A Project ECHO and community health worker intervention for patients with diabetes
BACKGROUND:Both community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes.We studied the effect of an intervention that combined these two approaches on glycemic control. METHODS:Patients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same EHR databases to estimate the average treatment effect. RESULTS:Among 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus post-intervention periods (p<0.001). As compared to the comparison group, the intervention was associated with a change in HbA1c of -0.2% (95% CI -0.4%-0.5%) and -0.3 (95% CI -0.5-0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percent of patients with HbA1c<8% in the late follow-up cohort (8.1%, 95%CI 2.2%-13.9%) but not the early follow-up cohort (3.6%, 95% CI -1.5%-8.7%) DISCUSSION: : The intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. While combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed.
Outcomes of Incidental Lung Nodules With Structured Recommendations and Electronic Tracking
OBJECTIVE:To evaluate the impact of structured recommendations on follow-up completion for incidental lung nodules (ILNs). METHODS:Patients with ILNs before and after implementation of structured Fleischner recommendations and electronic tracking were sampled randomly. The cohorts were compared for imaging follow-up. Multivariable logistic regression was used to assess appropriate follow-up and loss to follow-up, with independent variables including use of structured recommendations or tracking, age, gender, race, ethnicity, setting of the index test (inpatient, outpatient, emergency department), smoking history, and nodule features. RESULTS:In all, 1,301 patients met final inclusion criteria, including 255 patients before and 1,046 patients after structured recommendations or tracking. Baseline differences were found in the pre- and postintervention groups, with smaller ILNs and younger age after implementing structured recommendations. Comparing pre- versus postintervention outcomes, 40.0% (100 of 250) versus 29.5% (309 of 1,046) of patients had no follow-up despite Fleischner indications for imaging (PÂ = .002), and among the remaining patients, 56.6% (82 of 145) versus 75.0% (553 of 737) followed up on time (P < .001). Delayed follow-up was more frequent before intervention. Differences postintervention were mostly accounted for by nodules â‰¤ 8 mm in the outpatient setting (P < .001). In multivariable analysis, younger age, White race, outpatient setting, and larger nodule size showed significant association with appropriate follow-up completion (P < .015), but structured recommendations did not. Similar results applied for loss to follow-up. DISCUSSION/CONCLUSIONS:Consistent use of structured reporting is likely key to mitigate selection bias when benchmarking rates of appropriate follow-up of ILN. Emergency department patients and inpatients are at high risk of missed or delayed follow-up despite structured recommendations.
A Behavioral Economics-Electronic Health Record Module to Promote Appropriate Diabetes Management in Older Adults: Protocol for a Pragmatic Cluster Randomized Controlled Trial
BACKGROUND:The integration of behavioral economics (BE) principles and electronic health records (EHRs) using clinical decision support (CDS) tools is a novel approach to improving health outcomes. Meanwhile, the American Geriatrics Society has created the Choosing Wisely (CW) initiative to promote less aggressive glycemic targets and reduction in pharmacologic therapy in older adults with type 2 diabetes mellitus. To date, few studies have shown the effectiveness of combined BE and EHR approaches for managing chronic conditions, and none have addressed guideline-driven deprescribing specifically in type 2 diabetes. We previously conducted a pilot study aimed at promoting appropriate CW guideline adherence using BE nudges and EHRs embedded within CDS tools at 5 clinics within the New York University Langone Health (NYULH) system. The BE-EHR module intervention was tested for usability, adoption, and early effectiveness. Preliminary results suggested a modest improvement of 5.1% in CW compliance. OBJECTIVE:This paper presents the protocol for a study that will investigate the effectiveness of a BE-EHR module intervention that leverages BE nudges with EHR technology and CDS tools to reduce overtreatment of type 2 diabetes in adults aged 76 years and older, per the CW guideline. METHODS:A pragmatic, investigator-blind, cluster randomized controlled trial was designed to evaluate the BE-EHR module. A total of 66 NYULH clinics will be randomized 1:1 to receive for 18 months either (1) a 6-component BE-EHR module intervention + standard care within the NYULH EHR, or (2) standard care only. The intervention will be administered to clinicians during any patient encounter (eg, in person, telemedicine, medication refill, etc). The primary outcome will be patient-level CW compliance. Secondary outcomes will measure the frequency of intervention component firings within the NYULH EHR, and provider utilization and interaction with the BE-EHR module components. RESULTS:Study recruitment commenced on December 7, 2020, with the activation of all 6 BE-EHR components in the NYULH EHR. CONCLUSIONS:This study will test the effectiveness of a previously developed, iteratively refined, user-tested, and pilot-tested BE-EHR module aimed at providing appropriate diabetes care to elderly adults, compared to usual care via a cluster randomized controlled trial. This innovative research will be the first pragmatic randomized controlled trial to use BE principles embedded within the EHR and delivered using CDS tools to specifically promote CW guideline adherence in type 2 diabetes. The study will also collect valuable information on clinician workflow and interaction with the BE-EHR module, guiding future research in optimizing the timely delivery of BE nudges within CDS tools. This work will address the effectiveness of BE-inspired interventions in diabetes and chronic disease management. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT04181307; https://clinicaltrials.gov/ct2/show/NCT04181307. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)/UNASSIGNED:DERR1-10.2196/28723.
