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Emergency department (ED) providers play a critical role in the stabilization and diagnostic evaluation of patients presenting with acute heart failure (AHF), and EDs are key areas for establishing current best practices and future considerations for the disposition of and decision making for patients with AHF. These elements include accurate risk assessment; response to initial treatment and shared decision making concerning optimal venue of care; reframing of physicians' risk perceptions for patients presenting with AHF; exploration of alternative venues of care beyond hospitalization; population-level changes in demographics, management and outcomes of HF patients; development and testing of data-driven pathways to assist with disposition decisions in the ED; and suggested outcomes for measuring success.

INTRODUCTION: Video telehealth can offer people convenient, real-time access to clinicians without arranging transportation or time off work. Among people with diabetes, this study examines the association between video telehealth access and changes in HbA1c. METHODS: This longitudinal cohort study (2016–2019) used linear regression with person-level fixed effects, stratified by baseline HbA1c (last value in 2015), to examine the association between video visit access and changes in HbA1c. HbA1c values were categorized into 3 periods of video visit exposure: (1) before any video visit, (2) video visit transition year (calendar year of the first video visit), and (3) after video visits. The model compared changes in HbA1c values collected before the patient had any video visits with those collected after the transition year. Analyses was conducted in September 2020. RESULTS: Among 204,301 people with diabetes, video visit access was associated with a statistically significant reduction of 0.15 (95% CI= −0.19, −0.11) percentage points in HbA1c, with greater reductions among patients with an elevated baseline HbA1c value (−0.22 percentage points, 95% CI= −0.32, −0.11) and with no baseline HbA1c measurement (−0.39 percentage points, 95% CI= −0.71, −0.07). CONCLUSIONS: Gaining access to video telehealth was associated with reductions in HbA1c among people with diabetes. Video telehealth offers people with chronic conditions a new, convenient way to access health care, is not associated with worsening HbA1c, and may support better disease management, particularly among patients with higher baseline HbA1c.

It is unclear whether referral for cardiac noninvasive testing (NIT) following emergency department (ED) chest pain encounters improves short-term outcomes.This was a retrospective cohort study of patients presenting with chest pain, without ST-elevation myocardial infarction or myocardial injury by serum troponin testing, between 2013 and 2019 to 21 EDs within an integrated health care system. We examined the association between NIT referral (within 72 h of the ED encounter) and a primary outcome of 60-day major adverse cardiac events (MACE). Secondary outcomes were 60-day MACE without coronary revascularization (MACE-CR) and 60-day all-cause mortality. To account for confounding by indication for NIT, we grouped patient encounters into ranked tertiles of NIT referral intensity based on the likelihood of 72-h NIT referral associated with the initially assigned emergency physician, relative to local peers and within discrete time periods. Associations between NIT referral-intensity tertile and outcomes were assessed using risk-adjusted multivariable logistic regression.Among 210,948 eligible patient encounters, 72-h NIT referral frequency was 11.9%, 18.3%, and 25.9% in low, intermediate, and high NIT referral-intensity encounters, respectively. Compared with the low referral-intensity tertile, there was a higher risk of 60-day MACE within the high referral-intensity tertile (odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.04 to 1.17) due to more coronary revascularizations without corresponding differences in MACE-CR or all-cause mortality. In analyses stratified by patients' estimated risk (HEART score; 50.5% lower risk, 38.7% moderate risk, 10.8% higher risk), the difference in 60-day MACE was primarily attributable to moderate-risk encounters (OR = 1.15, 95% CI = 1.08 to 1.24), with no differences among either lower- (OR = 1.10, 95% CI = 0.92 to 1.31) or higher- (OR = 1.01, 95% CI = 0.90 to 1.14) risk encounters.Higher referral intensity for 72-h NIT was associated with higher risk of coronary revascularization but no difference in adverse events within 60 days. These findings further call into question the urgency of NIT among ED patients without objective evidence of myocardial injury.

