control practices; P < .001). Smokers in the intervention practices were no more likely to be prescribed smoking cessation medication (2% vs 2% in control practices; P = .40)., Conclusion: This electronic health record-based intervention improved smoking status documentation and increased counseling assistance to smokers but not the prescription of cessation medication.

Background: Anti-influenza antiviral medications reduce influenza-related morbidity, but may often be used inappropriately., Objective: To measure the rate of antiviral and antibiotic prescribing, the appropriateness of antiviral prescribing, and evaluate independent predictors of antiviral and antibiotic prescribing for influenza in primary care., Design and Patients: Retrospective analysis of 958 visits of clinician-diagnosed influenza in 21 primary care clinics in eastern Massachusetts from 1999 to 2007. We considered antiviral prescribing appropriate if patients had symptoms for 2 or fewer days, had fever, and any 2 of headache, sore throat, cough, or myalgias., Measurements and Main Results: Clinicians prescribed antivirals in 557 (58%) visits and antibiotics in 104 visits (11%). Of antiviral prescriptions, 38% were not appropriate, most commonly because of symptoms for more than 2 days (24% of antiviral prescriptions). In multivariate modeling, selected independent predictors of antiviral prescribing were symptom duration of 2 or fewer days (odds ratio [OR], 12.4; 95% confidence interval [CI], 8.3 to 18.6), year (OR, 1.4 for each successive influenza season; 95% CI, 1.3 to 1.7), patient age (OR, 1.3 per decade; 95% CI, 1.2 to 1.5), and, compared to having no influenza testing, having a negative influenza test (OR, 5.5; 95% CI, 3.4 to 9.1) or a positive influenza test (OR, 11.4; 95% CI, 6.7 to 19.3). Independent predictors of antibiotic prescribing included otoscopic abnormalities (OR, 3.3; 95% CI, 1.8 to 6.0), abnormal lung examination (OR, 4.0; 95% CI, 2.1 to 6.2), and having a chest x-ray performed (OR, 2.2; 95% CI, 1.3 to 3.8)., Conclusions: Primary care clinicians are much more likely to prescribe antivirals to patients with symptoms for 2 or fewer days, but also commonly prescribe antivirals inappropriately.

Background: Clinician perceptions of a newly implemented electronic health record play an important role in its success or failure., Objective: To measure changes in primary care clinician attitudes toward an electronic health record during the first year following implementation., Design: Longitudinal survey., Participants: 86 primary care clinicians surveyed between December 2006 and January 2008., Measurements: Perceived impact on overall quality of care, patient safety, communication, and efficiency at 1, 3, 6, and 12 months following implementation., Results: Response rates for months 1, 3, 6, and 12 were 92%, 95%, 90%, and 82%, respectively. The proportion of clinicians agreeing that the EHR improved the overall quality of care (63% to 86%; p < 0.001), reduced medication-related errors (72% to 81%; p = 0.03), improved follow-up of test results (62% to 87%; p < 0.001), and improved communication among clinicians (72% to 93%; p < 0.001) increased from month 1 to month 12. During the same time period, a decreasing proportion of clinicians agreed that the EHR reduced the quality of patient interactions (49% to 33%; p = 0.001), resulted in longer patient visits (68% to 51%; p = 0.001), and increased time spent on medical documentation (78% to 68%; p = 0.006). Significant improvements in perceptions related to test result follow-up were first detected at 6 months, while those related to overall quality, efficiency, and communication were first identified at 12 months., Conclusions: Primary care clinicians report increasingly positive perceptions of a new electronic health record within 1 year of implementation across a spectrum of domains of care.

