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Objectives Reduction in unnecessary services is one strategy for increasing the value of health care. Reference laboratory, or send-out, tests are associated with considerable costs. We investigated whether displaying cost and turnaround time (TAT), or time-to-result, for reference laboratory tests at the time of order entry in the electronic health record (EHR) system would impact provider ordering practices. Methods Reference laboratory test cost and TAT data were randomized prior to the study and only displayed for the intervention group. A 24-month dataset composed of 12 months each for baseline and study periods was extracted from the clinical data mart. A difference-in-differences (DID) analysis was conducted using a linear mixed-effects model to estimate the association between the intervention and changes in test-ordering patterns. Results In the inpatient setting, the DIDs of aggregate test-order costs and volume were not different among the control and intervention groups (p = 0.31 and p = 0.26, respectively). In the ambulatory setting, the DIDs of aggregate test-order costs and volume were not different among the control and intervention groups (p = 0.82 and p = 0.51, respectively). For both inpatient and ambulatory settings, no significant difference was observed in the DID of aggregate test-order costs and volumes calculated in respect to stratified relative cost and TAT groups (p > 0.05). Conclusion Lack of alternative tests, test orders placed at a late step in patient management, and orders facilitated by trainees or mid-level providers may have limited the efficacy of the intervention. Our randomized study demonstrated no significant association between the display of cost or TAT display and ordering frequency.

Background: No completed trials have compared carotid artery stenting (CAS) to medical therapy (MT). We examined the effectiveness of CAS compared with MT in patients with asymptomatic carotid stenosis. Methods: We conducted a retrospective cohort study of 219 979 Veterans ≥65 years who received carotid imaging for asymptomatic carotid stenosis between 2005 and 2009 in the US Veterans Health Administration. We constructed a sample of patients who received MT (n=2509) and comparable patients who received CAS (n=551) and followed them for 5 years. Using target trial methodology, we computed weighted Kaplan-Meier curves and estimated the risk of fatal and nonfatal stroke in each group over 5 years of follow-up. We also estimated the cumulative incidence functions for fatal and nonfatal stroke accounting for nonstroke deaths as competing risks. Results: Five hundred fifty-one patients received CAS, and 2509 patients received MT. The observed rate of stroke or death (perioperative complications) within 30 days in the CAS arm was 2.2%. Using the target trial methodology, the 5-year risk of fatal and nonfatal stroke was similar among patients assigned to CAS (6.9%) compared with patients assigned to MT (7.1%; risk difference, −0.1% [95% CI, −2.6% to 2.7%]). In an analysis that incorporated the competing risk of death, the risk difference between the two arms remained nonsignificant (risk difference, −1.5% [95% CI, −3.0% to 0.3%]). Conclusions: In this sample of older male adults, we found no difference between MT and CAS in the treatment of asymptomatic carotid stenosis. Future studies in other settings are needed to confirm these findings.

IntroductionRobust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory.Methods and analysisThis pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings.Ethics and disseminationThe study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country.Trial registration numberClinicalTrials.gov identifier: NCT04104256.

Purpose There is an increasing effort to allow patients open access to their physician notes through electronic medical record portals. However, limited data exist on the impact of such access on oncology patients, and concerns remain regarding potential harms. Therefore, we determined the baseline perceptions and impact of open access to oncology notes on radiation oncology patients. Methods and materials Patients receiving radiation therapy were provided instructional materials on accessing oncology notes at the time of their initial evaluation. Patients were prospectively surveyed to evaluate baseline interest and expectations before access and to determine the actual usage and impact at the end of their radiation treatment course. Results A total of 220 patients were surveyed; 136 (62%) completed the baseline survey, of which 88 (40%) completed the final survey. The majority of participants were age >60 years (n = 83; 61%), and 70 were male (51%). Before accessing the notes, the majority of patients agreed that open access to oncology notes would improve understanding of diagnosis (99%), understanding of treatment side effects (98%), reassurance about treatment goals (96%), and communication with family (99%). All patients who accessed the notes found them to be useful. After accessing the notes, approximately 96%, 94%, and 96% of patients reported an improved understanding of their diagnosis, an improved understanding of treatment side effects, and feeling more reassured about their treatment, respectively. Approximately 11%, 6%, and 4% of patients noted increased worry, increased confusion, and finding information they now regret reading, respectively. Patient age, sex, and specific cancer diagnoses were not predictive of experiencing negative effects from accessing the notes. Conclusions Radiation oncology patients have a strong interest in open access to their physician notes, and the majority of patients expect and actually report meaningful benefits. These data support strategies to allow more patients with cancer access to their physicians’ notes.

Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably. We sought to identify factors associated with the decision to admit patents with TIA. We conducted a secondary analysis of a prior study’s data including semi-structured interviews, administrative data, and chart review. We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011. For the qualitative data, we focused on interviewees’ responses to the prompt: “Tell me what influences you in the decision to or not to admit TIA patients.” We used administrative data to identify admission rates and chart review data to identify ABCD2 scores (a tool to classify stroke risk after TIA). Providers’ decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD2 score, and concerns about facilities’ ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD2 scores and related guidelines in admission decision-making. Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians’ uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies.

Key Points Question Is a team-based community health worker and advanced practice clinician (including nurse practitioners or physician assistants) intervention emphasizing evidence-based care, self-management, lifestyle change, and medication adherence superior to usual care for controlling blood pressure after stroke in safety-net settings? Findings In this randomized clinical trial that included 487 adults with recent stroke or transient ischemic attack, there was no difference between usual care and the multifaceted team-based intervention in blood pressure control at 12 months. Meaning These findings suggest that additional research is needed to determine the optimal care model for controlling risk factors after stroke in safety-net settings., This randomized clinical trial examines the effect of a multifaceted team intervention vs usual care on systolic blood pressure (SBP) among patients with stroke or transient ischemic attack (TIA) in safety-net settings., Importance Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations. Objective To determine if a chronic care model–based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay). Design, Setting, and Participants This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020. Interventions Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, ≥3 APC clinic visits, ≥3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials. Main Outcomes and Measures The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non–high density lipoprotein cholesterol, hemoglobin A1c, and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use. Results Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, −0.4 [95% CI, −0.7 to −0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose. Conclusions and Relevance This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement. Trial Registration ClinicalTrials.gov Identifier: NCT01763203

Background A recent nurse-led proactive care management intervention, Care Coordination for Health Promotion and Activities in Parkinson Disease (CHAPS), improved care quality when compared to usual care in a randomized controlled trial. Therefore, stakeholder (patient participants, nurse care managers, and Parkinson disease (PD) specialists) perceptions of key intervention components merit evaluation to inform decisions about dissemination. Methods This multi-site study occurred in five southwest United States Veterans Health Administration medical centers. Stakeholders were surveyed on their perceptions of CHAPS including the CHAPS Assessment, CHAPS nurse care managers, the Siebens Domain Management Model™ (a practical clinical model), and the Siebens Health Care Notebook (Notebook) (self-care tool). Participants’ electronic medical records were abstracted for perceptions of the Notebook. Statistical analysis software was used to provide summary statistics; open card sorting methodology was used to identify themes and attributes in qualitative data including usability of some components. Results Participants, overall, highly rated their medication self-management, acknowledged some challenges with the CHAPS self-care tools, reported knowledge of PD specialist follow-up and PD red flags, and rated CHAPS nurse care managers as helpful. Nurse care manager responses indicated the CHAPS Assessment and Program highly facilitated care of their patients. Most all PD specialists would refer other patients to CHAPS. Nurse care manager and PD specialist responses indicated improved participant management of their PD. Three themes emerged in participant perceptions of the Notebook: Notebook Assets (e.g., benefits and features-liked); Deferring Notebook Review (e.g., no time to review); and Reasons for Not Using (e.g., participant preference). Shared attributes regarding the Siebens Domain Management Model and Notebook usability, reported by nurse care managers, were user-friendly, person/patient-centered, and organized. Some challenges to their use were also reported. Conclusions Overall, stakeholder perceptions of the proactive nurse-led CHAPS intervention indicated its value in the care of individuals with PD. Responses about the CHAPS Assessment, Siebens Domain Management Model, and Notebook self-care tool signified their usefulness. Stakeholders’ constructive suggestions indicated their engagement in CHAPS. These findings support CHAPS dissemination and contribute to research in care management. Trial registration ClinicalTrials.gov as NCT01532986, registered on January 13, 2012.

