Table of Contents

The Issue in Brief

Developing a Clinician Friendly Tool to Identify Useful Clinical Practice Guidelines: G-TRUST

Allen F. Shaughnessy , and colleagues

Background Although clinical practice guidelines should be based on high quality research and practice experience, they vary in their relevance to practice, use of evidence, and other factors. This report describes the development of the Guideline Trustworthiness, Relevance, and Utility Scoring Tool (G-TRUST), a tool for clinicians to identify useful practice guidelines.

What This Study Found The 8-item G-TRUST is potentially helpful in identifying useful clinical practice guidelines.Twenty-two experts in evidence-based medicine, 17 developers of high-quality guidelines, and one consumer representative participated in a process to obtain consensus on a checklist of items and their relative impact on guideline quality. More than 75 percent of experts found three of the eight checklist items to be major indicators of guideline usefulness and, in comparison to a reference standard (the AGREE tool), a scoring system was developed identifying guidelines as "useful," "may not be useful," and "not useful." The checklist identified 92 percent of low-quality guidelines and disqualified many high quality guidelines because of a stricter definition of trustworthiness, including more stringent conflict of interest requirements.

Implications

• With the proliferation of practice guidelines, numbering in the thousands, the authors call for research to determine the reliability of G-TRUST and to examine how the tool might interact with technology, such as smart phone applications

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

Brian G. Arndt , and colleagues

Background US physicians spend numerous hours each day interacting with electronic health record (EHR) systems, which in turn contributes to work life imbalance, dissatisfaction, high rates of attrition, and burnout. This study assessed primary care physician time and usage patterns interacting with the EHR.

What This Study Found Primary care physicians spent more than one-half of their workday interacting with the electronic health record during and after clinic hours. Research based on data from EHR event logs (an automated tracking feature) and confirmed by direct observation data found that physicians spent 355 minutes (5.9 hours) of an 11.4 hour workday in the EHR, including 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after hours. Almost half of their total EHR time per day (44 percent) was devoted to clerical tasks and an additional 84 minutes per day (24 percent) was spent managing the inbox. Time spent on EHR activities differed by time of day on weekdays and weekends, with weekend EHR work peaking around 10:00 am and 10:00 pm. A number of factors contribute to physician burnout and increased workload related to the EHR, the authors explain. This includes the amount of time required for documentation (84 minutes) and order entry (43 minutes), as well as the inefficiency and distraction of communicating with team members through the EHR instead of verbally.

Implications

• The authors contend that solutions for common problems in primary care, such as proactive planned care, team-based care, and sharing of clerical tasks, require thoughtful EHR system applications.

Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial

Steven Lin , and colleagues

Background One of the largest contributors to physician burnout is a growing clerical workload requiring physicians to spend significant time working in the electronic health record. One strategy to decrease clerical burden is the use of scribes, non-licensed team members trained to document patient encounters in real time under the direct supervision of a physician. The objective of this study is to evaluate the effect of medical scribes on physician satisfaction, patient satisfaction, and charting efficiency.

What This Study Found This study--the first randomized controlled trial of scribes--finds that they produce significant improvements in physician satisfaction without detracting from patient satisfaction. Over the course of one year, family physicians were randomized to one week in which scribes drafted all relevant documentation, which was reviewed and signed by the physician, followed by one week without a scribe in which physicians performed all charting duties. Scribes improved all aspects of physician satisfaction, including overall satisfaction and satisfaction with length of time with patients, time spent charting, chart quality, and chart accuracy. Scribes had no effect on patient satisfaction and increased the proportion of charts that were completed within 48 hours. Physicians were more satisfied with scribed charts than with their own.

Implications

• Spending less time on documentation, the authors note, frees up physicians to pursue direct clinical care, care coordination, and teaching activities, which may help prevent burnout.
• Scribes could complement a high-functioning electronic health record and, until electronic records are redesigned for improved functionality, could provide an immediate solution to the clerical burden EHRs entail.

Uninsured Primary Care Visit Disparities Under the Affordable Care Act

Heather Holderness , and colleagues

Background Historically, racial and ethnic minorities in the United States have been significantly less likely to have insurance coverage than non-Hispanic whites. The Affordable Care Act was designed, in part, to reduce health disparities. This study aimed to assess changes in insurance coverage at community health center visits by race and ethnicity after Affordable Care Act Medicaid expansion.

