Faculty Bibliography

This study reports the first assessment of published comments in the family medicine literature using structured codes, which produced commentary annotations that will be the foundation of a knowledge base of appraisals of family medicine trials. Evidence appraisal occurs in a variety of formats and serves to shed light on the quality of research. However, scientific discourse generally and evidence appraisal in particular has not itself been analyzed for insights. A search strategy was devised to identify all journal comments indexed in PubMed linked to controlled intervention studies published in a recent 15-year period in major family medicine journals. A previously developed structured representation in the form of a list of appraisal concepts was used to formally annotate and categorize the journal comments through an iterative process. Trends in family medicine evidence appraisal were then analyzed. A total of 93 comments on studies from five journals over 15 years were included in the analysis. Two thirds of extracted appraisals were negative criticisms. All appraisals of measurement instruments were negative (100%). The participants baseline characteristics, the author discussions, and the design of the interventions were also criticized (respectively 91.7%, 84.6% and 83.3% negative). In contrast, appraisals of the scientific basis of the studies were positive (81.8%). The categories with the most appraisals were, most generally, those focused on the study design, and most specifically, those focused on the scientific basis. This study provides a new data-driven approach to review scientific discourse regarding the strengths and limitations of research within academic family medicine. This methodology can potentially generalize to other medical domains. Structured appraisal data generated here will enable future clinical, scientific, and policy decision-making and broader meta-research in family medicine.

BACKGROUND:Topical corticosteroids are available in many vehicles. However, patients' preference for vehicles are variable and could be tailored to maximize patient adherence. Spray vehicles may offer, convenience, and strong efficacy. METHODS:A literature review was conducted using keywords: clobetasol, desoximetasone, betamethasone, triamcinolone, corticosteroid, topical, spray, vehicles, treatment, and clinical trial. RESULTS:For moderate-to-severe plaque psoriasis, 87% of subjects achieved an Overall Disease Severity (ODS) Score ≤2 at week two and 78% achieved an ODS ≤1 after four weeks with clobetasol propionate (CP) 0.05% spray compared to 17% and 3% in the control group, respectively (P<0.001). For desoximetasone 0.25% spray, 31%-53% with moderate-to-severe psoriasis achieve Physician's Global Assessment (PGA) score ≤1 at day 28 versus 5%-18% in the vehicle spray group (P<0.01). For betamethasone dipropionate 0.05% spray, 19% with mild-to-moderate plaque psoriasis achieved an Investigator's Global Assessment (IGA) score ≤1 or a 2-grade reduction in IGA versus 2.3% in vehicle group (P≤0.001). For mild-to-severe steroid responsive inflammatory dermatoses, 64% using triamcinolone acetonide 0.2% spray achieved clear or almost clear skin at day 14 (no P value reported). Adverse events including burning, irritation, and dryness were similar across all corticosteroids.

Recent scholarship suggests that the genomes of those around us affect our own phenotypes. Much of the empirical evidence for such "metagenomic" effects comes from animal studies, where the socio-genetic environment can be easily manipulated. Among humans, it is more difficult to identify such effects given the nonrandom distribution of genes and environments. Here we leverage the as-if-random distribution of grade-mates' genomes conditional on school-level variation in a nationally representative sample. Specifically, we evaluate whether one's peers' genetic propensity to smoke affects one's own smoking behavior net of one's own genotype. Results show that peer genetic propensity to smoke has a substantial effect on an individual's smoking outcome. This is true not only when the peer group includes direct friends, and therefore where the individual plays an active role in shaping the metagenomic context but also when the peer group includes all grade-mates and thus in cases where the individual does not select the metagenomic environment. We explore these effects further and show that a small minority with high genetic risk to smoke ('bad apples') can greatly affect the smoking behavior of an entire grade. The methodology used in this paper offers a potential solution to many of the challenges inherent in estimating peer effects in nonexperimental settings and can be utilized to study a wide range of outcomes with a genetic basis. On a policy level, our results suggest that efforts to reduce adolescent smoking should take into account metagenomic effects, especially bad apples, within social networks.