Background and Purpose: Self-management programs may improve quality of life and self-efficacy for stroke survivors, but participation is low. In a randomized controlled trial of a complex, multidisciplinary, team-based secondary stroke prevention intervention, we offered participants Chronic Disease Self-Management Program (CDSMP) workshops in addition to clinic visits and home visits. To enhance participation, workshops were facilitated by community health workers who were culturally and linguistically concordant with most participants and scheduled CDSMP sessions at convenient venues and times. Over time, we implemented additional strategies such as free transportation and financial incentives. In this study, we aimed to determine factors associated with CDSMP participation and attendance. Methods: From 2014 to 2018, 18 CDSMP workshop series were offered to 241 English and Spanish-speaking individuals (age ≥40 years) with recent stroke or transient ischemic attack. Zero-inflated Poisson regression was used to identify factors associated with participation and attendance (ie, number of sessions attended) in CDSMP. Missing values were imputed using multiple imputation methods. Results: Nearly one-third (29%) of intervention subjects participated in CDSMP. Moderate disability and more clinic/home visits were associated with participation. Participants with higher numbers of clinic and home visits (incidence rate ratio [IRR], 1.06 [95% CI, 1.01–1.12]), severe (IRR, 2.34 [95% CI, 1.65–3.31]), and moderately severe disability (IRR, 1.55 [95% CI, 1.07–2.23]), and who enrolled later in the study (IRR, 1.12 [95% CI, 1.08–1.16]) attended more sessions. Individuals with higher chaos scores attended fewer sessions (IRR, 0.97 [95% CI, 0.95–0.99]). Conclusions: Less than one-third of subjects enrolled in the SUCCEED (Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities) intervention participated in CDSMP; however, participation improved as transportation and financial barriers were addressed. Strategies to address social determinants of health contributing to chaos and engage individuals in healthcare may facilitate attendance. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01763203.

This nonrandomized cluster trial with matched controls implements the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve transient ischemic attack quality of care., Key Points Question Is the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) program associated with improved care for transient ischemic attack? Findings This nonrandomized cluster trial with matched controls (including 6 PREVENT sites and 36 matched control sites) evaluated quality of care for transient ischemic attach across 7 guideline-recommended processes of care measured by the without-fail rate. Over the course of a 1-year implementation period, the mean without-fail rate improved 17% at the 6 PREVENT sites and only 3% at 36 matched control sites. Meaning These findings suggest that implementation of a multicomponent program such as PREVENT may improve quality of care for transient ischemic attack., Importance Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events. Timely management can reduce that risk by 70%; however, gaps in TIA quality of care exist. Objective To assess the performance of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve TIA quality of care. Design, Setting, and Participants This nonrandomized cluster trial with matched controls evaluated a multicomponent intervention to improve TIA quality of care at 6 diverse medical centers in 6 geographically diverse states in the US and assessed change over time in quality of care among 36 matched control sites (6 control sites matched to each PREVENT site on TIA patient volume, facility complexity, and quality of care). The study period (defined as the data period) started on August 21, 2015, and extended to May 12, 2019, including 1-year baseline and active implementation periods for each site. The intervention targeted clinical teams caring for patients with TIA. Intervention The quality improvement (QI) intervention included the following 5 components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Main Outcomes and Measures The primary outcome was the without-fail rate, which was calculated as the proportion of veterans with TIA at a specific facility who received all 7 guideline-recommended processes of care for which they were eligible (ie, anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high- or moderate-potency statin therapy, hypertension control, and neurological consultation). Generalized mixed-effects models with multilevel hierarchical random effects were constructed to evaluate the intervention associations with the change in the mean without-fail rate from the 1-year baseline period to the 1-year intervention period. Results Six facilities implemented the PREVENT QI intervention, and 36 facilities were identified as matched control sites. The mean (SD) age of patients at baseline was 69.85 (11.19) years at PREVENT sites and 71.66 (11.29) years at matched control sites. Most patients were male (95.1% [154 of 162] at PREVENT sites and 94.6% [920 of 973] at matched control sites at baseline). Among the PREVENT sites, the mean without-fail rate improved substantially from 36.7% (58 of 158 patients) at baseline to 54.0% (95 of 176 patients) during a 1-year implementation period (adjusted odds ratio, 2.10; 95% CI, 1.27-3.48; P = .004). Comparing the change in quality at the PREVENT sites with the matched control sites, the improvement in the mean without-fail rate was greater at the PREVENT sites than at the matched control sites (36.7% [58 of 158 patients] to 54.0% [95 of 176 patients] [17.3% absolute improvement] vs 38.6% [345 of 893 patients] to 41.8% [363 of 869 patients] [3.2% absolute improvement], respectively; absolute difference, 14%; P = .008). Conclusions and Relevance The implementation of this multifaceted program was associated with improved TIA quality of care across the participating sites. The PREVENT QI program is an example of a health care system using QI strategies to improve performance, and may serve as a model for other health systems seeking to provide better care. Trial Registration ClinicalTrials.gov Identifier: NCT02769338

Background The COVID-19 pandemic has resulted in reduced performance of elective surgeries and procedures at medical centers across the U.S. Awareness of the prevalence of asymptomatic disease is critical for guiding safe approaches to operative/procedural services. As COVID-19 PCR testing has been limited largely to symptomatic patients, healthcare workers (HCWs), or to those in communal care centers, data regarding asymptomatic viral disease carriage are limited. Study Design In this retrospective observational case series evaluating UCLA Health patients enrolled in pre-operative/pre-procedure protocol COVID-19 RT-PCR testing between 4/7/20 – 5/21/20, we determine the prevalence of COVID-19 infection in asymptomatic patients scheduled for surgeries and procedures. Results Primary outcomes include the prevalence of COVID-19 infection in this asymptomatic population. Secondary data analysis includes overall population testing results and population demographics. 18 of 4751 (0.38%) patients scheduled for upcoming surgeries and high risk procedures had abnormal (positive/inconclusive) COVID-19 RT-PCR testing results. 6/18 patients were confirmed asymptomatic. 4/18 had inconclusive results. 8/18 had positive results in the setting of recent symptoms or known COVID-19 infection. The prevalence of asymptomatic COVID-19 infection was 0.13%. More than 90% of patients had residential addresses within a 67 mile geographic radius of our medical center, the median age was 58, and there was equal male/female distribution. Conclusions These data demonstrating low levels (0.13% prevalence) of COVID-19 infection in an asymptomatic population of patients undergoing scheduled surgeries/procedures in a large urban area have helped to inform perioperative protocols during the COVID-19 pandemic. Testing protocols like ours may prove valuable for other health systems in their approaches to safe procedural practices during COVID-19., Highlights TOC Statement- 20200901 Universal COVID-19 RT-PCR protocol testing demonstrates low levels of COVID-19 infection (prevalence of 0.13%) in asymptomatic pre-operative/pre-procedure patients at an academic medical center in a large urban area. These data help guide safe perioperative algorithms for caring for surgical/procedural patients during the COVID-19 pandemic.