Practice guidelines recommend that patients with intracerebral hemorrhage (ICH) be treated in units with acute neuroscience care experience. However, most hospitals in the United States lack this degree of specialization. We sought to examine outcome differences for patients with nontraumatic ICH presenting to centers with and without advanced neuroscience care specialization.This was a retrospective study of adult patients presenting with nontraumatic ICH between 1/1/2011 and 9/30/2020 across 21 medical centers within Kaiser Permanente Northern California, an integrated care system that employs a "hub-and-spoke" model of neuroscience care in which two centers service as neuroscience "hubs" and the remaining 19 centers service as referral "spokes." Patients presenting to spokes can receive remote consultation (including image review) by neurosurgical or neurointensive care specialists located at hubs. The primary outcome was 90-day mortality. We used hierarchical logistic regression, adjusting for ICH score components, comorbidities, and demographics, to test a hypothesis that initial presentation to a spoke medical center was noninferior to hub presentation [defined as an odds ratio (OR) with an upper 95% confidence interval (CI) limit of 1.24 or less].A total of 6978 patients were included, with 6170 (88%) initially presenting to spoke medical centers. The unadjusted 90-day mortality for patients initially presenting to spoke versus hub medical centers was 32.2% and 32.7%, respectively. In adjusted analysis, presentation to a spoke medical center was neither noninferior nor inferior for 90-day mortality risk (OR 1.21, 95% CI 0.84-1.74). Sensitivity analysis excluding patients admitted to general wards or lacking continuous health plan insurance during the follow-up period trended closer to a noninferior result (OR 0.99, 95% CI 0.69-1.44).Within an integrated "hub-and-spoke" neuroscience care model, the risk of 90-day mortality following initial presentation with nontraumatic ICH to a spoke medical center was not conclusively noninferior compared with initial presentation to a hub medical center. However, there was also no indication that care for selected patients with nontraumatic ICH within medical centers lacking advanced neuroscience specialization resulted in significantly inferior outcomes. This finding may support the safety and efficiency of a "hub-and-spoke" care model for patients with nontraumatic ICH, although additional investigations are warranted.

INTRODUCTION: Video visits have created new opportunities to enhance access to care, but limited information exists on strategies medical groups can employ to facilitate video visit use by higher-risk patients. Our objective was to identify generalizable strategies to facilitate successful delivery of video visits by systems serving highly diverse patient populations. METHODS: The authors conducted a qualitative study of physicians and staff members in a large group practice with 4.5 million patients with diverse race and ethnicity and socioeconomic status. Semi-structured interviews were conducted between January 2021 and April 2021, with key informants identified via purposive and snowball sampling. Video-recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes. RESULTS: The 42 key informants included regional and medical center leaders, primary care physicians, service managers, and medical assistants. Participants described clinical leadership in technology and multidisciplinary collaboration as crucial to sustained video care adoption. Strategies to facilitate real-time learning included local innovation, rapid communication channels, and psychological safety. The organization offered broad access to frequently updated data reports to help managers and practitioners understand processes, measure performance, and share best practices. Medical assistants and physicians developed new approaches to empathize, tailor interactions with patients, and overcome psychological and technical barriers to connecting via video. CONCLUSIONS: Key strategies for sustained video care adoption included clinical leadership articulating its purpose, multidisciplinary collaboration, local innovation, effective data use, empathy, and personalized care. These findings provide a model for how health care systems can foster robust adoption of technologies to serve diverse populations.

The opioid abuse epidemic has focused attention on efforts to decrease opioid prescribing. Although education and feedback interventions are potential levers to affect opioid prescribing, their incremental contribution against a background of declining opioid prescriptions is unclear.We retrospectively evaluated opioid prescribing frequencies after an emergency physician-specific education and feedback initiative in an integrated health care system.We evaluated opioid prescriptions for adult patients discharged from 21 emergency departments (EDs) between January 1, 2014, and December 31, 2018. Applying interrupted time series methodology to account for time trends, we analyzed pre- to postintervention changes in prescribing of any opioid and in opioid prescriptions for greater than 20 tablets. We studied all ED visits, visits for back pain and acute extremity fracture, and visits stratified by physicians with high vs low frequency of opioid prescribing. We identified patient, physician, and visit characteristics associated with postintervention ED opioid prescriptions (2018).Of 1.01 million preintervention and 1.59 million postintervention ED visits, after adjusting for the background trend over time, the intervention was associated with a 3.4% decrease in frequency of opioid prescriptions post intervention (95% CI, -4% to -2.8%), with similar decreases in high-quantity prescriptions ( 20 tablets) and back pain- and acute extremity fracture-related ED visits. Postintervention adjusted analyses indicated no significant association between opioid prescription and race/ethnicity or prior history of opioid abuse.The ED Opioid Safety Initiative was associated with a near-term decrease in multiple categories of opioid prescribing, including for selected subgroups of common painful conditions.