BACKGROUND:Mineralocorticoid receptor antagonists (MRA) are an underutilized therapy for heart failure with a reduced ejection fraction (HFrEF), but the current impact of hospitalization on MRA use is not well characterized. The objective of this study was to describe contemporary MRA prescription for heart failure patients before and after the full scope of hospitalizations and the association between MRA discharge prescription and post-hospitalization outcomes. METHODS:We conducted a retrospective cohort study at an academic hospital system in 2013-2016. Among 1500 included hospitalizations of 1009 unique patients with HFrEF and without MRA contraindication, the mean age was 71.9 ± 13.6 years and 443 (29.5%) were female. We compared MRA prescription before and after hospitalizations with McNemar's test and between patients with principal and secondary diagnoses of HFrEF with the chi-square test, and association of MRA discharge prescription with 30-day and 180-day mortality and readmissions using generalized estimating equations. RESULTS:MRA prescriptions increased from 303 (20.2%) to 375 (25.0%) at discharge (+4.8%, p < 0.0001). More patients with principal diagnosis of HFrEF compared to those hospitalized for other reasons received MRA (34.9% versus 21.3%, p < 0.0001) and had them initiated (21.8% versus 9.7%, p < 0.0001). MRA prescription at discharge was not associated with mortality or readmission at 30 and 180 days, and there was no interaction with principal/secondary diagnosis. CONCLUSIONS:Among hospitalized HFrEF patients, 75% did not receive MRA before or after hospitalization, and nearly 90% of eligible patients did not have MRA initiated. As we found no signal for short-term harm after discharge, hospitalization may represent an opportunity to initiate guideline-directed heart failure therapy.

BACKGROUND:Increasingly, patients with limited English proficiency are accessing home health care services in the United States. Few studies have examined how language barriers influence provider role implementation or workload in the home health care setting. OBJECTIVES/OBJECTIVE:To explore home health care professionals' perspectives about how workload changes from managing language barriers influence quality and safety in home health care. DESIGN/METHODS:A qualitative secondary data analysis using a summative content analysis approach was used to analyze existing semi-structured interview data. SETTING/METHODS:A large urban home health care agency located on the East Coast of the United States. PARTICIPANTS/METHODS:Thirty five home health care providers [31 registered nurses, 3 physical therapists, 1 occupational therapist]. RESULTS:A total of 142 discrete incidents emerged from the analysis. Overall, home health care providers experienced distinct shifts in how they implemented their roles that added to their workload and time spent with Limited English Proficiency patients and family members. Providers were concerned about interpretation accuracy and perceived it as potentially posing risks to patient safety. Changes in work patterns, therefore, sought to maximize patient safety. CONCLUSIONS:Home health care providers decision-making about how they adapt practice when faced with a language barrier is a sequence of actions based on awareness of the patient's language preference and if they spoke another language. Subsequent choices showed proactive behaviors to manage increased workload shaped by their perceived risk of the threats posed by the quality of interpreter services. Future research should develop quantitative models examining differences in workload when caring for limited English proficiency versus English speaking patients as well as the relationship between visit length and patient outcomes to determine optimal quality models.

BACKGROUND:Hepatitis C virus (HCV) is a major public health problem in correctional settings. HCV treatment is often not possible in U.S. jails due to short lengths of stay. Linkage to care is crucial in these settings, but competing priorities complicate community healthcare engagement and retention after incarceration. METHODS:We conducted a single arm clinical trial of a combined transitional care coordination (TCC) and patient navigation intervention and assessed the linkage rate and factors associated with linkage to HCV care after incarceration. RESULTS:During the intervention, 84 participants returned to the community after their index incarceration. Most participants were male and Hispanic, with a history of mental illness and a mean age of 45 years. Of those who returned to the community, 26 (31%) linked to HCV care within a median of 20.5 days; 17 (20%) initiated HCV treatment, 15 (18%) completed treatment, 9 (11%) had a follow-up lab drawn to confirm sustained virologic response (SVR), and 7 (8%) had a documented SVR. Among those with follow-up labs the known SVR rate was (7/9) 78%. Expressing a preference to be linked to the participant's existing health system, being on methadone prior to incarceration, and feeling that family or a loved one were concerned about the participant's wellbeing were associated with linkage to HCV care. Reporting drinking alcohol to intoxication prior to incarceration was negatively associated with linkage to HCV care. CONCLUSION/CONCLUSIONS:We demonstrate that an integrated strategy with combined TCC and patient navigation may be effective in achieving timely linkage to HCV care. Additional multicomponent interventions aimed at treatment of substance use disorders and increasing social support could lead to further improvement. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov NCT04036760 July 30th, 2019 (retrospectively registered).