Background: The Patient-Centered Medical Home (PCMH), a popular model for primary care reorganization, includes several structural capabilities intended to enhance quality of care. The extent to which different types of primary care practices have adopted these capabilities has not been previously studied., Objective: To measure the prevalence of recommended structural capabilities among primary care practices and to determine whether prevalence varies among practices of different size (number of physicians) and administrative affiliation with networks of practices., Design: Cross-sectional analysis., Participants: One physician chosen at random from each of 412 primary care practices in Massachusetts was surveyed about practice capabilities during 2007. Practice size and network affiliation were obtained from an existing database., Measurements: Presence of 13 structural capabilities representing 4 domains relevant to quality: patient assistance and reminders, culture of quality, enhanced access, and electronic health records (EHRs)., Main Results: Three hundred eight (75%) physicians responded, representing practices with a median size of 4 physicians (range 2-74). Among these practices, 64% were affiliated with 1 of 9 networks. The prevalence of surveyed capabilities ranged from 24% to 88%. Larger practice size was associated with higher prevalence for 9 of the 13 capabilities spanning all 4 domains (P < 0.05). Network affiliation was associated with higher prevalence of 5 capabilities (P < 0.05) in 3 domains. Associations were not substantively altered by statistical adjustment for other practice characteristics., Conclusions: Larger and network-affiliated primary care practices are more likely than smaller, non-affiliated practices to have adopted several recommended capabilities. In order to achieve PCMH designation, smaller non-affiliated practices may require the greatest investments.

Objective: To evaluate the impact of rigorous WalkRounds on frontline caregiver assessments of safety climate, and to clarify the steps and implementation of rigorous WalkRounds., Data Sources/study Setting: Primary outcome variables were baseline and post WalkRounds safety climate scores from the Safety Attitudes Questionnaire (SAQ). Secondary outcomes were safety issues elicited through WalkRounds. Study period was August 2002 to April 2005; seven hospitals in Massachusetts agreed to participate; and the project was implemented in all patient care areas., Study Design: Prospective study of the impact of rigorously applied WalkRounds on frontline caregivers assessments of safety climate in their patient care area. WalkRounds were conducted weekly and according to the seven-step WalkRounds Guide. The SAQ was administered at baseline and approximately 18 months post-WalkRounds implementation to all caregivers in patient care areas., Results: Two of seven hospitals complied with the rigorous WalkRounds approach; hospital A was an academic teaching center and hospital B a community teaching hospital. Of 21 patient care areas, SAQ surveys were received from 62 percent of respondents at baseline and 60 percent post WalkRounds. At baseline, 10 of 21 care areas (48 percent) had safety climate scores below 60 percent, whereas post-WalkRounds three care areas (14 percent) had safety climate scores below 60 percent without improving by 10 points or more. Safety climate scale scores in hospital A were 62 percent at baseline and 77 percent post-WalkRounds (t=2.67, p=.03), and in hospital B were 46 percent at baseline and 56 percent post WalkRounds (t=2.06, p=.06). Main safety issues by category were equipment/facility (A [26 percent] and B [33 percent]) and communication (A [24 percent] and B [18 percent])., Conclusions: WalkRounds implementation requires significant organizational will; sustainability requires outstanding project management and leadership engagement. In the patient care areas that rigorously implemented WalkRounds, frontline caregiver assessments of patient safety increased. SAQ results such as safety climate scores facilitate the triage of quality improvement efforts, and provide consensus assessments of frontline caregivers that identify themes for improvement.

Background: Physicians are increasingly asked to improve the delivery of clinical services and patient experiences of care., Objective: We evaluated the association between clinical performance and patient experiences in a statewide sample of physician practice sites and a sample of physicians within a large physician group., Design, Setting, Participants: We separately identified 373 practice sites and 119 individual primary care physicians in Massachusetts., Measurements: Using Health Plan Employer Data and Information Set data, we produced two composites addressing processes of care (prevention, disease management) and one composite addressing outcomes. Using Ambulatory Care Experiences Survey data, we produced seven composite measures summarizing the quality of clinical interactions and organizational features of care. For each sample (practice site and individual physician), we calculated adjusted Spearman correlation coefficients to assess the relationship between the composites summarizing patient experiences of care and those summarizing clinical performance., Results: Among 42 possible correlations (21 correlations involving practice sites and 21 involving individual physicians), the majority were positive in site level (71%) and physician level (67%) analyses. For the 28 possible correlations involving patient experiences and clinical process composites, 8 (29%) were significant and positive, and only 2 (7%) were significant and negative. The magnitude of the significant positive correlations ranged from 0.13 to 0.19 at the site level and from 0.28 to 0.51 at the physician level. There were no significant correlations between patient experiences and the clinical outcome composite., Conclusions: The modest correlations suggest that clinical quality and patient experience are distinct, but related domains that may require separate measurement and improvement initiatives.