The substantial expansion of secure messaging (SM) via the patient portal in the last decade suggests that it is becoming a standard of care, but few have examined SM use longitudinally. We examined SM patterns among a diverse cohort of patients with diabetes (N = 19 921) and the providers they exchanged messages with within a large, integrated health system over 10 years (2006-2015), linking patient demographics to SM use. We found a 10-fold increase in messaging volume. There were dramatic increases overall and for patient subgroups, with a majority of patients (including patients with lower income or with self-reported limited health literacy) messaging by 2015. Although more physicians than nurses and other providers messaged throughout the study, the distribution of health professions using SM changed over time. Given this rapid increase in SM, deeper understanding of optimizing the value of patient and provider engagement, while managing workflow and training challenges, is crucial.

OBJECTIVEHigh-deductible health plans (HDHPs) are increasingly more common but can be challenging for patients to navigate and may negatively affect care engagement for chronic conditions such as type 2 diabetes. We sought to understand how higher out-of-pocket costs affect participation in provider visits, medication adherence, and routine monitoring by patients with type 2 diabetes with an HDHP.RESEARCH DESIGN AND METHODSIn a retrospective cohort of 19,379 Kaiser Permanente Northern California patients with type 2 diabetes (age 18–64 years), 6,801 patients with an HDHP were compared with those with a no-deductible plan using propensity score matching. We evaluated the number of telephone and office visits with primary care, oral diabetic medication adherence, and rates of HbA1c testing, blood pressure monitoring, and retinopathy screening.RESULTSPatients with an HDHP had fewer primary care office visits compared with patients with no deductible (4.25 vs. 4.85 visits per person; P < 0.001), less retinopathy screening (49.9% vs. 53.3%; P < 0.001), and fewer A1c and blood pressure measurements (46.7% vs. 51.4%; P < 0.001 and 93.2% vs. 94.4%; P = 0.004, respectively) compared with the control group. Medication adherence was not significantly different between patients with an HDHP and those with no deductible (57.4% vs. 58.6%; P = 0.234).CONCLUSIONSHDHPs seem to be a barrier for patients with type 2 diabetes and reduce care participation in both visits with out-of-pocket costs and preventive care without out-of-pocket costs, possibly because of the increased complexity of cost sharing under an HDHP, potentially leading to decreased monitoring of important clinical measurements.

Introduction: Syncope is common among emergency department (ED) patients with acute pulmonary embolism (PE) and indicates a higher acuity and worse prognosis than in patients without syncope. Whether presyncope carries the same prognostic implications has not been established. We compared incidence of intensive care unit (ICU) admission in three groups of ED PE patients: those with presyncope; syncope; and neither. Methods: This retrospective cohort study included all adults with acute, objectively confirmed PE in 21 community EDs from January 2013–April 2015. We combined electronic health record extraction with manual chart abstraction. We used chi-square test for univariate comparisons and performed multivariate analysis to evaluate associations between presyncope or syncope and ICU admission from the ED, reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results: Among 2996 PE patients, 82 (2.7%) had presyncope and 109 (3.6%) had syncope. ICU admission was similar between groups (presyncope 18.3% vs syncope 25.7%) and different than their non-syncope counterparts (either 22.5% vs neither 4.7%; p

