Although alert fatigue is blamed for high override rates in contemporary clinical decision support systems, the concept of alert fatigue is poorly defined. We tested hypotheses arising from two ...possible alert fatigue mechanisms: (A) cognitive overload associated with amount of work, complexity of work, and effort distinguishing informative from uninformative alerts, and (B) desensitization from repeated exposure to the same alert over time.
Retrospective cohort study using electronic health record data (both drug alerts and clinical practice reminders) from January 2010 through June 2013 from 112 ambulatory primary care clinicians. The cognitive overload hypotheses were that alert acceptance would be lower with higher workload (number of encounters, number of patients), higher work complexity (patient comorbidity, alerts per encounter), and more alerts low in informational value (repeated alerts for the same patient in the same year). The desensitization hypothesis was that, for newly deployed alerts, acceptance rates would decline after an initial peak.
On average, one-quarter of drug alerts received by a primary care clinician, and one-third of clinical reminders, were repeats for the same patient within the same year. Alert acceptance was associated with work complexity and repeated alerts, but not with the amount of work. Likelihood of reminder acceptance dropped by 30% for each additional reminder received per encounter, and by 10% for each five percentage point increase in proportion of repeated reminders. The newly deployed reminders did not show a pattern of declining response rates over time, which would have been consistent with desensitization. Interestingly, nurse practitioners were 4 times as likely to accept drug alerts as physicians.
Clinicians became less likely to accept alerts as they received more of them, particularly more repeated alerts. There was no evidence of an effect of workload per se, or of desensitization over time for a newly deployed alert. Reducing within-patient repeats may be a promising target for reducing alert overrides and alert fatigue.
Informal care plays an important role in the care of care‐recipients. Most of the previous studies focused on the primary caregivers and ignored the importance of non‐primary caregivers. Moreover, ...little is known about the provision of informal care in the context of home‐based palliative care. The purpose of this study was to examine the provision of primary and non‐primary informal care‐giving and their respective determinants. Primary caregivers assume the main responsibility for care, while non‐primary caregivers are those other than the primary caregiver who provide care‐giving. A longitudinal, prospective cohort design was conducted and data were drawn from two palliative care programs in Canada between November 2013 and August 2017. A total of 273 caregivers of home‐based palliative care cancer care‐recipients were interviewed biweekly until the care recipient died. The outcomes were the propensity and intensity of informal care‐giving. Regression analysis with instrumental variables was used. About 90% of primary caregivers were spouses and children, while 53% of non‐primary caregivers were others rather than spouses and children. The average number of hours of primary and non‐primary informal care‐giving reported for each 2‐week interview period was 83 hr and 23 hr, respectively. Hours of home‐based personal support workers decreased the intensity of primary care‐giving and the likelihood of non‐primary care‐giving. Home‐based nursing visits increased the propensity of non‐primary care‐giving. The primary care‐giving and non‐primary care‐giving complement each other. Care recipients living alone received less primary informal care‐giving. Employed primary caregivers decreased their provision of primary care‐giving, but promoted the involvement of non‐primary care‐giving. Our study has clinical practices and policy implications. Suitable and targeted interventions are encouraged to make sure the provision of primary and non‐primary care‐giving, to balance the work of the primary caregivers and their care‐giving responsibility, and to effectively arrange the formal home‐based palliative care services.
The Independence at Home (IAH) Demonstration Year 2 results confirmed that the first‐year savings were 10 times as great as those of the pioneer accountable care organizations during their initial 2 ...years. We update projected savings from nationwide conversion of the IAH demonstration, incorporating Year 2 results and improving attribution of IAH‐qualified (IAH‐Q) Medicare beneficiaries to home‐based primary care (HBPC) practices. Applying IAH qualifying criteria to beneficiaries in the Medicare 5% claims file, the effect of expanding HBPC to the 2.4 million IAH‐Q beneficiaries is projected using various growth rates. Total 10‐year system‐wide savings (accounting for IAH implementation but before excluding shared savings) range from $2.6 billion to $27.8 billion, depending on how many beneficiaries receive HBPC on conversion to a Medicare benefit, mix of clinical practice success, and growth rate of IAH practices. Net projected savings to the Centers for Medicare and Medicaid Services (CMS) after routine billing for IAH services and distribution of shared savings ranges from $1.8 billion to $10.9 billion. If aligning IAH with other advanced alternative payment models achieved at least 35% penetration of the eligible population in 10 years, CMS savings would exceed savings with the current IAH design and HBPC growth rate. If the demonstration were simply extended 2 years with a beneficiary cap of 50,000 instead of 15,000 (as currently proposed), CMS would save an additional $46 million. The recent extension of IAH, a promising person‐centered CMS program for managing medically complex and frail elderly adults, offers the chance to evaluate modifications to promote more rapid HBPC growth.