Background A recent nurse-led, telephone-administered 18-month intervention, Care Coordination for Health Promotion and Activities in Parkinson’s Disease (CHAPS), was tested in a randomized controlled trial and improved care quality. Therefore, intervention details on nurse care manager activity (types and frequencies) and participant actions are needed to support potential dissemination. Activities include nurse care manager use of a holistic organizing framework, identification of Parkinson's disease (PD)-related problems/topics, communication with PD specialists and care coordination, participant coaching, and participant self-care actions including use of a notebook self-care tool. Methods This article reports descriptive data on the CHAPS intervention. The study setting was five sites in the Veterans Affairs Healthcare System. Sociodemographic data were gathered from surveys of study participants (community-dwelling veterans with PD). Nurse care manager intervention activities were abstracted from electronic medical records and logbooks. Statistical analysis software was used to provide summary statistics; closed card sorting was used to group some data. Results Intervention participants (n = 140) were primarily men, mean age 69.4 years (standard deviation 10.3) and community-dwelling. All received the CHAPS Initial Assessment, which had algorithms designed to identify 31 unique CHAPS standard problems/topics. These were frequently documented (n = 4938), and 98.6% were grouped by assigned domain from the Organizing Framework (Siebens Domain Management Model™). Nurse care managers performed 27 unique activity types to address identified problems, collaborating with participants and PD specialists. The two most frequent unique activities were counseling/emotional support (n = 387) and medication management (n = 349). Both were among 2749 total performed activities in the category Implementing Interventions (coaching). Participants reported unique self-care action types (n = 23) including use of a new notebook self-care tool. Conclusions CHAPS nurse care managers implemented multiple activities including participant coaching and care coordination per the CHAPS protocol. Participants reported various self-care actions including use of a personalized notebook. These findings indicate good quality and extent of implementation, contribute to ensuring reproducibility, and support CHAPS dissemination as a real-world approach to improve care quality. Trial registration ClinicalTrials.gov as NCT01532986, registered on January 13, 2012.

Supplemental Digital Content is available in the text., Background and Purpose— Lowering blood pressure and cholesterol, antiplatelet/antithrombotic use, and smoking cessation reduce risk of recurrent stroke. However, gaps in risk factor control among stroke survivors warrant development and evaluation of alternative care delivery models that aim to simultaneously improve multiple risk factors. Randomized trials of care delivery models are rarely of sufficient duration or size to be powered for low-frequency outcomes such as observed recurrent stroke. This creates a need for tools to estimate how changes across multiple stroke risk factors reduce risk of recurrent stroke. Methods— We reviewed existing evidence of the efficacy of interventions addressing blood pressure reduction, cholesterol lowering, antiplatelet/antithrombotic use, and smoking cessation and extracted relative risks for each intervention. From this, we developed a tool to estimate reductions in recurrent stroke risk, using bootstrapping and simulation methods. We also calculated a modified Global Outcome Score representing the proportion of potential benefit (relative risk reduction) achieved if all 4 individual risk factors were optimally controlled. We applied the tool to estimate stroke risk reduction among 275 participants with complete 12-month follow-up data from a recently published randomized trial of a healthcare delivery model that targeted multiple stroke risk factors. Results— The recurrent stroke risk tool was feasible to apply, yielding an estimated reduction in the relative risk of ischemic stroke of 0.36 in both the experimental and usual care trial arms. Global Outcome Score results suggest that participants in both arms likely averted, on average, 45% of recurrent stroke events that could possibly have been prevented through maximal implementation of interventions for all 4 individual risk factors. Conclusions— A stroke risk reduction tool facilitates estimation of the combined impact on vascular risk of improvements in multiple stroke risk factors and provides a summary outcome for studies testing alternative care models to prevent recurrent stroke. Registration— URL: https://www.clinicaltrials.gov; Unique identifier: NCT00861081.

Objective A growing body of evidence suggests that testing for influenza virus alone is more appropriate than multiplex respiratory viral panel (RVP) testing for general populations of patients with respiratory tract infections. We aimed to decrease the proportion of RVPs out of total respiratory viral testing ordered during influenza season. Methods We implemented two consecutive interventions: reflex testing for RVPs only after a negative influenza test, and noninterruptive clinical decision support (CDS) including modifications of the computerized physician order entry search behavior and cost display. We conducted an interrupted time series of RVPs and influenza polymerase chain reaction tests pre- and postintervention, and performed a mixed-effects logistic regression analysis with a primary outcome of proportion of RVPs out of total respiratory viral tests. The primary predictor was the intervention period, and covariates included the provider, clinical setting, associated diagnoses, and influenza incidence. Results From March 2013 to April 2019, there were 24,294 RVPs and 26,012 influenza tests (n = 50,306). Odds of ordering an RVP decreased during the reflex testing period (odds ratio: 0.432, 95% confidence interval: 0.397–0.469), and decreased more dramatically during the noninterruptive CDS period (odds ratio: 0.291, 95% confidence interval: 0.259–0.327). Discussion The odds of ordering an RVP were 71% less with the noninterruptive CDS intervention, which projected 4,773 fewer RVPs compared with baseline. Assuming a cost equal to Medicare reimbursement rates for RVPs and influenza tests, this would generate an estimated averted cost of $1,259,474 per year. Conclusion Noninterruptive CDS interventions are effective in reducing unnecessary and expensive testing, and avoid typical pitfalls such as alert fatigue.

Although healthy lifestyle practices mitigate recurrent stroke risk and mortality, few stroke survivors adhere to them, particularly among socioeconomically disadvantaged communities. We developed and pilot tested a occupational therapy-based lifestyle management intervention, Healthy Eating And Lifestyle after Stroke (HEALS), to improve stroke survivors' self-management skills relating to diet and physical activity and evaluated it in a diverse safety-net population.One hundred English- or Spanish-speaking participants with stroke or transient ischemic attack were randomized to a 6-week occupational therapist-led group lifestyle intervention vs. usual care. Each of the six 2-h group sessions included didactic presentations on diet and physical activity, peer exchange, personal exploration with goal setting, and direct experience through participation in a relevant activity. Primary outcomes at 6 months were change in body mass index, fruit/vegetable intake, and physical activity. Secondary outcomes included change in waist circumference, smoking, blood pressure, high-density lipoprotein, low-density lipoprotein, triglyceride, total cholesterol, glycosylated hemoglobin levels, quality of care, and perceptions of care. Effect sizes were determined in preparation for a larger randomized controlled trial powered to detect a difference in primary outcomes. A nested formative evaluation assessed facilitators and barriers to implementation, acceptance, and intervention adherence.There were no significant changes in primary or secondary outcomes at 6 months. Effect sizes for all outcomes were small ( 0.2). Focus group participants recommended extending the intervention program duration with more sessions, additional information on stroke and vascular risk factors, an interdisciplinary approach, additional family involvement, and incentives. Providers recommended longer program duration, more training, fidelity checks to ensure standardized program delivery, and additional incentives for participants.The HEALS intervention was feasible in a safety-net setting, but effect sizes were small. A longer-duration intervention, with intervener fidelity checks may be warranted.NCT01550822.

Introduction: Filipino Americans (FilAms) in Los Angeles make up the largest Filipino community outside of the Philippines and 2nd largest Asian subgroup in L.A. County. FilAms also have higher rates of stroke, high blood pressure, and diabetes not only compared to other Asian subgroups but also to African American and Latino communities. Little is known about FilAm knowledge and cultural barriers in accessing acute stroke care. Methods: Using a qualitative descriptive design, we studied knowledge, attitudes, and health behaviors of the L.A. FilAm community with regard to acute stroke care by conducting 5 focus groups of 5-7 people each and 6 semi-structured interviews with key community leaders. Participants were recruited through L.A. FilAm community organizations. Focus groups were organized as follows: 1st: elderly community members at high stroke risk; 2 nd : spouses of those at high stroke risk; 3 rd : paid caregivers of those with stroke risk; 4 th : unpaid caregivers of those with stroke risk; 5 th : young FilAms with family members with stroke risk. Six individual interviews were with elderly FilAms identified as exceptionally healthy by community leaders. We conducted thematic analysis, coding for themes on barriers to acute stroke care. Results: Two key themes have emerged: 1) spiritualistic fatalism and the belief that God is in control of all outcomes despite an individual’s will and 2) fear of calling 911, specifically linked to shame in being perceived as unhealthy by neighbors, fear of deportation among undocumented FilAms, and fear of high ambulance cost. Elderly participants perceived social media as one of the most effective ways to widely engage FilAms on stroke. Conclusion: Beliefs related to spiritualistic fatalism as well as fear of calling 911 are powerful barriers to acute stroke care among FilAms. The results can inform a culturally-relevant intervention for the community using social media, the Internet, and Filipino television programs to encourage FilAms to obtain acute stroke care. Data collected is currently being integrated into a FilAm stroke media tool. Lessons learned from this project will also be used to create stroke education for other U.S. Asian Pacific Islander communities.