Advanced HeartÂ Failure Epidemiology and Outcomes: A Population-Based Study
OBJECTIVES/OBJECTIVE:The goal of this study was to evaluate the prevalence, characteristics, and outcomes of patients with advanced heart failure (HF) in a geographically defined population. BACKGROUND:Some patients with HF progress to advanced HF, characterized by debilitating HF symptoms refractory to therapy. Limited data are available on the epidemiology and outcomes of patients with advanced HF. METHODS:This was a population-based cohort study of all Olmsted County, Minnesota, adults with and without HF from 2007 to 2017. The 2018 European Society of Cardiology advanced HF diagnostic criteria were operationalized and applied to all patients with HF. Hospitalization and mortality in advanced HF, overall and according to ejection fraction (EF) type (reduced EFÂ <40% [HFrEF], mid-range EF 40%-49% [HFmrEF], and preserved EFÂ â‰¥50% [HFpEF]) were examined using Andersen-Gill and Cox models. RESULTS:Of 6,836 adults with HF, 936 (13.7%) met criteria for advanced HF. The prevalence of advanced HF increased with age and was higher in men. At advanced HF diagnosis, 396 (42.3%) patients had HFrEF, 134 (14.3%) had HFmrEF, and 406 (43.4%) had HFpEF. The median (interquartile range) time from advanced HF diagnosis to death was 12.2 months (3.7-29.9 months). The mean rate of hospitalization was 2.91 (95%Â CI: 2.78-3.06) per person-year in the first year after advanced HF diagnosis. There were no differences in risks of all-cause mortality or hospitalization by EF. Patients with advanced HFpEF were at lower risk for cardiovascular mortality compared with advanced HFrEF (HR: 0.79; 95%Â CI: 0.65-0.97). CONCLUSIONS:In this population-based study, more than one-half of patients with advanced HF had mid-range or preserved EF, and survival was poor regardless of EF.
Validation of EHR medication fill data obtained through electronic linkage with pharmacies
Hospitalizations for Chronic Disease and Acute Conditions in the Time of COVID-19
Homelessness and Medicaid Churn
Objectives/UNASSIGNED:To identify ICD-10-CM diagnostic codes associated with the social determinants of health (SDOH), determine frequency of use of the code for homelessness across time, and examine the frequency of interrupted periods of Medicaid eligibility (ie, Medicaid churn) for beneficiaries with and without this code. Design/UNASSIGNED:Retrospective data analyses of New York State (NYS) Medicaid claims data for years 2006-2017 to determine reliable indicators of SDOH hypothesized to affect Medicaid churn, and for years 2016-2017 to examine frequency of Medicaid churn among patients with and without an indicator for homelessness. Main Outcome Measures/UNASSIGNED:Any interruption in the eligibility for Medicaid insurance (Medicaid churn), assessed via client identification numbers (CIN) for continuity. Methods/UNASSIGNED:Analyses were conducted to assess the frequency of use and pattern of New York State Medicaid claims submission for SDOH codes. Analyses were conducted for Medicaid claims submitted for years 2016-2017 for Medicaid patients with and without a homeless code (ie, ICD-10-CM Z59.0) in 2017. Results/UNASSIGNED:ICD-9-CM / ICD-10-CM codes for lack of housing / homelessness demonstrated linear reliability over time (ie, for years 2006-2017) with increased usage. In 2016-2017, 22.9% of New York Medicaid patients with a homelessness code in 2017 experienced at least one interruption of Medicaid eligibility, while 18.8% of Medicaid patients without a homelessness code experienced Medicaid churn. Conclusions/UNASSIGNED:Medicaid policies would do well to take into consideration the barriers to continued enrollment for the Medicaid population. Measures ought to be enacted to reduce Medicaid churn, especially for individuals experiencing homelessness.
Implementation of a behavioral economics electronic health record (BE-EHR) module to optimize diabetes management in older adults [Meeting Abstract]
Diabetes Phenotyping Using the Electronic Health Record [Letter]
Implementation of a Behavioral Economics Electronic Health Record (BE-EHR) Module to Reduce Overtreatment of Diabetes in Older Adults
BACKGROUND:Intensive glycemic control is of unclear benefit and carries increased risk for older adults with diabetes. The American Geriatrics Society's (AGS) Choosing Wisely (CW) guideline promotes less aggressive glycemic targets and reduction in pharmacologic therapy for older adults with type II diabetes. Meanwhile, behavioral economic (BE) approaches offer promise in influencing hard-to-change behavior, and previous studies have shown the benefits of using electronic health record (EHR) technology to encourage guideline adherence. OBJECTIVE:This study aimed to develop and pilot test an intervention that leverages BE with EHR technology to promote appropriate diabetes management in older adults. DESIGN/METHODS:A pilot study within the New York University Langone Health (NYULH) EHR and Epic system to deliver BE-inspired nudges at five NYULH clinics at varying time points from July 12, 2018, through October 31, 2019. PARTICIPANTS/METHODS:Clinicians across five practices in the NYULH system whose patients were older adults (age 76 and older) with type II diabetes. INTERVENTIONS/METHODS:A BE-EHR module comprising six nudges was developed through a series of design workshops, interviews, user-testing sessions, and clinic visits. BE principles utilized in the nudges include framing, social norming, accountable justification, defaults, affirmation, and gamification. MAIN MEASURES/METHODS:Patient-level CW compliance. KEY RESULTS/RESULTS:CW compliance increased 5.1% from a 16-week interval at baseline to a 16-week interval post intervention. From February 14 to June 5, 2018 (prior to the first nudge launch in Vanguard clinics), CW compliance for 1278 patients was mean (95% CI)-16.1% (14.1%, 18.1%). From July 3 to October 22, 2019 (after BE-EHR module launch at all five clinics), CW compliance for 680 patients was 21.2% (18.1%, 24.3%). CONCLUSIONS:The BE-EHR module shows promise for promoting the AGS CW guideline and improving diabetes management in older adults. A randomized controlled trial will commence to test the effectiveness of the intervention across 66 NYULH clinics. NIH TRIAL REGISTRY NUMBER/UNASSIGNED:NCT03409523.