Recent US health care reforms incentivize improved population health outcomes and primary care functions. It remains unclear how much improving primary care physician supply can improve population ...health, independent of other health care and socioeconomic factors.
To identify primary care physician supply changes across US counties from 2005-2015 and associations between such changes and population mortality.
This epidemiological study evaluated US population data and individual-level claims data linked to mortality from 2005 to 2015 against changes in primary care and specialist physician supply from 2005 to 2015. Data from 3142 US counties, 7144 primary care service areas, and 306 hospital referral regions were used to investigate the association of primary care physician supply with changes in life expectancy and cause-specific mortality after adjustment for health care, demographic, socioeconomic, and behavioral covariates. Analysis was performed from March to July 2018.
Age-standardized life expectancy, cause-specific mortality, and restricted mean survival time.
Primary care physician supply increased from 196 014 physicians in 2005 to 204 419 in 2015. Owing to disproportionate losses of primary care physicians in some counties and population increases, the mean (SD) density of primary care physicians relative to population size decreased from 46.6 per 100 000 population (95% CI, 0.0-114.6 per 100 000 population) to 41.4 per 100 000 population (95% CI, 0.0-108.6 per 100 000 population), with greater losses in rural areas. In adjusted mixed-effects regressions, every 10 additional primary care physicians per 100 000 population was associated with a 51.5-day increase in life expectancy (95% CI, 29.5-73.5 days; 0.2% increase), whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase (95% CI, 7.0-31.3 days). A total of 10 additional primary care physicians per 100 000 population was associated with reduced cardiovascular, cancer, and respiratory mortality by 0.9% to 1.4%. Analyses at different geographic levels, using instrumental variable regressions, or at the individual level found similar benefits associated with primary care supply.
Greater primary care physician supply was associated with lower mortality, but per capita supply decreased between 2005 and 2015. Programs to explicitly direct more resources to primary care physician supply may be important for population health.
Community paramedicine in dementia care Parsons, Colby; Escobar, Christian; Jasani, Amy ...
Journal of the American Geriatrics Society (JAGS),
July 2024, Letnik:
72, Številka:
7
Journal Article
Recenzirano
Background
Novel hospital diversion strategies are needed to support a growing number of patients with dementia living in the community. One promising model is community paramedicine (CP), which ...deploys paramedics to the home, who consult with a physician to coordinate treatment and assess disposition. While evidence suggests CP can manage many patients without escalation to the emergency department (ED), no studies have evaluated optimal CP utilization for patients with dementia. Therefore, we compare the use and outcomes of CP for homebound patients with and without dementia.
Methods
This retrospective cohort study examines 251 homebound patients receiving home‐based primary care, who utilized a physician‐led CP service between March 2017 and May 2022. Linked electronic health record data included patient demographics, clinical characteristics, and CP encounter details. Dementia status and CP outcomes, including rates of ED transport, over‐transport (i.e., transported, but not hospitalized), and under‐transport (i.e., not transported, but ED visit within 3 days), were determined via chart review. Using logistic regression, we modeled the association of dementia status with over‐ and under‐transport, adjusting for age, sex, and chief complaint.