Background: Minority and socioeconomically disadvantaged individuals are underrepresented in secondary stroke prevention trials. Little is known about factors associated with study retention in these populations. Objective: To evaluate the impact of sociodemographic characteristics on retention in the Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED) trial. Methods: 487 participants ≥40 years with stroke/TIA were recruited from 4 safety-net hospitals and 1 stroke center serving low income zip codes. Strategies for boosting retention included: having bilingual research assistants from similar cultures establish rapport and follow participants; culturally and linguistically tailoring materials; arranging visits around participants’ schedules; offering transportation, and conducting assessments in the home and community. We compared sociodemographic characteristics among those retained at 12 months (n=412) vs. those not retained (n=75) using t-test, Chi Square, and Fisher exact tests. Independent factors associated with retention were determined using logistic regression. Results: Average age was 57 years, 18% were black, 71% were Hispanic, 58% were Spanish-speaking, and 72% were born outside the US. 12-month retention was 85%. On bivariate analysis, factors associated with retention were: Spanish-speaking, Hispanic ethnicity, younger age, born outside the US, and married status (all p Discussion: In this secondary prevention trial of stroke survivors from predominantly minority backgrounds, younger age, marriage, and insurance were associated with retention, suggesting that addressing barriers in the elderly, and those without insurance or spousal support may be beneficial. Financial constraints were associated with retention suggesting that study participation appealed to more socioeconomically vulnerable individuals.

Background: Approximately 25 million people in the US are Limited English Proficient (LEP). LEP individuals are more likely to feel dissatisfied with the quality of healthcare when compared to the English proficient, but little is known about LEP stroke survivors. Objective: To evaluate differences in stroke literacy, self-efficacy, and perceptions of healthcare delivery in English and Spanish-speaking individuals enrolled in the Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED) trial. Methods: SUCCEED participants were given the option of receiving the intervention in English or Spanish. Baseline differences in stroke literacy (Schneider et al), self-efficacy (General Self-Efficacy Scale), and perceptions of care (Patient Assessment of Chronic Illness Care and Consumer Assessment of Healthcare Providers and Systems) were compared using T-test, Chi Square, and Fisher Exact in individuals who chose Spanish vs. English. Results: Of 487 participants, 207 preferred English and 280 chose Spanish. Despite feeling more worried about having a stroke (77 % vs. 67%), and feeling at risk of having a stroke (63% vs. 45%), Spanish-speakers were less likely to identify 3 stroke risk factors (19% vs. 33%, all p Conclusion: Among stroke survivors, Spanish-speakers were more likely to have low stroke literacy, low self-efficacy, and a negative perception of healthcare delivery despite feeling that healthcare was accessible. Recognizing language barriers as a contributor to healthcare disparities, and tailoring interventions to address these barriers are crucial.

Objectives: Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) trial evaluated the implementation of a quality improvement (QI) program aligned with Learning Healthcare System principles to improve TIA care. Methods: A facility-based, stepped-wedge trial was conducted at six diverse sites. The intervention included five components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Implementation strategies included: team activation via audit and feedback, goal setting, reflecting and evaluating, and planning; external facilitation; and building a community of practice. The primary effectiveness outcome was the Without Fail rate (WFR); proportion of TIA patients who received all processes of care for which they were eligible among: brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, high/moderate potency statins. The primary implementation outcomes were the number of improvement activities completed and the Group Organization (GO) scores for providing and improving care (scale of 1-10). Results: The 6 PREVENT facilities cared for N=162 control period TIA patients and N=191 intervention period TIA patients. The mean facility WFR increased from 36.7% (baseline) to 53.9% (active implementation); p=0.002 (adjusted for temporal trend, hospital admission). The mean number of improvement activities completed during the 1-year implementation period was 26 (range 11-39). The mean facility GO scores increased: providing care, 1.2 to 6.5; improving care, 1.0 to 6.7. Conclusions: PREVENT advances three aspects of a learning healthcare system: Learning from Data (teams interacted with their facility’s performance data to explore hypotheses, plan QI activities, and evaluate change over time); Learning from Each Other (teams participated in monthly virtual collaborative conferences), and Sharing Best Practices (teams shared tools and protocols).

Background: Carotid endarterectomy (CEA) reduces stroke risk compared to medical therapy alone among patients with asymptomatic carotid stenosis. CEA involves a tradeoff between higher perioperative short-term risks in exchange for a lower long-term risk of stroke. However, overall declines in stroke rates raise concerns that CEA may no longer be a preferred treatment. We examined the effectiveness of CEA compared to medical therapy (MT) among asymptomatic patients in preventing stroke and stroke-death within 5 years of follow-up. Methods: We identified Veterans ≥65 years old with carotid stenosis (n=2712 CEA and n=2509 MT patients) who did not have a history of stroke or transient ischemic attack. We propensity score-matched MT patients to CEA patients to control for baseline confounding and used methods to mimic analyses from the Asymptomatic Carotid Stenosis Trial, the last published trial to compare CEA to MT. We accounted for “immortal time” bias by randomizing patients to CEA and MT groups and censoring patients if their actual treatment became inconsistent with the arm in which they were randomized (e.g., patient received CEA, but was randomized to MT). We accounted for the informative censoring by estimating time-dependent inverse probability of censoring weights using measured covariates (demographics and 72 time-varying comorbidities). We computed weighted Kaplan-Meier (KM) curves and estimated the risk of stroke/stroke-death in each group over 5 years of follow-up. Results: The observed stroke or death rate (perioperative complications) within 30 days in the CEA arm was 3%. The 5-year risk were similar among patients randomized to CEA 5.5% (95% CI, 4.3%-6.7%) versus MT 7.6% (95% CI,5.9%-9.2%) (risk difference, -2.1%, 95% CI -4%- 0%) with little difference in the KM curves (logrank p=0.2). Conclusion: CEA was not superior to MT in a community sample of Veterans after 5 years of follow-up, suggesting that CEA may no longer be the preferred treatment strategy.

BackgroundAmerican Heart Association/American Stroke Association expert consensus guidelines recommend consideration of cardiac stress testing to screen for occult coronary heart disease (CHD) among patients with ischemic stroke/TIA who have a high-risk Framingham Cardiac Risk Score (FCRS). Whether this guideline is being implemented in routine clinical practice, and the association of its implementation with mortality, is less clear.MethodsStudy participants were Veterans with stroke/TIA (n = 11,306) during fiscal year 2011 who presented to a VA Emergency Department or who were admitted. Patients were excluded (n = 6,915) based on prior CHD/angina/chest pain history, receipt of cardiac stress testing within 18 months prior to cerebrovascular event, death within 90 days of discharge, discharge to hospice, transfer to a non-VA acute care facility, or missing/unknown race. FCRS ≥20% was classified as high risk for CHD. ICD-9 and Common Procedural Terminology codes were used to identify receipt of any cardiac stress testing.ResultsAmong 4,391 eligible patients, 62.8% (n = 2,759) had FCRS ≥20%. Cardiac stress testing was performed infrequently and in similar proportion among high-risk (4.5% [123/2,759]) vs low/intermediate-risk (4.4% [72/1,632]) patients (adjusted odds ratio [aOR] 0.77, 95% confidence interval [CI] 0.54–1.10). Receipt of stress testing was not associated with reduced 1-year mortality (aOR 0.59, CI 0.26–1.30).ConclusionsIn this observational cohort study of patients with cerebrovascular disease, cardiac screening was relatively uncommon and was not associated with 1-year mortality. Additional work is needed to understand the utility of CHD screening among high-risk patients with cerebrovascular disease.