Key Points Question What are the perceptions and experiences of multidisciplinary cancer care clinicians (medical oncologists, radiation oncologists, surgical oncologists, oncology navigators, and cancer survivorship) with regard to telehealth visits and exchanging secure messages with patients during the COVID-19 pandemic? Findings In this survey study of 202 multidisciplinary cancer care clinicians, most were satisfied with telehealth and wished to maintain or increase future use. Despite being thought to promote a weaker patient-clinician connection, telehealth was considered appropriate by most to handle the greater part of patient assessment and care; however, some clinicians preferred in-person visits for certain activities. Meaning Results of this survey study suggest that telehealth is well accepted by various cancer care clinicians, and is likely to remain used to some extent for most aspects of cancer care in the future., Importance Telehealth use including secure messages has rapidly expanded since the COVID-19 pandemic, including for multidisciplinary aspects of cancer care. Recent reports described rapid uptake and various benefits for patients and clinicians, suggesting that telehealth may be in standard use after the pandemic. Objective To examine attitudes and perceptions of multidisciplinary cancer care clinicians toward telehealth and secure messages. Design, Setting, and Participants Cross-sectional specialty-specific survey (ie, some questions appear only for relevant specialties) among multidisciplinary cancer care clinicians, collected from April 29, 2020, to June 5, 2020. Participants were all 285 clinicians in the fields of medical oncology, radiation oncology, surgical oncology, survivorship, and oncology navigation from all 21 community cancer centers of Kaiser Permanente Northern California. Main Outcomes and Measures Clinician satisfaction, perceived benefits and challenges of telehealth, perceived quality of telehealth and secure messaging, preferred visit and communication types for different clinical activities, and preferences regarding postpandemic telehealth use. Results A total of 202 clinicians (71%) responded (104 of 128 medical oncologists, 34 of 37 radiation oncologists, 16 of 62 breast surgeons, 18 of 28 navigators, and 30 of 30 survivorship experts; 57% (116 of 202) were women; 73% [147 of 202] between ages 36-55 years). Seventy-six percent (n = 154) were satisfied with telehealth without statistically significant variations based on clinician characteristics. In-person visits were thought to promote a strong patient-clinician connection by 99% (n = 137) of respondents compared with 77% (n = 106) for video visits, 43% (n = 59) for telephone, and 14% (n = 19) for secure messages. The most commonly cited benefits of telehealth to clinicians included reduced commute (79%; n = 160), working from home (74%; n = 149), and staying on time (65%; n = 132); the most commonly cited negative factors included internet connection (84%; n = 170) or equipment problems (72%; n = 146), or physical examination needed (64%; n = 131). Most respondents (59%; n = 120) thought that video is adequate to manage the greater part of patient care in general; and most deemed various telehealth modalities suitable for any of the queried types of patient-clinician activities. For some specific activities, less than half of respondents thought that only an in-person visit is acceptable (eg, 49%; n = 66 for end-of-life discussion, 35%; n = 58 for new diagnosis). Most clinicians (82%; n = 166) preferred to maintain or increase use of telehealth after the pandemic. Conclusions and Relevance In this survey of multidisciplinary cancer care clinicians in the COVID-19 era, telehealth was well received and often preferred by most cancer care clinicians, who deemed it appropriate to manage most aspects of cancer care. As telehealth use becomes routine in some cancer care settings, video and telephone visits and use of asynchronous secure messaging with patients in cancer care has clear potential to extend beyond the pandemic period., This survey study assesses the attitudes and perceptions of multidisciplinary cancer care clinicians (from the fields of medical oncology, radiation oncology, surgical oncology, survivorship, and oncology navigation) toward telehealth and secure messages.

The Patient Protection and Affordable Care Act eliminated cost sharing for preventive services, including colorectal cancer screening for individuals aged 50-75 years with private health insurance. This study examines the impact of the Affordable Care Act's removal of cost sharing for colorectal cancer screening on colorectal cancer incidence and mortality.Trends in colorectal cancer incidence and colorectal cancer‒related mortality were modeled among 2,113,283 Kaiser Permanente Northern California members aged ≥50 years between 2003 and 2016 using an interrupted time-series design. As a sensitivity analysis, a controlled analysis utilized a comparison group of members covered with pre‒Affordable Care Act zero cost sharing for colorectal cancer screening. Analyses were performed in 2019 and 2020.The colorectal cancer incidence dropped by 17% around the time the Affordable Care Act was enacted (change in level incidence rate ratio; 95% CI=0.77, 0.90, 2-sided p-value0.0001), followed by a 3% further decrease per year (95% CI=0.93, 1.00, p=0.05). A similar pattern was observed for colorectal cancer‒related mortality. The controlled results indicated that the elimination of cost sharing for screening due to the Affordable Care Act was associated with greater improvements in colorectal cancer outcomes among members previously covered by health plans with out-of-pocket costs for screening than among those with health plans with zero cost sharing for screening before the Affordable Care Act.The elimination of cost sharing for colorectal cancer screening due to the Affordable Care Act was associated with a decrease in age-, race/ethnicity-, and sex-adjusted colorectal cancer incidence and colorectal cancer‒related mortality, implying that policies that remove barriers to screening, particularly financial burden from cost sharing, can result in improved colorectal cancer outcomes.