Results
Fifty‐three percent of CP patients had dementia. Their most common chief complaints were dyspnea (24.3%), altered mental status (17.9%), and generalized weakness (9.8%). We found no significant difference in ED transport rates by dementia status (25.4 vs. 22.8%, p = 0.54). Dementia diagnosis was associated with lower rates of over‐transport (OR = 0.21, p = 0.03, CI 0.05, 0.85) and comparable rates of under‐transport (OR = 0.70, p = 0.47, CI 0.27, 1.83) in adjusted models.
Conclusions
CP has effectively managed a diverse population of homebound patients with dementia cared for via home‐based primary care. Future work should examine potential cost savings and use of CP in dementia care across geographic and healthcare settings.
See related article by Kim et al. in this issue.
Abstract
Introduction
Undetected and untreated sleep disorders likely precipitate or exacerbate medical and/or psychiatric illnesses. Given this, primary care is an ideal point for managing sleep ...disorders, yet prior research shows that PCPs diagnose and/or treat sleep disorders at rates far below population prevalences. The purpose of this study was to determine the current rate of detection and treatment of sleep disorders within primary care settings.
Methods
EMR data from two health care systems was analyzed. The proportion of PCPs diagnosing and treating one or more sleep disorders was calculated (per year) for 5 years (2014-2018). Also calculated was the percent of PCP caseload diagnosed and/or treated for sleep disorders.
Results
The two systems comprised n=1021 PCPs. From 2014-2018, the proportion of PCPs diagnosing patients with sleep disorders fluctuated between 58-89%. The proportion treating sleep disorders fluctuated between 50-91%. Non-parametric one-sample run tests (SPSS) indicate these are random distributions (p>0.05). PCPs’ use of medications to treat sleep disorders is trending downward over time within one system (per linear regression, p=0.03, R-squared=0.8). Other temporal trends were not evidenced. The average percentage of diagnosed and treated patients per PCP was around 2.5% of their caseloads. Between-system differences were observed.
Conclusion
There is a profound mismatch between percentage of PCPs identifying patients with sleep disorders (60-90%) and the percentage of patient caseload diagnosed and/or treated for sleep disorders (2.5%). This suggests that the majority of PCPs are willing to assess for sleep health but do so in only a small minority of patients. These data, along with our survey data (elsewhere in this volume) suggest that the intention-action gap could be closed if PCPs were appropriately resourced.
Support
There was no funding for this study.
Abstract
Introduction
Conditions commonly managed by primary care providers (PCPs) such as depression, diabetes, and heart disease, commonly co-occur with sleep disorders. If PCPs could readily ...identify comorbid sleep disorders in this context, it may provide a pathway to more effective management of both types of disorders. Currently, it is unknown what might encourage or discourage PCPs from routinely screening their patients for sleep disorders.
Methods
PCPs from UPENN and GHS completed surveys regarding sleep health. The 30-item instrument comprised demographic, 14 VAS (0%-100%=strongly disagree-strongly agree), 4 open-ended, 3 yes/no, and 2 multiple-choice questions.
Results
Ninety-nine PCPs responded and were predominately female (61% F, 37%M, 2% other), Caucasian (81%), on-average 45yrs old (25-70) and in primary care for 16yrs (1-43). Fifty-six percent were MDs, 21%DOs, 17%PAs, and 6%NPs. PCPs rated sleep disorders as highly important for cardiopulmonary, mental, and general health (85, 84, & 83%), with no difference (per linear regression, p>0.05) according to system or provider characteristics. PCPs reported high importance for knowing about and diagnosing sleep disorders (88% & 82%) within their practices. Lower comfort levels were reported for discussing (78%) sleep disorders, overseeing/following (62%), diagnosing (60%), or treating (48%) patients. Eighty percent of PCPs stated an efficient sleep disorders screener would be useful for their practice; this perception varied (per logistic regression) according to provider credentials (Wald=0.037) and Hispanic/Latino ethnicity (Wald=0.025). PCPs reported time constraints limit their responsiveness to sleep disorders
Conclusion
A large disparity exists between the importance PCPs place on sleep disorders and their low comfort levels with following, diagnosing, and treating sleep disorders. PCPs endorsed the need to have available an efficient sleep disorders screener to use in their practice.
Support
No funding was received for this study.
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