Background Stroke survivors have high rates of subsequent cardiovascular and recurrent cerebrovascular events, and mortality. While healthy lifestyle practices - including a diet rich in fruits and vegetables, limited alcohol intake, and regular physical activity - can mitigate these outcomes, few stroke survivors adhere to them. Minorities from socioeconomically disadvantaged communities who obtain care in safety-net health systems experience the most barriers to implementing healthy lifestyle changes after stroke. Purpose To report the design of Healthy Eating and Lifestyle After Stroke (HEALS), a randomized controlled trial (RCT) was designed to test the feasibility of using a manualized, lifestyle management intervention in a safety-net setting to improve lifestyle practices among ethnically diverse individuals with stroke or transient ischemic attack (TIA). Methods Design: Pilot RCT. Participants: Inclusion criteria: 1) Adults (≥40 years) with ischemic stroke or TIA (≥ 90 days prior); 2) English- or Spanish-speaking. Setting: Outpatient clinic, safety-net setting. Intervention: Weekly two-hour small group sessions led by an occupational therapist for six weeks. The sessions focused on implementing nutrition, physical activity, and self-management strategies tailored to each participant's goals. Main Outcome Measures: Body mass index, diet, and physical activity. Conclusions Recruitment for this study is complete. If the HEALS intervention study is feasible and effective, it will serve as a platform for a large-scale RCT that will investigate the efficacy and cost-effectiveness of life management interventions for racially and ethnically diverse, low-income individuals with a history of stroke or TIA who seek healthcare in the safety-net system.

Purpose Salvage radiotherapy (SRT) is the standard of care offered when postprostatectomy prostate-specific antigen (PSA) levels are ≥ 0.2 ng/mL. However, emerging evidence suggests that early SRT (ie, SRT delivered at PSA values < 0.2 ng/mL, but generally ≥ 0.05 ng/mL) improves oncologic outcomes. We evaluated the feasibility of improving referral rates for discussion of early SRT by using a dynamic registry that identifies through the electronic medical record patients with rising postprostatectomy PSA levels. Methods We developed an iteratively updated registry that identifies patients who fall within two postoperative PSA strata: ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL. We compared referral rates to radiation oncology during a 3-year period before use of this registry with those during a 1-year period after promotion of the registry in multidisciplinary tumor board settings. Results Before promotion of the registry, referral rates for patients with PSA values ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL were 35% and 65%, respectively. After promotion of the registry, referral rates within each stratum increased significantly to 82% and 94%, respectively ( P < .05 for both by Fisher’s exact test). The overall rate of referral for patients with PSA values ≥ 0.05 to < 0.2 ng/mL rose from 48% to 90% ( P < .001). Conclusion The creation of a registry of patients with rising postprostatectomy PSA values can facilitate increased referral rates for early SRT without burdening providers with a clinical support tool embedded within the EMR itself. This is true even in the case of already high baseline rates of referral for early SRT. The changes reported herein most likely reflect a Hawthorne effect wherein the ability to track referrals rather than a direct function of the registry influenced practice patterns. Nonetheless, the registry provided an integral framework to allow for tracking.

Objective: Choosing Wisely is a campaign of the American Board of Internal Medicine that aims to promote evidence-based practices to reduce unnecessary ordering of tests or procedures. As ...

Key Points Question Which processes of care are associated with reduced risk of mortality or recurrent stroke after transient ischemic attack or nonsevere ischemic stroke? Findings In this cohort study of 8076 patients with transient ischemic attack or nonsevere ischemic stroke, only 1216 (15.3%) received without-fail care, defined as receiving all guideline-concordant processes of care for which they were eligible (ie, brain imaging, carotid artery imaging, antihypertensive intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation). Receiving all 6 processes was associated with lower risk of death (31.2% reduction at 1 year) but not lower risk of recurrent stroke. Meaning Clinicians should ensure that patients with transient ischemic attack and nonsevere ischemic stroke receive all guideline-concordant processes of care for which they are eligible., This cohort study identifies processes of care that are associated with reduced risk of death or recurrent stroke among patients with transient ischemic attack or nonsevere ischemic stroke., Importance Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. Objective To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. Design, Setting, and Participants This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. Main Outcomes and Measures Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. Conclusions and Relevance Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.

Introduction Polyneuropathy (PN) is a common condition with significant morbidity. We developed tele-polyneuropathy (tele-PN) clinics to improve access to neurology and increase guideline-concordant PN care. This article describes the mixed-methods evaluation of pilot tele-PN clinics at three community sites within the Greater Los Angeles VA Healthcare System. Methods For the first 25 patients (48 scheduled visits), we recorded the duration of the tele-PN visit and exam; the performance on three guideline-concordant care indicators (PN screening labs, opiate reduction, physical therapy for falls); and patient-satisfaction scores. We elicited comments about the tele-PN clinic from patients and the clinical team. We combined descriptive statistics with qualitative themes to determine the feasibility and acceptability of the tele-PN clinics. Results The average tele-PN encounter and exam times were 28.5 and 9.1 min, respectively. PN screening lab completion increased from 80 to 100%. Opiate freedom improved from 68 to 88%. Physical therapy for patients with recent falls increased from 58 to 100%. The tele-PN clinic was preferred for follow-up over in-person clinics in 86% of cases. Convenience was paramount to the clinic’s success, saving an average of 231 min per patient in round-trip travel. The medical team’s caring and collaborative spirit received high praise. While the clinic’s efficiency was equal or superior to in-person care, the limited treatment options for PN and the small clinical exam space are areas for improvement. Conclusion In this pilot, we were able to efficiently see and examine patients remotely, promote guideline-concordant PN care, and provide a high-satisfaction encounter.

BackgroundTransient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles.MethodsThis stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability.DiscussionPREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines.Trial registrationclinicaltrials.gov: NCT02769338 [May 11, 2016].

Background In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released a revised guideline on statin therapy initiation. The guideline included a 10-year risk calculation based on regression modeling, which made hand calculation infeasible. Compliance to the guideline has been suboptimal, as many patients were recommended but not prescribed statin therapy. Clinical decision support (CDS) tools may improve statin guideline compliance. Few statin guideline CDS tools evaluated clinical outcome. Objectives We determined if use of a CDS tool, the statin macro, was associated with increased 2013 ACC/AHA statin guideline compliance at the level of statin prescription versus no statin prescription. We did not determine if each patient's statin prescription met ACC/AHA 2013 therapy intensity recommendations (high vs. moderate vs. low). Methods The authors developed a clinician-initiated, EHR-embedded statin macro command (“statin macro”) that displayed the 2013 ACC/AHA statin guideline recommendation in the electronic health record documentation. We included patients who had a primary care visit during the study period (January 1–June 30, 2016), were eligible for statin therapy based on the ACC/AHA guideline prior to the study period, and were not prescribed statin therapy prior to the study period. We tested the association of macro usage and statin therapy prescription during the study period using relative risk and mixed effect logistic regression. Results Subjects included 11,877 patients seen in primary care, who were retrospectively recommended statin therapy at study initiation based on the ACC/AHA guideline, but who had not received statin therapy. During the study period, 125 clinicians used the statin macro command for 389 of the 11,877 patients (3.2%). Of the 389 patients for whom that statin macro was used, 108 patients (28%) had a statin prescribed during the study period. Of the 11,488 for whom the statin macro was not used, 1,360 (13%) patients received a clinician-prescribed statin (relative risk 2.3, p Conclusion Although the statin macro had low uptake, its use was associated with a greater rate of statin prescriptions (dosage not determined) for patients whom 2013 ACC/AHA guidelines required statin therapy.