Background: Anticoagulation is a commonly prescribed and effective therapy for several medical conditions but requires detailed communication among clinicians to avoid adverse patient outcomes following hospital discharge., Methods: Discharge documentation packets of a sample of patients discharged from all five acute care hospitals of the Partners Healthcare System to 30 subacute facilities in Boston and prescribed anticoagulation for treatment or prophylaxis of thromboembolic disease were evaluated. Required data elements included information on anticoagulation indication, duration, dosing, monitoring, and follow-up. Discharge documentation packets were randomly selected for reviewers at acute sites, whereas reviewers at subacute sites selected which packets to review., Results: Of 757 patients prescribed anticoagulation at discharge from March 2005 through June 2007, duration of therapy (for unfractionated or low-molecular-weight heparin [UFH/LMWH]) and recent dosing and monitoring information (for warfarin) were the areas with the biggest deficits. Of the patients prescribed UFH/LMWH or warfarin, 45.4% and 16.4%, respectively, had all the required information in the discharge summary. Patients discharged from community hospitals were more likely to be discharged with all the information needed for the use of warfarin (Odds Ratio [OR], 2.56; 95% confidence interval [CI], 1.20-5.46) or UFH/LMWH (OR, 2.97; 95% CI, 1.98-4.44) than patients discharged from academic medical centers., Discussion: Important information to safely prescribe anticoagulation after discharge was often missing from the discharge summaries of patients transferred from acute hospitals to subacute facilities. Future research should focus on developing, implementing, and evaluating quality improvement interventions to address this gap.

Background: Chronic kidney disease (CKD) is a growing problem among the elderly. Early detection is considered essential to ensure proper treatment and to avoid drug toxicity, but detection is challenging because elderly patients with CKD often have normal serum creatinine levels. We hypothesized that most cases of CKD in the elderly would go undetected, resulting in inappropriate prescribing., Objective: To determine whether recognition of CKD is associated with more appropriate treatment, Design: Retrospective chart review, Participants: All patients aged >/=65 years with a measured serum creatinine in the past 3 years at 2 inner city academic health centers., Measurements: Estimated glomerular filtration rate (eGFR) calculated using the Modified Diet in Renal Disease equation, and for patients with eGFR < 60, documentation of CKD by the provider, diagnostic testing, nephrology referral and prescription of appropriate or contraindicated medications., Results: Of 814 patients with sufficient information to estimate eGFR, 192 (33%) had moderate (eGFR < 60 mL/min) and 5% had severe (eGFR < 30 mL/min) CKD. Providers identified 38% of moderate and 87% of severe CKD. Compared to patients without recognized CKD, recognized patients were more likely to receive an ACE/ARB (80% vs 61%, p = .001), a nephrology referral (58% vs 2%, p < .0001), or urine testing (75% vs 47%, p < .0001), and less likely to receive contraindicated medications (26% vs 40%, p = .013)., Conclusions: Physicians frequently fail to diagnose CKD in the elderly, leading to inappropriate treatment. Efforts should focus on helping physicians better identify patients with low GFR.

