Cheryl D. Stults

An evaluation of two interventions to enhance patient-physician communication using the observer OPTION5 measure of shared decision making

OBJECTIVE Evaluate interventions to enhance patient-physician communication and shared decision making (SDM). METHODS We used Observer OPTION5 to evaluate primary care visits within a cluster randomized controlled trial in a California delivery organization. Trial interventions included Open Communication (OpenComm), combining patient activation and physician coaching, and AskShareKnow, a patient activation tool, and were compared to a usual care arm. Scores were analyzed with descriptive statistics and generalized estimating equation analysis for 40 visits containing 200 decision topics. RESULTS The mean overall OPTION5 score was 26.5 out of 100 (s.d.=15.2). Compared to visits in the usual care arm, OpenComm visits had higher mean item scores (0-4 scale) for eliciting (mean=1.0 vs 0.8) and integrating patient preferences (mean=1.0 vs 0.8). OpenComm and AskShareKnow visits had higher scores for presenting options (mean=1.5, 1.5 vs 1.3). AskShareKnow visits had higher scores for discussing pros/cons (mean=1.5 vs 1.1). Lower patient education attainment was associated with lower scores. CONCLUSIONS OpenComm and AskShareKnow were associated with improved SDM relative to usual care. PRACTICE IMPLICATIONS Results suggest targeting patient and physician behaviors promotes SDM better than patient activation only. Improving SDM for less educated patients is crucial.

Using CollaboRATE, a brief patient‐reported measure of shared decision making: Results from three clinical settings in the United States

CollaboRATE is a brief patient survey focused on shared decision making. This paper aims to (i) provide insight on facilitators and challenges to implementing a real‐time patient survey and (ii) evaluate CollaboRATE scores and response rates across multiple clinical settings with varied patient populations.

Estimating the Human Resource Costs of Developing and Implementing Shared Medical Appointments in Primary Care.

We used activity-based costing to estimate the human resource costs for developing and implementing a program to support shared medical appointments (SMAs) and an additional SMA on cancer survivorship. In-depth, key informant interviews were conducted to determine completed tasks, personnel involved, and time to complete tasks. Introducing new providers or a new type of SMA may require relatively modest incremental organizational resources and provider time (<8% of time and about 15% of the finances required to start the initial SMA). Time and cost could possibly be further decreased by leveraging relevant materials from existing SMAs.

How do primary care physicians respond when patients cry during routine ambulatory visits

Abstract Although crying is universally recognized as a sign of distress in adults, its role in assessing and diagnosing depression in medical settings has received little attention. We sought to describe the interactional circumstances surrounding patients who cry during routine periodic health examinations and the subsequent actions of their physicians. Qualitative content analysis of audio-recorded visits and administrative claims data for adult primary care patients for one year before and after an index visit were used to explore the context of patients’ crying and how physicians responded. Most patients began to cry while discussing emotional pain over the loss or illness of a loved one. While physicians generally responded with immediate expressions of empathy, the intensity of their responses varied. Some patients received minimal assessment regarding their mental health, whereas others were assessed more extensively. Although most physicians did express empathy in response to patients’ tears, some did not systematically assess patients’ mental health status and overall functioning. Physicians may want to view crying as a sign of distress and more fully evaluate whether it fits into a more complex clinical presentation of depression.

CA7-05: Transforming Primary Care in 3 NCQA-Certified PCMHs

Background/Aims Hopes are high for revitalizing primary care through transformation to a Patient- Centered Medical Home (PCMH) model. This model has been implemented in some capitated integrated delivery systems, but the transferability of PCMH to practices with a mixture of fee-for- service (FFS) and capitation contracts is uncertain. This study documents and analyzes how a transformation into a PCMH was achieved in a largely FFS multispecialty group practice in Northern California which has 30 clinics in three geographically distinct divisions. Division A was certified by NCQA at level 3 PCMH, Divisions B and C at level 2 PCMH. Methods Multi-method case study includes qualitative data from semi-structured key informant interviews and quantitative data from medical records and administrative sources in 2005–2010. Key informants were purposefully sampled to capture experiences in all divisions and included executives, frontline physicians, nurse, health educators and medical assistants. We report on the interviews that were audio recorded, transcribed and analyzed thematically. We also present some initial quantitative findings on the association between the levels of NCQA PCMH certification and measures of process and outcomes of care. Results Thirty-three key informant interviews have been completed to date. Four emerging themes are: quality improvement efforts and responses to local market pressures pre-dated the national focus on PCMH; successful implementation of some PCMH components occurred in a top-down fashion with physician champions; dominant business line (FFS) presents disincentive for some PCMH components; and organizational culture differences may affect how well certain initiatives are taken up and sustained. EHR data reveal that the level 3 PCMH division had the shortest wait time to a 3rd next available appointment for a longer visit (i.e., improved access), the highest proportion of patients with diabetes having their HbA1c measured every 6 months (improved process) and the highest proportion of patients with diabetes with their blood pressure under control (130/80) (improved outcomes). Discussion We conclude that implementation of many PCMH components pre-dated the national focus on PCMH. Successfully implemented elements had organizational champions in practice cultures supportive of innovations. Some clinical process and outcome performance are consistent with the level of NCQA certification.

Patient Experiences in Selecting a Medicare Part D Prescription Drug Plan

Introduction: Medicare beneficiaries often report that the process of choosing a prescription drug plan is frustrating and confusing and many do not enroll in the plan that covers their drugs at the lowest cost. Methods: We conducted 4 focus groups to understand beneficiaries’ experiences in selecting a drug plan to identify what resources and factors were most important to them. Participants were patients served by a multispecialty delivery system and were primarily affluent and Caucasian. Results: While low cost was essential to many, other characteristics like having the same plan as a partner, company reputation, convenience, and anticipation of possible future health problems were sometimes more important. Although some used resources including insurance brokers, counselors, and websites beyond Medicare.gov, many expressed a desire for greater assistance with and greater simplicity in the choice process. Conclusion: Although older adults would likely benefit from greater assistance in choosing Medicare Part D prescription drug plans, more research is necessary to understand how to help with decision-making in this context.