This cohort study evaluates whether rates of treatment or follow-up office or emergency visits associated with telemedicine visits differ from those associated with in-person visits in a large integrated health system., Key Points Question In patient-scheduled primary care video or telephone visits with existing physicians, do rates of treatment or follow-up office or emergency visits differ from rates of in-person visits? Findings In this cohort study of 1 131 722 patients, adjusted rates of prescribing and nonmedication orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher rates of follow-up office visits after telemedicine visits but no significant difference in rates of 7-day emergency visits or hospitalizations. Meaning The findings suggest that video or telephone visits may offer a convenient way to address some primary care needs within ongoing patient-physician relationships, without substantially higher rates of follow-up office visits or health events (emergency department visits or hospitalizations)., Importance Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up. Objective To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events. Design, Setting, and Participants This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018. Main Outcomes and Measures Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics. Results This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type. Conclusions and Relevance In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Background Coronavirus disease 2019 (COVID‐19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), has extracted devastating tolls. Despite its pervasiveness, robust information on disease characteristics in the emergency department (ED) and how that information predicts clinical course remain limited. Methods We conducted a retrospective cohort study of the first ED visit from SARS‐CoV‐2‐positive patients in our health system, from February 21, 2020 to April 5, 2020. We reviewed each patient's ED visit(s) and included the first visit with symptoms consistent with COVID‐19. We collected demographic, clinical, and treatment variables from electronic health records and structured manual chart review. We used multivariable logistic regression to examine the association between patient characteristics and 2 primary outcomes: a critical outcome and hospitalization from index visit. Our critical outcome was defined as death or advanced respiratory support (high flow nasal cannula or greater) within 21 days. Results Of the first 1030 encounters, 801 met our inclusion criteria: 15% were over age 75 years, 47% were female, and 24% were non‐Hispanic white. We found 161 (20%) had a critical outcome and 393 (49%) were hospitalized. Independent predictors of a critical outcome included a history of hypertension, abnormal chest x‐ray, elevated neutrophil to lymphocyte ratio, elevated blood urea nitrogen (BUN), measured fever, and abnormal respiratory vital signs (respiratory rate, oxygen saturation). Independent predictors of hospitalization included abnormal pulmonary auscultation, elevated BUN, measured fever, and abnormal respiratory vital signs. Conclusions In this large, diverse study of ED patients with COVID‐19, we have identified numerous clinical characteristics that have independent associations with critical illness and hospitalization.

The management and outcomes of patients diagnosed with acute pulmonary embolism in primary care have not been characterized.To describe 30-day outcomes stratified by initial site-of-care decisions DESIGN: Multicenter retrospective cohort study PARTICIPANTS: Adults diagnosed with acute pulmonary embolism in primary care in a large, diverse community-based US health system (2013-2019) MAIN MEASURES: The primary outcome was a composite of 30-day serious adverse events (recurrent venous thromboembolism, major bleeding, and all-cause mortality). The secondary outcome was 7-day pulmonary embolism-related hospitalization, either initial or delayed.Among 652 patient encounters (from 646 patients), median age was 64 years; 51.5% were male and 70.7% identified as non-Hispanic white. Overall, 134 cases (20.6%) were sent home from primary care and 518 cases (79.4%) were initially referred to the emergency department (ED) or hospital. Among the referred, 196 (37.8%) were discharged home from the ED without events. Eight patients (1.2%; 95% CI 0.5-2.4%) experienced a 30-day serious adverse event: 4 venous thromboemboli (0.6%), 1 major bleed (0.2%), and 3 deaths (0.5%). Seven of these patients were initially hospitalized, and 1 had been sent home from primary care. All 3 deaths occurred in patients with known metastatic cancer initially referred to the ED, hospitalized, then enrolled in hospice following discharge. Overall, 328 patients (50.3%) were hospitalized within 7 days: 322 at the time of the index diagnosis and 6 following initial outpatient management (4 clinic-only and 2 clinic-plus-ED patients).Patients diagnosed with acute pulmonary embolism in this primary care setting uncommonly experienced 30-day adverse events, regardless of initial site-of-care decisions. Over 20% were managed comprehensively by primary care. Delayed 7-day pulmonary embolism-related hospitalization was rare among the 51% treated as outpatients. Primary care management of acute pulmonary embolism appears to be safe and could have implications for cost-effectiveness and patient care experience.

