Background
Patient-centered care reflecting patient preferences and needs is integral to high-quality care. Individualized care is important for psychosocially complex or high-risk patients with ...multiple chronic conditions (i.e., multimorbidity), given greater potential risks of interventions and reduced benefits. These patients are increasingly prevalent in primary care. Few studies have examined provision of patient-centered care from the clinician perspective, particularly from primary care physicians serving in integrated, patient-centered medical home settings within the US Veterans Health Administration.
Objective
We sought to clarify facilitators and barriers perceived by primary care physicians in the Veterans Health Administration to delivering patient-centered care for high-risk or complex patients with multimorbidity.
Design
We conducted semi-structured telephone interviews from April to July 2020 among physicians across 20 clinical sites. Findings were analyzed with deductive content analysis based on conceptual models of patient-centeredness and hierarchical factors affecting care delivery.
Participants
Of 23 physicians interviewed, most were female (
n
= 14/23, 61%), serving in hospital-affiliated outpatient clinics (
n
= 14/23, 61%). Participants had a mean of 21 (SD = 11.3) years of experience.
Key Results
Facilitators included the following: effective physician-patient communication to individualize care, prioritize among multiple needs, and elicit goals to improve patient engagement; access to care, enabled by interdisciplinary teams, and dictating personalized care planning; effortful but worthwhile care coordination and continuity; meeting complex needs through effective teamwork; and integrating medical and non-medical care aspects in recognition of patients’ psychosocial contexts. Barriers included the following: intra- and interpersonal (e.g., perceived patient reluctance to engage in care); organizational (e.g., limited encounter time); and community or policy impediments (e.g., state decisional capacity laws) to patient-centered care.
Conclusions
Physicians perceived individual physician-patient interactions were the greatest facilitators or barriers to patient-centered care. Efforts to increase primary care patient-centeredness for complex or high-risk patients with multimorbidity could focus on targeting physician-patient communication and reducing interpersonal conflict.
Valvular calcification is central to the pathogenesis and progression of aortic stenosis, with preclinical and observational studies suggesting that bone turnover and osteoblastic differentiation of ...valvular interstitial cells are important contributory mechanisms. We aimed to establish whether inhibition of these pathways with denosumab or alendronic acid could reduce disease progression in aortic stenosis.
In a single-center, parallel group, double-blind randomized controlled trial, patients >50 years of age with calcific aortic stenosis (peak aortic jet velocity >2.5 m/s) were randomized 2:1:2:1 to denosumab (60 mg every 6 months), placebo injection, alendronic acid (70 mg once weekly), or placebo capsule. Participants underwent serial assessments with Doppler echocardiography, computed tomography aortic valve calcium scoring, and
F-sodium fluoride positron emission tomography and computed tomography. The primary end point was the calculated 24-month change in aortic valve calcium score.
A total of 150 patients (mean age, 72±8 years; 21% women) with calcific aortic stenosis (peak aortic jet velocity, 3.36 m/s 2.93-3.82 m/s; aortic valve calcium score, 1152 AU 655-2065 AU) were randomized and received the allocated trial intervention: denosumab (n=49), alendronic acid (n=51), and placebo (injection n=25, capsule n=25; pooled for analysis). Serum C-terminal telopeptide, a measure of bone turnover, halved from baseline to 6 months with denosumab (0.23 0.18-0.33 µg/L to 0.11 µg/L 0.08-0.17 µg/L) and alendronic acid (0.20 0.14-0.28 µg/L to 0.09 µg/L 0.08-0.13 µg/L) but was unchanged with placebo (0.23 0.17-0.30 µg/L to 0.26 µg/L 0.16-0.31 µg/L). There were no differences in 24-month change in aortic valve calcium score between denosumab and placebo (343 198-804 AU versus 354 AU 76-675 AU; P=0.41) or alendronic acid and placebo (326 138-813 AU versus 354 AU 76-675 AU;
=0.49). Similarly, there were no differences in change in peak aortic jet velocity or
F-sodium fluoride aortic valve uptake.
Neither denosumab nor alendronic acid affected progression of aortic valve calcification in patients with calcific aortic stenosis. Alternative pathways and mechanisms need to be explored to identify disease-modifying therapies for the growing population of patients with this potentially fatal condition. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02132026.
Recombinant human interleukin-6 (IL-6) was assessed for its ability to stimulate bone resorption in prelabeled mouse calvariae in vitro. IL-6 had no effect on bone resorption at concentrations ...ranging from 300 to 10,000 U/ml (3-1000 pg/ml). Neither the presence of indomethacin nor prolonged incubation periods (96 h) affected this result. IL-6 did not affect resorption stimulated by human recombinant IL-1 alpha (rIL-1 alpha) but inhibited resorption stimulated by parathyroid hormone (PTH) and 1,25-dihydroxyvitamin D3 1,25-(OH)2D3. rIL-1 alpha, PTH, and 1,25-(OH)2D3 induced IL-6 release by calvariae. We conclude from these studies that IL-6 does not stimulate bone resorption in neonatal mouse calvariae. However, it may act as a locally produced inhibitor and therefore a paracrine regulator of bone resorption induced by osteotropic hormones. IL-6 could also function as a long-range stimulator of systemic reactions and acute-phase responses to local inflammatory and neoplastic lesions in bone.