Objectives: Depression is common in persons with HIV infection and with alcohol problems, and it has important prognostic implications. Neurocognitive dysfunction has been reported with chronic hepatitis C virus (HCV) infection. We hypothesized that HCV infection is associated with more depressive symptoms in HIV-infected persons with a history of alcohol problems., Methods: We performed a cross-sectional analysis of baseline data from a prospective cohort study of 391 HIV-infected subjects with a history of alcohol problems, of whom 59% were HCV antibody (Ab) positive and 49% were HCV RNA-positive. We assessed depressive symptoms (Center for Epidemiologic Studies Depression [CES-D]) and past month alcohol consumption. In the primary analysis, we evaluated whether there were more depressive symptoms in HCV Ab-positive and RNA-positive subjects in unadjusted analyses and adjusting for alcohol consumption, gender, age, race, CD4 count, homelessness, drug dependence, and medical comorbidity., Results: Mean CES-D scores were higher in subjects who were HCV Ab-positive compared with those who were HCV Ab-negative (24.3 vs 19.0; p < 0.001). In adjusted analyses, the difference in CES-D scores between HCV Ab-positive and Ab-negative subjects persisted (24.0 vs 19.0; p < 0.001). Unadjusted mean CES-D scores were also significantly higher in HCV RNA-positive subjects compared with those who were RNA-negative, and the difference remained significant (24.6 vs 19.3; p < 0.001) in adjusted analyses., Conclusions: HCV/HIV coinfected persons with a history of alcohol problems have more depressive symptoms than those without HCV, and this association is unexplained by a variety of population characteristics. These data suggest that HCV may have a direct effect on neuropsychiatric function.

Objectives: To compare outcomes of patients admitted to postacute skilled nursing facilities with delirium, subsyndromal delirium, and no delirium., Design: Observational cohort study., Setting: Seven skilled nursing facilities that specialize in postacute care within a single metropolitan region., Participants: Five hundred four subjects chosen from 1,248 consenting subjects aged 65 and older who underwent mental status testing within 5 days of admission to the participating facilities. Subjects who met full Confusion Assessment Method (CAM) criteria were classified as delirious, those with one or more CAM criteria were classified as having subsyndromal delirium, and those with no CAM features were classified as having no delirium. All subjects with delirium and with available medical records were included. A random subset of subjects with no delirium and subsyndromal delirium with available medical records was included., Measurements: The medical records of all subjects underwent a structured review by trained research nurses who were masked to the subjects' initial delirium status. Records were reviewed for the development of new complications within the postacute setting and to determine whether the subjects were discharged within 30 days and, if so, the discharge destination. The National Death Index was used to assess 6-month mortality., Results: Subjects with delirium were more likely to experience one or more complications than subjects with no delirium (73% vs 41%, P < .01). Within 30 days of postacute admission, subjects with delirium were more than twice as likely to be rehospitalized (30% vs 13%), and less than half as likely to be discharged to the community (30% vs 73%) than subjects without delirium (differences P < .01). Subjects with subsyndromal delirium had outcomes intermediate between those with and without delirium. Finally, subjects admitted to the postacute setting with delirium experienced a 6-month mortality rate of 25.0%, compared with 5.7% in subjects admitted without delirium. Subjects with subsyndromal delirium had a 6-month mortality rate of 18.3%., Conclusion: Patients admitted to postacute skilled nursing facilities with delirium are more likely to experience complications, rehospitalization, and death than patients without delirium. These findings support the need for improved case finding and management of delirium in postacute care.

Think HIV offered HIV counseling, testing, and referral to patients at 4 Massachusetts urgent care centers from January to September 2002. We compared the positive diagnosis yield of Think HIV with that of state-funded HIV counseling, testing, and referral sites. Think HIV found an HIV prevalence of 2.0% compared with 1.9% identified by self-referral testing. Urgent care center-based routine HIV counseling, testing, and referral programs are feasible, can have high positive diagnosis yields, and should be the standard of care in high HIV prevalence areas.