Video telemedicine can offer patients direct real-time convenient access to clinicians without arranging transportation or work time-off, improving access to diabetes care and self-management support. We examined the association between video visit use and hemoglobin A1c (HbA1c) among patients with diabetes. In a longitudinal study, within a large integrated delivery system where patients were first able to self-schedule real-time physician video visits in 2016, we used the clinical registry to identify patients with diabetes (2015), and followed their video visit use and subsequent HbA1c values over time (2016-2019). Using linear regression with patient-level fixed effects (within-patient changes), adjusting for calendar year and month and time-changing patient mobile portal access, we measured the association between use of video visits as a time-changing variable and the patient’s yearly HbA1c values (in subsequent calendar years after video visit use). We then stratified analyses by baseline HbA1c value: Among 204,301 patients with diabetes, 50% were 65 years or older, 48% were women, and 45% were of white race/ethnicity. Overall, 95% of patients had a baseline HbA1c value, 24% had HbA1c values ≥8%. Patient use of video visits was associated with an overall statistically significant reduction in HbA1c value by 0.15% (95% CI: 0.11%-0.19%). Among those with baseline HbA1c values ≥8%, using video visits was associated with a HbA1c value reduction of 0.22% (95% CI: 0.12%-0.32%), and among patients with lower baseline engagement (i.e., no baseline HbA1c measurement), using video visits was associated with a HbA1c reduction of 0.39% (95% CI: 0.07%-0.71%). Use of video visit was associated with improved glycemic control among patients with diabetes, with greater improvements found among patients with worse baseline control and lower engagement. Video visits may offer convenient health care access to improve diabetes management. Disclosure M. Reed: None. A. Gopalan: None. I. Graetz: None. L. Hsueh: None. J. Huang: None. E. Muelly: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK085070)

The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS).We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC.We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (≥85%). In the very-low- and low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS.The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.

BACKGROUND: Little is known about patients who have caregiver proxies communicate with healthcare providers via portal secure messaging (SM). Since proxy portal use is often informal (e.g., sharing patient accounts), novel methods are needed to estimate the prevalence of proxy-authored SMs. OBJECTIVE: (1) Develop an algorithm to identify proxy-authored SMs, (2) apply this algorithm to estimate predicted proxy SM (PPSM) prevalence among patients with diabetes, and (3) explore patient characteristics associated with having PPSMs. DESIGN: Retrospective cohort study. PARTICIPANTS: We examined 9856 patients from Diabetes Study of Northern California (DISTANCE) who sent ≥ 1 English-language SM to their primary care physician between July 1, 2006, and Dec. 31, 2015. MAIN MEASURES: Using computational linguistics, we developed ProxyID, an algorithm that identifies phrases frequently found in registered proxy SMs. ProxyID was validated against blinded expert categorization of proxy status among an SM sample, then applied to identify PPSM prevalence across patients. We examined patients’ sociodemographic and clinical characteristics according to PPSM penetrance, “none” (0%), “low” (≥ 0–50%), and “high” (≥ 50–100%). KEY RESULTS: Only 2.3% of patients had ≥ 1 registered proxy-authored SM. ProxyID demonstrated moderate agreement with expert classification (Κ = 0.58); 45.7% of patients had PPSMs (40.2% low and 5.5% high). Patients with high percent PPSMs were older than those with low percent and no PPSMs (66.5 vs 57.4 vs 56.2 years, p

This quality improvement study assesses the success of medical assistant–supported virtual rooming for physician video visits among patients in Kaiser Permanente Northern California.

We took advantage of a change in protocol in an integrated delivery system's telephone consultation service-routing callers complaining of chest pain to physicians instead of registered nurses, whenever feasible-to explore whether tele-triage outcomes differed by staffing type. Comparing outcomes of 11,315 physician-directed calls to those of an equal number of nurse-directed calls in 2013, we found that the physician-directed calls were briefer (eight minutes versus thirteen minutes), produced fewer ED referrals (10 percent versus 16 percent), and resulted in higher patient adherence to the providers' site-of-care recommendation (86 percent versus 82 percent). Mortality rates at seven days were low for both physician- and nurse-directed calls (0.1 percent). We suspect that providers' immediate access to callers' comprehensive electronic health records and patients' rapid access to outpatient care likely contributed to the program's success. Our findings suggest that tele-triage can be used to safely and effectively manage an emergent complaint, and that physicians' expertise may bring additional efficiency to the process.