We provide a perspective on steepness, reference points for fishery management, and stock assessment. We first review published data and give new results showing that key reference points are fixed ...when steepness and other life history parameters are fixed in stock assessments using a Beverton–Holt stock–recruitment relationship. We use both production and age-structured models to explore these patterns. For the production model, we derive explicit relationships for steepness and life history parameters and then for steepness and major reference points. For the age-structured model, we are required to generally use numerical computation, and so we provide an example that complements the analytical results of the production model. We discuss what it means to set steepness equal to 1 and how to construct a prior for steepness. Ways out of the difficult situation raised by fixing steepness and life history parameters include not fixing them, using a more complicated stock–recruitment relationship, and being more explicit about the information content of the data and what that means for policy makers. We discuss the strengths and limitations of each approach.
Like many estuaries in the world, salinity levels in the Delaware River and Estuary are expected to increase due to a deepened navigational channel and sea-level rise. This study estimated ...operational cost increases resulting from increased ambient salinity likely to be incurred at PSEG-Hope Creek, an evaporatively cooled electricity generating station. To estimate cost increases, a linked physical-economic model was developed to generate daily forecasts of salinity and the resulting changes in facility's cooling water treatment and pumping requirements. Salinity increases under potential future bathymetric configurations were simulated using a hydrodynamic model. On an equivalent annual basis (discounted at 5%), average cost increases were $0.4M per year, or approximately 0.1% of estimated total annual operating costs for the facility. Methods developed here could be employed at other facilities anticipating future salinity increases. Results inform cost-benefit analyses for dredging projects and contribute to estimates of the indirect costs to society from carbon emissions through sea-level rise. Future research refinements can focus on modeling changes in suspended sediment concentrations and estimating their impacts on operational costs.
•Sea-level rise and deepened channels increase salinity intrusion in estuaries.•Increased salinity can increase operational costs for evaporative cooling systems.•A method for quantifying these costs is developed.•For a nuclear electricity generating facility, annualized costs increase modestly.•Previous estimates of net benefits of channel deepening may be overstated.
Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors' office notes.
To explore attitudes toward potential benefits or ...harms if PCPs offered patients ready access to visit notes.
The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors' notes.
Primary care practices in 3 U.S. states.
Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington.
Doctors' and patients' attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics.
110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 203 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors.
Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels.
Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability.
The Robert Wood Johnson Foundation's Pioneer Portfolio, Drane Family Fund, and Koplow Charitable Foundation.
Providers and policymakers are pursuing strategies to increase patient engagement in health care. Increasingly, online sections of medical records are viewable by patients though seldom are ...clinicians' visit notes included. We designed a one-year multi-site trial of online patient accessible office visit notes, OpenNotes. We hypothesized that patients and primary care physicians (PCPs) would want it to continue and that OpenNotes would not lead to significant disruptions to doctors' practices.
Using a mixed methods approach, we designed a quasi-experimental study in 3 diverse healthcare systems in Boston, Pennsylvania, and Seattle. Two sites had existing patient internet portals; the third used an experimental portal. We targeted 3 key areas where we hypothesized the greatest impacts: beliefs and attitudes about OpenNotes, use of the patient internet portals, and patient-doctor communication. PCPs in the 3 sites were invited to participate in the intervention. Patients who were registered portal users of participating PCPs were given access to their PCPs' visit notes for one year. PCPs who declined participation in the intervention and their patients served as the comparison groups for the study. We applied the RE-AIM framework to our design in order to capture as comprehensive a picture as possible of the impact of OpenNotes. We developed pre- and post-intervention surveys for online administration addressing attitudes and experiences based on interviews and focus groups with patients and doctors. In addition, we tracked use of the internet portals before and during the intervention.
PCP participation varied from 19% to 87% across the 3 sites; a total of 114 PCPs enrolled in the intervention with their 22,000 patients who were registered portal users. Approximately 40% of intervention and non-intervention patients at the 3 sites responded to the online survey, yielding a total of approximately 38,000 patient surveys.
Many primary care physicians were willing to participate in this "real world" experiment testing the impact of OpenNotes on their patients and their practices. Results from this trial will inform providers, policy makers, and patients who contemplate such changes at a time of exploding interest in transparency, patient safety, and improving the quality of care.
PDF