Objectives: We assessed the impact of interpreter services on the cost and the utilization of health care services among patients with limited English proficiency., Methods: We measured the change in delivery and cost of care provided to patients enrolled in a health maintenance organization before and after interpreter services were implemented., Results: Compared with English-speaking patients, patients who used the interpreter services received significantly more recommended preventive services, made more office visits, and had more prescriptions written and filled. The estimated cost of providing interpreter services was $279 per person per year., Conclusions: Providing interpreter services is a financially viable method for enhancing delivery of health care to patients with limited English proficiency.

Background: The recent public health risks arising from bioterrorist threats and outbreaks of infectious diseases like SARS (Severe Acute Respiratory Syndrome) highlight the challenges of effectively communicating accurate health information to an alarmed public., Objective: To evaluate use of the Internet in accessing information related to the anthrax scare in the United States in late 2001, and to strategize about the most effective use of this technology as a communication vehicle during times of public health crises., Methods: A paper-based survey to assess how individuals obtained health information relating to bioterrorism and anthrax during late 2001. We surveyed 500 randomly selected patients from two ambulatory primary care clinics affiliated with the Brigham and Women's Hospital in Boston, Massachusetts., Results: The response rate was 42%. While traditional media provided the primary source of information on anthrax and bioterrorism, 21% (95% CI, 15%-27%) of respondents reported searching the Internet for this information during late 2001. Respondents reported trusting information from physicians the most, and information from health websites slightly more than information from any traditional media source. Over half of those searching the Internet reported changing their behavior as a result of information found online., Conclusions: Many people already look to the Internet for information during a public health crisis, and information found online can positively influence behavioral responses to such crises. However, the potential of the Internet to convey accurate health information and advice has not yet been realized. In order to enhance the effectiveness of public-health communication, physician practices could use this technology to pro-actively e-mail their patients validated information. Still, unless Internet access becomes more broadly available, its benefits will not accrue to disadvantaged populations.

Background: A culture of safety survey was used to study features of the safety culture and their relationship with patient safety indicators., Study Design: Anonymous written surveys were collected from 455 of 1,027 (44%) workers at four Massachusetts hospitals. Respondents characterized their organizations' patient safety, workplace safety, and features of a safety culture, such as leadership commitment, professional salience, presence of a nonpunitive environment, error reporting, and communication., Results: Employees universally regarded patient safety as an essential part of their job. Two-thirds of workers worried at least once a day about making a mistake that could injure a patient; 43% said that the work load hindered their ability to keep patients safe. Workers' overall assessment of patient safety was associated with their perceptions of workplace safety (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.02-3.43, p = .044) and leadership commitment to patient safety (OR 3.20, 95% CI 1.97-5.19, p < .001). Incident reporting rates correlated with survey results, while adoption of best practices and expert opinion did not., Discussion: Patient safety is salient to workers, who universally embraced patient safety as an essential part of their job. Independent indicators of patient safety did not line up neatly with safety culture survey results. Incident reporting rates correlated directly, while adoption of best practices and expert opinion varied inversely with survey results. The safety culture is a complex phenomenon that requires further study.

Objective: To determine the impact that upper respiratory tract infections have on patients' physical, social, and emotional functioning, we measured the health-related quality of life (HRQL) of adults with upper respiratory tract infections., Setting: Acute care clinic from November 2001 to February 2002., Design: Prospectively administered survey. To measure HRQL, we used the Acute Form of the Short Form-36, version 2 (SF-36). For all 8 SF-36 subscales, we used norm-based scoring, in which the general U.S. population has a mean of 50., Patients: Adults who had symptoms for fewer than 30 days completed the SF-36; and were diagnosed with nonspecific upper respiratory infection, viral syndrome, otitis media, sinusitis, nonstreptococcal pharyngitis, streptococcal pharyngitis, or acute bronchitis., Measurements and Main Results: The sample of 318 patients was 63% female, 81% white, and had a mean age of 35 years. The primary diagnoses were nonspecific upper respiratory infection (42%), acute bronchitis (16%), sinusitis (12%), viral syndrome (9%), nonstreptococcal pharyngitis (8%), otitis media (7%), and streptococcal pharyngitis (6%). Patients had a mean general health subscale score of 50.9, which is not significantly different from the mean population value of 50 (P =.09). However, there were significant decrements in the remaining 7 subscales of the SF-36: physical functioning (45.5), role-physical (38.5), bodily pain (42.6), vitality (40.8), social functioning (37.8), role-emotional (46.8), and mental health (46.8; P <.0001 for all 7 subscales compared with normative values). Results were similar for the subset of patients with no comorbid illnesses (P <.001 for the same 7 subscales) and patients diagnosed with nonspecific upper respiratory infection (P <.001 for the same 7 subscales). These decrements were similar in magnitude, but somewhat different in subscale pattern, to those of adults with chronic lung disease, osteoarthritis, and depression., Conclusions: Physicians should remember that adults who seek care for upper respiratory tract infections have measurable, significant decrements in HRQL. For researchers, HRQL is an attractive, potential measure of outcome in future trials of established and novel therapies for upper respiratory tract infections.