Comparative Usability Study of a Newly Created Patient-Centered Tool and Medicare.gov Plan Finder to Help Medicare Beneficiaries Choose Prescription Drug Plans:

Introduction: In response to reported difficulties in selecting a Medicare Part D prescription drug plan, we designed a patient-centered online Part D plan selection tool (CHOICE1.0) to simplify the selection process and to provide personalized, expert recommendations. Methods: This ethnographic comparative usability study observed 44 patients using the first version of the tool during Medicare 2016 Open Enrollment. Participants were observed as they chose their drug plan using Medicare.gov and 1 of 3 versions of CHOICE1.0 that varied in amount of expert guidance. Descriptive statistics were used to analyze exit survey data. The observations were video-recorded, and field notes were analyzed thematically. Results: Participants were significantly more satisfied with CHOICE1.0 for choosing a plan, understanding information, and ease of use compared to Medicare.gov. Those using expert versions of CHOICE1.0 were more likely to indicate their intention to switch plans than those using Medicare.gov, though they wanted to know the source and content. Conclusion: The more patient-centered prescription drug choice tool improved user experience and enabled users to choose plans more consistent with expert recommendations.

Estimating the Human Resource Costs of Developing and Implementing Shared Medical Appointments in Primary Care

We used activity-based costing to estimate the human resource costs for developing and implementing a program to support shared medical appointments (SMAs) and an additional SMA on cancer survivorship. In-depth, key informant interviews were conducted to determine completed tasks, personnel involved, and time to complete tasks. Introducing new providers or a new type of SMA may require relatively modest incremental organizational resources and provider time (<8% of time and about 15% of the finances required to start the initial SMA). Time and cost could possibly be further decreased by leveraging relevant materials from existing SMAs.

D4-4: Shared Medical Appointments: A Promising Innovation to Improve Patient-Physician Relationship and Ease Primary Care Shortage

Background/Aims Shared medical appointments (SMAs) or group visits have been touted as a primary care system change to overcome the challenges of short visits, underused self-management education, and to relieve physician shortage. However, few studies have examined SMAs from the patient’s perspective. Using data collected through focus groups, we present the thoughts and experiences of patients participating in SMAs. Methods We conducted five focus groups with participants who had attended SMAs at a large, non-profit, multispecialty group practice in northern California which serves four counties and more than 700,000 patients. Focus groups were recorded, transcribed, and thematically coded according to study aims. Transcripts were coded at the paragraph level. Disagreements in coding were discussed until consensus was reached. Results Similar themes emerged across the focus groups. Patients expressed many benefits to SMAs including enhanced learning by being able to cover more information than what would be provided in a traditional visit, increased motivation for health behavior change, and were able to connect with others in a similar situation. Patients also felt that the SMA altered their relationship with their physician. Patients now saw the more “human” side to their physician which placed them at ease for future visits. Overall, the power dynamic between patient and physician was lessened as the patient now viewed themselves as being able to impart information to the physician. Conclusions Given the upcoming Affordable Care Act and existing primary care shortage, SMAs provide a way for patients to improve access, relationships with physicians, and an increased knowledge of health, but also to help ease patient load for physicians. Thus, SMAs are an innovative form of delivery that can improve efficiencies and better use the scare resource of primary care physicians.

PS2-24: 60 Seconds or Less: Factors Influencing the Likelihood of a Mental Health Discussion During Periodic Health Exams

Background/Aims The majority of patients with mental health concerns turn to their primary care physician (PCP). We investigate whether periodic health exams (PHEs) may be a good opportunity for these patients to receive mental health services. We examine the impact of patients’ need for mental health care, competing demands from biomedical issues, and the availability of behavioral health providers on the probability of discussing mental health. Methods The study uses audio recordings of 308 unique patients’ PHEs with 59 PCPs. Visits took place in 22 clinics of an integrated delivery system in metropolitan Detroit between 2007–2009. Administrative data and electronic medical records spanning 12-months before the PHE are also used. Patients are aged 50 to 80; all were deemed to be potentially in need of mental health services because of their Personal Health Questionnaire (PHQ2) score, prior diagnosis of mental illnesses, use of behavioral health services, or psychotropic medication use. We coded the audio to capture visit contents and time spent on each “topic” (defined as an issue that had at least two complete exchanges between patient and physician). We examined the probability of a mental health discussion using a logit generalized estimating equation (GEE) regression. Results The median length of patient-physician interaction was 26 minutes. The median number of “topics” was 19. Biomedical discussions were present in all visits; 38% (118 of 308) of the visits included a mental health discussion. The median length of a mental health discussion was 47 seconds. Logit results suggest the likelihood of mental health discussion increased if the patient had a PHQ2 =3 (odds ratio [OR]=5.30, p<0.01), was on psychotropic medication (OR=2.47, p<0.05), had a mental health diagnosis in prior year (OR=2.52, p<0.05), and was female (OR=1.88, p<0.05). The likelihood decreased if the clinic has co-located behavioral health (OR=0.47, p<0.05). Percent time spent on biomedical issues did not significantly impact the probability of a mental health discussion. Conclusions Many discussions occurred during PHEs with patients potentially needing mental health care. Only 38% (118 of 308) of all visits contained mental health discussions, and in those that did more than half lasted less than a minute.