ObjectiveTo test effects on care quality of Chronic Care Model-based Parkinson disease (PD) management.MethodsThis 2-group stratified randomized trial involved 328 veterans with PD in southwestern United States. Guided care management, led by PD nurses, was compared to usual care. Primary outcomes were adherence to 18 PD care quality indicators. Secondary outcomes were patient-centered outcome measures. Data sources were telephone survey and electronic medical record (EMR). Outcomes were analyzed as intent-to-treat comparing initial and final survey and repeated-measures mixed-effects models.ResultsAverage age was 71 years; 97% of participants were male. Mean proportion of participants receiving recommended PD care indicators was significantly higher for the intervention than for usual care (0.77 vs 0.58) (mean difference 0.19, 95% confidence interval [CI] 0.16, 0.22). Of 8 secondary outcomes, the only significant difference of the changes over time was in the positive Patient Health Questionnaire–2 depression screen for intervention minus usual care (−11.52 [95% CI −20.42, −2.62]).ConclusionA nurse-led chronic care management intervention, Care Coordination for Health Promotion and Activities in Parkinson's Disease (CHAPS), substantially increased adherence to PD quality of care indicators among veterans with PD, as documented in the EMR. Of 8 secondary outcomes assessed, a screening measure for depressive symptomatology was the only measure that was better in the intervention compared to usual care. More telephone calls in CHAPS were the only utilization difference over usual care. While CHAPS appears promising for improving PD care, additional iterative research is needed to refine the CHAPS model in routine clinical care so that it measurably improves patient-centered outcomes (NCT01532986).Classification of evidenceThis study provides Class I evidence that for patients with PD, CHAPS increased adherence to PD quality of care indicators.

Background: Choosing Wisely is a campaign of the American Board of Internal Medicine that aims to promote evidence-based practices to reduce unnecessary ordering of tests or procedures. As part of this campaign, national organizations including the Endocrine Society have identified common tests or procedures that providers should be aware of in their practices. The Endocrine Society advises, “Don’t order a total or free T3 level when assessing levothyroxine (T4) dosing in hypothyroid patients.” This is in line with the co-sponsored American Thyroid Association and American Association of Clinical Endocrinologists clinical practice guidelines for hypothyroidism in adults, which states there is “limited utility” in measuring serum T3 in patients with hypothyroidism, due to typically normal T3 levels (resulting from stimulation of thyroid hormone synthesis by increased TSH) and up-regulation of type 2 iodothyronine deiodinase in these patients. Methods: This study assessed the ordering practices among providers who manage patients with hypothyroidism within our institution, a large urban tertiary/quaternary care academic health system. A best practice advisory (BPA) alert was developed following the collection of baseline data. This BPA consisted of a pop-up window triggered when any type of T3 laboratory test (total and/or free levels) was ordered among patients who have thyroid hormone (both generic and brand-name levothyroxine formulations) listed in the medical record. The BPA alert required user acknowledgement and a clinical decision-making process before the T3 laboratory test order could be placed. Results: Prior to launching the BPA, silent mode testing showed that T3 laboratory tests were inappropriately ordered a mean of 165.8 times per week (standard deviation 17.0). After the BPA alert was actively launched in Sept 2018, inappropriate T3 ordering was triggered a mean of 127.3 times (standard deviation 25.0) in the initial three weeks, dropping to a mean of 115.0 (standard deviation 13.5) in the next three week time period. As a result of the BPA, providers canceled 4.9-12.3% of triggered T3 orders during the six weeks after the BPA launch. The BPA alert currently remains active at our institution. Conclusions: Although national guidelines recommend against ordering serum T3 concentrations during the monitoring of patients with hypothyroidism managed on thyroid hormone replacement therapy, these laboratory tests are inappropriately ordered in many patients. Development of a triggered alert may reduce inappropriate monitoring practices for this common clinical condition, decrease costs, and improve utilization of limited healthcare resources.

Importance Randomized clinical trials have demonstrated that patients with asymptomatic carotid stenosis are eligible for carotid endarterectomy (CEA) if the 30-day surgical complication rate is less than 3% and the patient’s life expectancy is at least 5 years. Objective To develop a risk prediction tool to improve patient selection for CEA among patients with asymptomatic carotid stenosis. Design, Setting, and Participants In this cohort study, veterans 65 years and older who received both carotid imaging and CEA in the Veterans Administration between January 1, 2005, and December 31, 2009 (n = 2325) were followed up for 5 years. Data were analyzed from January 2005 to December 2015. A risk prediction tool (the Carotid Mortality Index [CMI]) based on 23 candidate variables identified in the literature was developed using Veterans Administration and Medicare data. A simpler model based on the number of 4 key comorbidities that were prevalent and strongly associated with 5-year mortality was also developed (any cancer in the past 5 years, chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease [the 4C model]). Model performance was assessed using measures of discrimination (eg, area under the curve [AUC]) and calibration. Internal validation was performed by correcting for optimism using 500 bootstrapped samples. Main Outcome and Measure Five-year mortality. Results Among 2325 veterans, the mean (SD) age was 73.74 (5.92) years. The cohort was predominantly male (98.8%) and of white race/ethnicity (94.4%). Overall, 29.5% (n = 687) of patients died within 5 years of CEA. On the basis of a backward selection algorithm, 9 patient characteristics were selected (age, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, any cancer diagnosis in the past 5 years, congestive heart failure, atrial fibrillation, remote stroke or transient ischemic attack, and body mass index) for the final logistic model, which yielded an optimism-corrected AUC of 0.687 for the CMI. The 4C model had slightly worse discrimination (AUC, 0.657) compared with the CMI model; however, the calibration curve was similar to the full model in most of the range of predicted probabilities. Conclusions and Relevance According to results of this study, use of the CMI or the simpler 4C model may improve patient selection for CEA among patients with asymptomatic carotid stenosis.

Background: Minority, disadvantaged populations are often underrepresented in secondary stroke prevention trials despite known disparities in risk factor control. When they do enroll, retention is poor due to competing needs, transiency, unstable housing, transportation barriers, and inconsistent telephone access. Methods: We recruited 487 English- or Spanish-speaking adults (age >40 yrs) with a recent TIA or ischemic/hemorrhagic stroke, and systolic BP ≥130 mm Hg or diagnosed hypertension and SBP≥120mm Hg, from 4 Los Angeles County-Department of Health Services hospitals and 1 stroke center serving low income zip codes. We used recruitment and retention strategies from a prior trial; leadership and staff met regularly to track progress and design and implement new strategies. Meeting notes were reviewed to compile approaches . Results: Average age was 57.1 years; race/ethnicity was 71.4% Hispanic, 17.6% black, 6.4% Asian; 72.5% were born outside the US; 62.6% had not graduated high school; 40% rarely spoke English at home. Follow-up data collection was 440/487 (90%) at 3 months, 382/487 (78%) at 8 months, and 394/475 (83%) of eligibles at 12 months. Prior recruitment strategies used were bilingual research assistants (RAs) from similar cultural backgrounds, inpatient clinical team introduction of potential enrollees to RAs, embedding RAs on the inpatient unit, piloting and tailoring recruitment scripts prior to study initiation, and allowing potential participants to discuss the study with others prior to enrollment. Prior retention strategies used were obtaining ≥3 contact numbers at enrollment and reviewing medical records for upcoming appointments. New retention strategies developed and applied were offering in-home assessments, providing transportation, offering weekend/evening visits, using phone, mail, and registered mail to contact participants, routinely using the same RA for a given participant, and reminding patients of prior interactions with RAs/visits. Conclusion: To maximize retention and recruitment, the combined approach of beginning with a broad set of previously effective strategies, and tracking and developing new ones over the course of the trial was effective. Trial Registry Trial Number: NCT01763203