What This Study Found Expansion of Medicaid coverage under the Affordable Care Act has contributed to sizeable decreases in medical visits in which people were uninsured. This is true across all racial and ethnic groups, although disparities remain. Using electronic health record data from 10 states that expanded Medicaid and six states that did not, the study examined 359 community health centers and 870,319 patients with more than four million visits. Rates of Medicaid-insured visits increased in expansion states for all racial/ethnic groups immediately following ACA Medicaid expansion, whereas no significant change was observed for Medicaid-insured visits for any racial/ethnic group in non-expansion states. Rates of uninsured visits decreased for all racial/ethnic groups in both expansion and non-expansion states, but the declines were more immediate and pronounced in expansion states. Specifically, rates of Medicaid-insured visits in expansion states increased 60 percent from before the Affordable Care Act to after its implementation among non-Hispanic whites, 77 percent for Hispanics, and 40 percent for non-Hispanic blacks. The most notable changes in non-expansion states were in private insurance visit rates: all racial/ethnic groups increased significantly in the post-implementation period, with Hispanics utilizing community health centers with private coverage at 3.6 times their rate prior to the ACA. This suggests that fewer Hispanic patients were eligible for Medicaid and therefore sought private coverage to comply with the Affordable Care Act's individual mandate. In spite of these improvements, disparities remain. For example, Hispanic patients had the highest uninsured visit rates before Medicaid expansion and, after Medicaid expansion, a significantly smaller decline in rates of uninsured visits than non-Hispanic whites and non-Hispanic blacks. Thus, gaps in Medicaid coverage appear to have continued for Hispanic patients while disparities have been reduced for non-Hispanic blacks.

Implications

• These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.

Physician Support of Smoking Cessation After Diagnosis of Lung, Bladder, or Aerodigestive Tract Cancer

, and colleagues

Background Stopping smoking after being diagnosed with lung, bladder, and upper aerodigestive tract cancer appears to improve patients' survival. Support to quit smoking could strengthen these efforts. This study set out to assess how often general practitioners in the UK provide smoking cessation support in patients with lung, bladder, and upper aerodigestive tract cancer compared to patients with coronary heart disease and whether this effort is influenced by incentive payments.

What This Study Found Physicians are more likely to support smoking cessation in primary care patients with coronary heart disease than those with cancer, and patients with cancer are less likely to stop smoking. Using electronic records, 12,393 incident cases of lung, bladder and upper aerodigestive tract cancers diagnosed between 1999-2013 were matched 1:1 with incident coronary heart disease cases. At diagnosis, 32 percent of patients with cancer and 18 percent of patients with coronary heart disease smoked. People with cancer were less likely than controls to have smoking status recorded by their GP (37 percent versus 78 percent), be given advice to quit smoking (23 percent versus 45 percent), or be prescribed smoking cessation medication (12 percent versus 21 percent). Of the 3,706 cancer/heart disease patients who smoked at diagnosis and had at least one smoking status update in the year following diagnosis, 1,359 (37 percent) of patients with cancer and 1,645 (44 percent) of patients with heart disease stopped smoking. The frequency of recording of smoking status, advice and pharmacotherapy increased after introduction of incentive payments for GPs to manage smoking but there were no differences in the rates of quitting.

Implications

• The authors call for improvements in the management of smoking cessation by general practitioners for patients with cancer.

Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices

Ashok Reddy , and colleagues

Background Risk stratified care management�assigning a patient to a risk category on which care is based�is increasingly viewed as a way to improve care and reduce costs. This study describes risk stratification patterns and association with care management services for practices in the Comprehensive Primary Care initiative.

What This Study Found An analysis of 484 practices finds that they used four primary methods to risk stratify their patient populations: a practice-developed algorithm (215 practices), an American Academy of Family Physicians clinical algorithm (155 practices), payer claims/electronic health record (62 practices), and clinical intuition (52 practices). Practices that developed their own algorithm identified more patients in the highest two risk tiers than practices that used the AAFP algorithm, claims/electronic health record-derived algorithm, or clinical intuition. However, practices using a practice-developed algorithm had statistically significant lower numbers of patients receiving care management (69 patients) when compared to clinical intuition (91 patients). Practices that primarily used clinical intuition provided care management to the highest proportion of high-risk patients.

Implications

• The authors suggest that, as payers shift reimbursement from volume-based to value-driven care, more primary care practices will focus on finding the best ways to implement high-risk care management.

Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database

Andrew Carson-Stevens , and colleagues

Background A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. The extent to which blame is assigned in patient safety incidents reports is unknown. This study set out to explore the nature of blame in family medicine incident reports.