Objective: Prior studies have shown that 60% to 75% of adults with upper respiratory tract infections want antibiotics. More recent research indicates declines in antibiotic prescribing for upper respiratory tract infections. To investigate whether there has been a comparable decrease in patients' desire for antibiotics, we measured the proportion of adults with upper respiratory tract infections who wanted antibiotics in the winter of 2001-2002. We also sought to identify factors independently associated with wanting antibiotics and antibiotic prescribing., Design: Prospective survey of adults with upper respiratory tract infections prior to visiting an acute care clinic from November 2001 to February 2002., Measurements and Main Results: Thirty-nine percent of 310 patients wanted antibiotics. Many patients wanted relief from symptoms (43%) or pain (24%) and many patients expected to receive a diagnosis (49%) or reassurance during the visit (13%). In multivariable modeling, independent predictors of wanting antibiotics were prior antibiotic use (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.3 to 4.7) and current smoking (OR, 3.1; 95% CI, 1.3 to 7.3). Physicians prescribed antibiotics to 46% of patients who wanted antibiotics and 29% of patients who did not want antibiotics (P=.01). In multivariable modeling, wanting antibiotics was an independent predictor of antibiotic prescribing (OR, 2.1; 95% CI, 1.1 to 4.4)., Conclusions: Only 39% of adults seeking care for upper respiratory tract infections wanted antibiotics, less than in previous studies. In continuing efforts to break the cycle of inappropriate antibiotic use, physicians should not assume that most patients with upper respiratory tract infections want antibiotics.

Context: Primarily because of immigration, Asian Americans are one of the fastest growing and most ethnically diverse minority groups in the United States. However, little is known about their perspectives on health care quality., Objective: To examine factors contributing to quality of care from the perspective of Chinese- and Vietnamese-American patients with limited English language skills., Design: Qualitative study using focus groups and content analysis to determine domains of quality of care., Setting: Four community health centers in Massachusetts., Participants: A total of 122 Chinese- and Vietnamese-American patients were interviewed in focus groups by bilingual interviewers using a standardized, translated moderator guide., Main Outcome Measures: Domains of quality of care mentioned by patients in verbatim transcripts., Results: In addition to dimensions of health care quality commonly expressed by Caucasian, English-speaking patients in the United States, Chinese- and Vietnamese-American patients with limited English proficiency wanted to discuss the use of non-Western medical practices with their providers, but encountered significant barriers. They viewed providers' knowledge, inquiry, and nonjudgmental acceptance of traditional Asian medical beliefs and practices as part of quality care. Patients also considered the quality of interpreter services to be very important. They preferred using professional interpreters rather than family members, and preferred gender-concordant translators. Furthermore, they expressed the need for help in navigating health care systems and obtaining support services., Conclusions: Cultural and linguistically appropriate health care services may lead to improved health care quality for Asian-American patients who have limited English language skills. Important aspects of quality include providers' respect for traditional health beliefs and practices, access to professional interpreters, and assistance in obtaining social services.