Background: Although healthy lifestyle practices mitigate stroke risk and mortality, few stroke survivors adhere to them, particularly among socioeconomically disadvantaged communities. We developed and pilot tested a lifestyle management intervention, HEALS, to improve stroke survivors’ diet and physical activity and tested it in a diverse population receiving care at a safety-net county facility. Methods: One hundred English- or Spanish-speaking participants with stroke or TIA were randomly assigned to a 6-week weekly occupational therapist-led group lifestyle intervention vs. usual care. Each 2 hour session included didactics, goal setting, activities, and peer exchange. Primary outcomes measured at baseline and 6 months were body mass index, abdominal obesity, fruit/vegetable intake, and physical activity. Secondary outcomes were blood pressure, high-density lipoprotein cholesterol, and glycosylated hemoglobin. Outcomes were compared with repeated measures analysis. Effect sizes for continuous variables were determined using partial eta-squared. A nested formative evaluation assessed facilitators and barriers to implementation, acceptance, and adherence to the intervention. Results: Mean age was 60 years, 62% were men, 68% were Hispanic, 60% were Spanish-speaking, 35% had ≤8 th grade education, 31% were working at enrollment, and 69% had modified Rankin scale Conclusions: The HEALS intervention was feasible in a safety-net setting, but the effect sizes were small. An RCT of a longer-duration intervention, with more formal provider training, may be warranted.

ObjectiveTo see if systematic collection of patient-reported epilepsy quality measures can identify opportunities to improve care, and to examine the associations between these measures and physical and mental health.MethodsWe developed a patient-reported questionnaire for medication adherence, seizure frequency, medication side effects, and driving that included the Patient-Reported Outcome Measurement Information System–10 (PROMIS-10) (physical and mental health). We offered it to all adult patients seen twice in an epilepsy clinic (January 2017–January 2018). The questionnaire was available on the web as well as a tablet provided at appointment check-in. We used the first completed questionnaire to explore the relationship between patient-reported care quality and measures of physical and mental health.ResultsA total of 610 unique patients (15% of the total encounters) completed a survey. Respondents were comparable to nonrespondents. Respondents reported gaps in care or opportunities for quality improvement in 48.4% (n = 295) of the encounters. Of patients who reported at least 1 seizure per month over the previous 3 months, 55.2% (n = 100) reported problems with adherence, 30.0% (n = 131) reported having problems believed to be adverse reactions to anticonvulsants, and 15.2% (n = 41) reported driving. In addition, respondents who reported either seizures over the recent 3 months, nonadherence to treatment due to cost, or anticonvulsant-associated adverse effects had consistently worse physical and mental health (all p < 0.05).ConclusionsSystematic collection of epilepsy quality measures endorsed by the American Academy of Neurology can identify opportunities for quality improvement. Measures of epilepsy care quality predict outcomes that matter to patients.

IMPACT: We report a novel metric for assessing clinical informatics fellows relative to their personal goals, using standardized milestones that have been approved for the field by ACGME. OBJECTIVES/GOALS: ACGME has defined 20 milestones that serve as the goals for fellows in clinical informatics. Each fellow is rated from 1 to 5 on the achievement of each milestone, where 1 is entry-level, 4 is the level expected of a graduating fellow, and 5 is aspirational. We assessed fellows’ progress toward the personal goal levels that they set for each milestone. METHODS/STUDY POPULATION: At the start of the fellowship, we asked each fellow to rate the personal target levels that they want to achieve for each milestone. Since the default target level of achievement for a graduating fellow is a 4, we asked fellows to document exceptions from this target. We calculated a metric for each fellow’s achievement of each milestone as their achievement rating (assigned by mentors and rotation leaders during the semi-annual Clinical Competency Committee meeting) divided by the fellow’s desired level of achievement. In summarizing across the milestones, we counted those milestones having achievement metrics >=1.0 as ‘achieved,’ and then for milestones that were not achieved, we calculated an average for the fellow. RESULTS/ANTICIPATED RESULTS: As of June, 2020, our two graduating 2nd-year fellows had fully met 9/20 and 18/20 milestones, respectively. For the unmet milestones they averaged 81% and 85% achievement. The largest shortfalls were 75% achievements in Assessing User Needs for one fellow, and in Recognition of Errors for the other. One of our three 1st-year fellows had fully met 3/20 milestones; the other two had met none at 1st-year’s end. For unmet milestones, the 1st-year fellows’ average achievement metrics were 69%, 67%, and 52%. The greatest shortfalls were in Resource Utilization (creating job descriptions, budgeting etc.) and in Communication with Patients and Families. However, the rotations that would expose them to project management and to patient-facing systems such as MyChart come in our 2nd-year. DISCUSSION/SIGNIFICANCE OF FINDINGS: Assessing milestones met plus the percent achievement for those not yet met provides a useful metric for comparing fellows and identifying areas in need of more training. Although milestones will soon change to reflect the recent practice analysis for clinical informatics, we expect that this approach to assessing fellows will remain equally useful.

Importance Carotid endarterectomy (CEA) among asymptomatic patients involves a trade-off between a higher short-term perioperative risk in exchange for a lower long-term risk of stroke. The clinical benefit observed in randomized clinical trials (RCTs) may not extend to real-world practice. Objective To examine whether early intervention (CEA) was superior to initial medical therapy in real-world practice in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis. Design, Setting, and Participants This comparative effectiveness study was conducted from August 28, 2018, to March 2, 2020, using the Corporate Data Warehouse, Suicide Data Repository, and other databases of the US Department of Veterans Affairs. Data analyzed were those of veterans of the US Armed Forces aged 65 years or older who received carotid imaging between January 1, 2005, and December 31, 2009. Patients without a carotid imaging report, those with carotid stenosis of less than 50% or hemodynamically insignificant stenosis, and those with a history of stroke or transient ischemic attack in the 6 months before index imaging were excluded. A cohort of patients who received initial medical therapy and a cohort of similar patients who received CEA were constructed and followed up for 5 years. The target trial method was used to compute weighted Kaplan-Meier curves and estimate the risk of fatal and nonfatal strokes in each cohort in the pragmatic sample across 5 years of follow-up. This analysis was repeated after restricting the sample to patients who met RCT inclusion criteria. Cumulative incidence functions for fatal and nonfatal strokes were estimated, accounting for nonstroke deaths as competing risks in both the pragmatic and RCT-like samples. Exposures Receipt of CEA vs initial medical therapy. Main Outcomes and Measures Fatal and nonfatal strokes. Results Of the total 5221 patients, 2712 (51.9%; mean [SD] age, 73.6 [6.0] years; 2678 men [98.8%]) received CEA and 2509 (48.1%; mean [SD] age, 73.6 [6.0] years; 2479 men [98.8%]) received initial medical therapy within 1 year after the index carotid imaging. The observed rate of stroke or death (perioperative complications) within 30 days in the CEA cohort was 2.5% (95% CI, 2.0%-3.1%). The 5-year risk of fatal and nonfatal strokes was lower among patients randomized to CEA compared with patients randomized to initial medical therapy (5.6% vs 7.8%; risk difference, −2.3%; 95% CI, −4.0% to −0.3%). In an analysis that incorporated the competing risk of death, the risk difference between the 2 cohorts was lower and not statistically significant (risk difference, −0.8%; 95% CI, −2.1% to 0.5%). Among patients who met RCT inclusion criteria, the 5-year risk of fatal and nonfatal strokes was 5.5% (95% CI, 4.5%-6.5%) among patients randomized to CEA and was 7.6% (95% CI, 5.7%-9.5%) among those randomized to initial medical therapy (risk difference, −2.1%; 95% CI, −4.4% to −0.2%). Accounting for competing risks resulted in a risk difference of −0.9% (95% CI, −2.9% to 0.7%) that was not statistically significant. Conclusions and Relevance This study found that the absolute reduction in the risk of fatal and nonfatal strokes associated with early CEA was less than half the risk difference in trials from 20 years ago and was no longer statistically significant when the competing risk of nonstroke deaths was accounted for in the analysis. Given the nonnegligible perioperative 30-day risks and the improvements in stroke prevention, medical therapy may be an acceptable therapeutic strategy.