What This Study Found When primary care staff members report patient safety incidents, they often attribute blame not to system failures but to the actions of individuals. Based on analysis of incident reports from the England and Wales National Reporting and Learning System, researchers found that healthcare professionals making incident reports attributed blame to a person in 45 percent of cases. In 36 percent of cases, reporters attributed fault to another person, while 2 percent of reporters took personal responsibility. Blame directed at others was more likely in discharge planning, communication, referrals, and diagnosis and assessment incidents, and was commonly associated with incidents where a complaint was anticipated.

Implications

• The high frequency of blame in primary care incident reports, the authors suggest, may reflect a health care culture that leads to blame and retribution. Improving patient safety through analysis of incident reports and identifying areas for learning will require a shift towards a culture that identifies system failures rather than blaming individuals, they conclude.

Preventable Emergency Hospital Admissions Among Adults With Intellectual Disability in England

Iain M. Carey , and colleagues

Background Avoiding acute hospitalization is important for people with intellectual disabilities, who tend to have poorer health than people in the general population. This study describes overall and preventable emergency admissions for adults with intellectual disabilities and assesses differences in primary care management of two common preventable (ambulatory care sensitive) conditions: lower respiratory and urinary tract infections.

What This Study Found Adults with intellectual disabilities have more than twice as many emergency hospital admissions and five times more preventable emergency admissions than other comparable individuals. Researchers linked primary care records with hospital admission data among 16,666 adults with intellectual disabilities and 113,562 age-, sex- and practice-matched controls without intellectual disabilities from England�s general population. In adults with intellectual disabilities, 3,847 (23 percent) had an emergency admission and 1,809 (11 percent) had multiple admissions. In comparison, 12 percent of those in the control group had one or more emergency hospitalizations and 4 percent had multiple admissions. The overall annual rate for emergency hospitalizations in adults with intellectual disabilities was 182 per 1,000 adults, nearly three times higher than their matched controls and more than double the control group when adjusted for comorbidities, smoking and deprivation. The most common ambulatory care sensitive conditions resulting in admission for adults with intellectual disabilities were convulsions/epilepsy (36 percent), lower respiratory tract infection (19 percent) and urinary tract infection (11 percent).

Implications

• This study, the first in the United Kingdom to use an unselected group of adults with intellectual disabilities to accurately quantify differences in emergency admissions, lays the foundation for health interventions for adults with such disabilities, particularly as their life expectancy increases. Higher emergency admission rates represent an area where improvements can be made, the authors suggest.

Health Care Disparities of Ohioans With Developmental Disabilities Across the Lifespan

Susan M. Havercamp , and colleagues

Background Developmental disabilities are severe, chronic conditions that impair cognitive and/or physical functioning, resulting in significant functional limitations throughout the lifespan. This study explores differences in a range of health indicators between people with and without developmental disabilities.

What This Study Found There are significant disparities between individuals with and without developmental disabilities in health status, health care quality, utilization, access to care, and unmet healthcare needs. A telephone survey found that children and older adults with developmental disabilities experienced the greatest disparities in unmet healthcare needs. Fourteen percent of children 0-18 years of age with developmental disabilities reported problems getting needed care, compared to 2 percent of children without developmental disabilities. Among adults age 65 and older, 50 percent of those with developmental disabilities reported one or more unmet health care needs, compared to 17 percent of those without such disabilities.

Implications

• The authors call for medical schools to incorporate training in developmental disabilities into their curricula to help reduce health care disparities.

Agriculture and Health Sectors Collaborate in Addressing Population Health

Arthur Kaufman , and colleagues

Background A focus on population health is increasingly important in the changing healthcare environment. The Cooperative Extension Service, a program of the US Department of Agriculture in partnership with land-grant universities, has a major impact on population health through its many community-based efforts. This report describes a collaboration between the Cooperative Extension Service and a parallel Health Extension program.

What This Study Found In at least 18 states around the United States, academic health science centers are partnering with cooperative extension systems to better address population health. While the extension system is increasing its focus on health, the health sector sees extension as a model for working with local communities, including through the Primary Care Extension Program established by the Affordable Care Act. The report, from experts in cooperative extension systems and medicine in New Mexico, describes national activities as well as that state�s joint efforts to provide nutrition education in community health centers, health and nutrition education for seniors, and healthy cooking demonstrations for immigrants.

Implications

• The authors encourage dialogue between states to identify best practices for the future of this important, multi-sector collaboration.