IMPORTANCE:Many believe a major cause of the epidemic of clinician burnout is poorly designed electronic health records (EHRs). OBJECTIVES:To determine which EHR design and use factors are associated with clinician stress and burnout and to identify other sources that contribute to this problem. DESIGN, SETTING, AND PARTICIPANTS:This survey study of 282 ambulatory primary care and subspecialty clinicians from 3 institutions measured stress and burnout, opinions on EHR design and use factors, and helpful coping strategies. Linear and logistic regressions were used to estimate associations of work conditions with stress on a continuous scale and burnout as a binary outcome from an ordered categorical scale. The survey was conducted between August 2016 and July 2017, with data analyzed from January 2019 to May 2019. MAIN OUTCOMES AND MEASURES:Clinician stress and burnout as measured with validated questions, the EHR design and use factors identified by clinicians as most associated with stress and burnout, and measures of clinician working conditions. RESULTS:Of 640 clinicians, 282 (44.1%) responded. Of these, 241 (85.5%) were physicians, 160 (56.7%) were women, and 193 (68.4%) worked in primary care. The most prevalent concerns about EHR design and use were excessive data entry requirements (245 [86.9%]), long cut-and-pasted notes (212 [75.2%]), inaccessibility of information from multiple institutions (206 [73.1%]), notes geared toward billing (206 [73.1%]), interference with work-life balance (178 [63.1%]), and problems with posture (144 [51.1%]) and pain (134 [47.5%]) attributed to the use of EHRs. Overall, EHR design and use factors accounted for 12.5% of variance in measures of stress and 6.8% of variance in measures of burnout. Work conditions, including EHR use and design factors, accounted for 58.1% of variance in stress; key work conditions were office atmospheres (β̂ = 1.26; P < .001), control of workload (for optimal control: β̂ = -7.86; P < .001), and physical symptoms attributed to EHR use (β̂ = 1.29; P < .001). Work conditions accounted for 36.2% of variance in burnout, where challenges included chaos (adjusted odds ratio, 1.39; 95% CI, 1.10-1.75; P = .006) and physical symptoms perceived to be from EHR use (adjusted odds ratio, 2.01; 95% CI, 1.48-2.74; P < .001). Coping strategies were associated with only 2.4% of the variability in stress and 1.7% of the variability in burnout. CONCLUSIONS AND RELEVANCE:Although EHR design and use factors are associated with clinician stress and burnout, other challenges, such as chaotic clinic atmospheres and workload control, explain considerably more of the variance in these adverse clinician outcomes.

AIMS/OBJECTIVE:To conduct a needs assessment of public hospitals in Mexico to determine workforce specific capacity building needs in the care of older people. BACKGROUND:The older population in Mexico is growing rapidly. The healthcare system and workforce may not be prepared to handle the needs of older people, especially those with chronic illnesses who are also disadvantaged socioeconomically. Determining workforce and system needs is important to strategically develop capacity. METHODS:A needs assessment using a pragmatic qualitative approach structured this study. Semi-structured interviews and focus groups were conducted with healthcare professionals at five public hospitals in Mexico. Directed content analysis techniques analysed the data. RESULTS:Ninety-two healthcare professionals participated in the study. Three themes emerged, including geriatric service delivery, social changes and human resources for health. Participants reported a lack of gerontology knowledge and related clinical skills deficits to provide care for hospitalised elders and expressed emotional distress related to the lack of resources in their institutions. All healthcare professionals expressed strong concern at the social toll the ageing population had on families. The support of government organisations emerged as a facilitator for adoption of geriatric care principles. CONCLUSIONS:This qualitative study uncovered important data to inform the implementation of quality improvement and capacity building models for older people care in Mexico. There appears to be strong potential for a culturally appropriate translation of high-income country older people care models within the Mexican healthcare context. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:Findings suggests there is a need to increase geriatric capacity building among helathcare professionals in Mexico. This will be an important step in improving care for hospitalised older people.