Purpose: To evaluate whether exposure to MyFamilyPlan—a web-based preconception health education module—changes the proportion of women discussing reproductive health with providers at well-woman visits. Design: Cluster randomized controlled trial. One hundred thirty participants per arm distributed among 34 clusters (physicians) required to detect a 20% change in the primary outcome. Setting: Urban academic medical center (California). Participants: Eligible women were 18 to 45 years old, were English speaking, were nonpregnant, were able to access the Internet, and had an upcoming well-woman visit. E-mail and phone recruitment between September 2015 and May 2016; 292 enrollees randomized. Intervention: Intervention participants completed the MyFamilyPlan module online 7 to 10 days before a scheduled well-woman visit; control participants reviewed standard online preconception health education materials. Measures: The primary outcome was self-reported discussion of reproductive health with the physician at the well-woman visit. Self-reported secondary outcomes were folic acid use, contraceptive method initiation/change, and self-efficacy score. Analysis: Multilevel multivariate logistic regression. Results: After adjusting for covariates and cluster, exposure to MyFamilyPlan was the only variable significantly associated with an increase in the proportion of women discussing reproductive health with providers (odds ratio: 1.97, 95% confidence interval: 1.22-3.19). Prespecified secondary outcomes were unaffected. Conclusion: MyFamilyPlan exposure was associated with a significant increase in the proportion of women who reported discussing reproductive health with providers and may promote preconception health awareness; more work is needed to affect associated behaviors.

Background Disparities of care among stroke survivors are well documented. Effective interventions to improve recurrent stroke preventative care in vulnerable populations are lacking. Methods and Results In a randomized controlled trial, we tested the efficacy of components of a chronic care model–based intervention versus usual care among 404 subjects having an ischemic stroke or transient ischemic attack within 90 days of enrollment and receiving care within the Los Angeles public healthcare system. Subjects had baseline systolic blood pressure (SBP) ≥120 mm Hg. The intervention included a nurse practitioner/physician assistant care manager, group clinics, self-management support, report cards, decision support, and ongoing care coordination. Outcomes were collected at 3, 8, and 12 months, analyzed as intention-to-treat, and used repeated-measures mixed-effects models. Change in SBP was the primary outcome. Low-density lipoprotein reduction, antithrombotic medication use, smoking cessation, and physical activity were secondary outcomes. Average age was 57 years; 18% were of black race; 69% were of Hispanic ethnicity. Mean baseline SBP was 150 mm Hg in both arms. SBP decreased to 17 mm Hg in the intervention arm and 14 mm Hg in the usual care arm; the between-arm difference was not significant (−3.6 mm Hg; 95% confidence interval, −9.2 to 2.2). Among secondary outcomes, the only significant difference was that persons in the intervention arm were more likely to lower their low-density lipoprotein Conclusions This intervention did not improve SBP control beyond that attained in usual care among vulnerable stroke survivors. A community-centered component could strengthen the intervention impact. Clinical Trial Registration URL: https://clinicaltrials.gov . Unique identifier: NCT00861081.

All clinicians believe they provide quality care, yet most clinicians do not directly measure quality parameters in their practice to provide verifiable health care outcomes.1 Quality measures related to a chronic disease provide reportable and repeatable measures that can either document performance of quality care or identify gaps in care for future action/improvement. Disease-specific quality measures in neurology provide a framework that can assist clinicians in practice measurement and modification; these have the potential to benefit both subspecialist and generalist alike. Multiple sclerosis (MS) is a common, chronic, and ultimately disabling disease with multiple potential clinical intervention points during its course. It is therefore appropriate to have quality measures specific for this condition that span the course of the disease.

Headache and migraine are common, debilitating, and costly. Headaches are among the most prevalent neurologic disorders. In US studies, somewhere between 12% and 23% of adults over the age of 18 have had a migraine headache in the past 3 months.1 In fact, the WHO ranks migraine headache in the top 20 of the world's most disabling medical illnesses.2 Frequent headache or migraine can significantly and negatively impact an individual's quality of life, family interactions, and ability to work.3,4 Hawkins et al.5 found that nationally, migraine-associated expenditures include outpatient care costs of $5.21 billion; prescription costs of $4.61 billion; inpatient care costs of $0.73 billion; and emergency department care costs of $0.52 billion. At work, people with migraine have higher levels of lost productivity and reduced performance, and more absences from work.6 The authors thank the Headache Measure Development Workgroup members for their contributions and work that supported the development of this manuscript: Stephen Ross, MD (Neurology); Eric Wall, MD (Family Medicine); Wayne Anderson, MD (Neurology); David Roeltgen, MD (Neurology); Stephen Silberstein, MD (Neurology); Amy Schneider, MD (Family Medicine); Thomas K. Koch, MD (Pediatrics); Thomas Watanabe, MD (Physical Medicine and Rehabilitation); Robert P. Wahl, MD (Emergency Medicine); Andy Jagoda, MD (Emergency Medicine); James Foody, MD (Internal Medicine); David Seidenwurm, MD (Radiology); J. Mark Bailey, DO, PhD (Osteopathy); Shannon Petersen, PT (Physical Therapy); Jon Streltzer, PhD (Psychiatry); Robert Nicholson, PhD (Psychology); M. Cristina Victorio, MD (Child Neurology); William B. Young, MD (Alliance for Headache Disorders Advocacy); Elizabeth Loder, MD (American Headache Society); Mary Franklin (National Headache Foundation); Charles Flippen II, MD (Neurology); Eric Cheng, MD, MS (Neurology); Amy Sanders, MD, MS (Neurology); Elvia Chavarria, MPH (American Medical Association Physician Consortium for Performance Improvement); Judy Burleson (American College of Radiology); Colleen Tallant (American College of Radiology); Samantha Shugarman (American Psychiatric Association); Robert Plovnick (American Psychiatric Association); Staci Jones (American College of Emergency Physicians); Diane Crowley (American College of Emergency Physicians); Dainsworth Chambers (American College of Emergency Physicians); Rebecca J. Swain-Eng, MS, CAE (American Academy of Neurology); Gina Gjorvad (American Academy of Neurology); Becky Schierman, MPH (American Academy of Neurology).

Background and Purpose— The Veterans Health Administration has engaged in quality improvement to improve vascular risk factor control. We sought to examine blood pressure ( Methods— We identified patients who were hospitalized (fiscal year 2011) with ischemic stroke, AMI, congestive heart failure, transient ischemic attack, or pneumonia/chronic obstructive pulmonary disease. The primary analysis compared risk factor control after incident ischemic stroke versus AMI. Facilities were included if they cared for ≥25 ischemic stroke and ≥25 AMI patients. A generalized linear mixed model including patient- and facility-level covariates compared risk factor control across diagnoses. Results— Forty thousand two hundred thirty patients were hospitalized (n=75 facilities): 2127 with incident ischemic stroke and 4169 with incident AMI. Fewer stroke patients achieved blood pressure control than AMI patients (64%; 95% confidence interval, 0.62–0.67 versus 77%; 95% confidence interval, 0.75–0.78; P P =0.534). Among patients with diabetes mellitus, the odds of glycemic control were lower for AMI than ischemic stroke patients (odds ratio, 0.72; 95% confidence interval, 0.54–0.96). Conclusions— Given that hypertension control is a cornerstone of stroke prevention, interventions to improve poststroke hypertension management are needed.