Michael D. Reis

Electronic health record-based surveillance of diagnostic errors in primary care

Background Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice. Methods The authors conducted a retrospective study of primary care visit records ‘triggered’ through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician–reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer. Results Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44)). Conclusions While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.

Patient preferences and physician practices for laboratory test results notification.

Introduction: This study assessed patient preferences and physician practices for laboratory test results notification in ambulatory care. Methods: Patients aged 18 years or older (n = 728) who were scheduled to see their primary care physician at 5 clinics were offered the opportunity to participate in an anonymous survey during their clinic visit. Their primary care physicians were also invited to participate in a separate online survey. Questions on both surveys included the current method of laboratory test results notification and satisfaction with the method. Results: The majority of patients reported satisfaction with the current method of notification of normal results—the US mail—which was also the preferred method for notification of normal test results by both patients and physicians. Direct phone contact by the physician was the preferred method for notification of abnormal results by both patients (64%) and physicians (41%). Patients’ preferred method of notification of normal results significantly agreed with the current method (P < .0001), whereas that of abnormal results did not (P = .52). Conclusions: Our findings indicate that patients and physicians both prefer the US mail for notification of normal laboratory test results and a direct phone call by the physician for notification of abnormal results.

Incorporating PDA Use in Diabetes Self-Care: A Central Texas Primary Care Research Network (CenTexNet) Study

Introduction: We investigated the feasibility of incorporating the use of the personal digital assistant (PDA) in diabetes self-care in primary care. Methods: Adults with type 2 diabetes whose last measured HbA1c value was 8.0% or greater were recruited from 4 family practice clinics. A trained research assistant provided one-on-one training on the use of a loaned PDA preinstalled with Diabetes Pilot software. Results: Of 550 potential subjects invited for participation, only 98 (17.8%) called to schedule an orientation visit. However, 18 were never contacted when the recruitment goal was reached. Of the remaining 80 respondents, 43 (53.8%) met all study inclusion criteria. Participants’ mean age was 55.2 years (SD = 10.1). The majority were female (62.8%) and white (62.8%), 83.7% had at least some college education, and most reported an income of

Influenza Antiviral Prescribing for Outpatients With an Acute Respiratory Illness and at High Risk for Influenza-Associated Complications During 5 Influenza Seasons—United States, 2011–2016

30,000 to

Influenza Vaccine Effectiveness in the United States During the 2016–2017 Season

69,999. The mean baseline HbA1c was 10.0% (SD = 1.5). Major challenges of concern to the practicing family physician included few subjects agreeing to participate even though it was free, subjects who agreed to participate being generally different from those who decided not to participate, some PDAs not returned, and the relatively high cost of the intervention. Conclusions: Attempts to incorporate PDA use in diabetes self-care may be significantly challenging, although feasible. We identified several challenges and suggest strategies to overcome them.

Building a Patient-Centered Medical Home in an Integrated Healthcare System: A Survey of Patient Preferences and Needs

Background Influenza causes millions of illnesses annually; certain groups are at higher risk for complications. Early antiviral treatment can reduce the risk of complications and is recommended for outpatients at increased risk. We describe antiviral prescribing among high-risk outpatients for 5 influenza seasons and explore factors that may influence prescribing. Methods We analyzed antiviral prescription and clinical data for high-risk outpatients aged ≥6 months with an acute respiratory illness (ARI) and enrolled in the US Influenza Vaccine Effectiveness Network during the 2011-2012 through 2015-2016 influenza seasons. We obtained clinical information from interviews and electronic medical records and tested all enrollees for influenza with real-time reverse-transcription polymerase chain reaction (rRT-PCR). We calculated the number of patients with ARI that must be treated to treat 1 patient with influenza. Results Among high-risk outpatients with ARI who presented to care within 2 days of symptom onset (early), 15% (718/4861) were prescribed an antiviral medication, including 472 of 1292 (37%) of those with rRT-PCR-confirmed influenza. Forty percent of high-risk outpatients with influenza presented to care early. Earlier presentation was associated with antiviral treatment (odds ratio [OR], 4.1; 95% confidence interval [CI], 3.5-4.8), as was fever (OR, 3.2; 95% CI, 2.7-3.8), although 25% of high-risk outpatients with influenza were afebrile. Empiric treatment of 4 high-risk outpatients with ARI was needed to treat 1 patient with influenza. Conclusions Influenza antiviral medications were infrequently prescribed for high-risk outpatients with ARI who would benefit most. Efforts to increase appropriate antiviral prescribing are needed to reduce influenza-associated complications.

Types and Origins of Diagnostic Errors in Primary Care Settings

BACKGROUND In recent influenza seasons, the effectiveness of inactivated influenza vaccines against circulating A(H3N2) virus has been lower than against A(H1N1)pdm09 and B viruses, even when circulating viruses remained antigenically similar to vaccine components. METHODS During the 2016-2017 influenza season, vaccine effectiveness (VE) across age groups and vaccine types was examined among outpatients with acute respiratory illness at 5 US sites using a test-negative design that compared the odds of vaccination among reverse transcription polymerase chain reaction-confirmed influenza positives and negatives. RESULTS Among 7083 enrollees, 1342 (19%) tested positive for influenza A(H3N2), 648 (9%) were positive for influenza B (including B/Yamagata, n = 577), and 5040 (71%) were influenza negative. Vaccine effectiveness was 40% (95% confidence interval [CI], 32% to 46%) against any influenza virus, 33% (95% CI, 23% to 41%) against influenza A(H3N2) viruses, and 53% (95% CI, 43% to 61%) against influenza B viruses. CONCLUSIONS The 2016-2017 influenza vaccines provided moderate protection against any influenza among outpatients but were less protective against influenza A(H3N2) viruses than B viruses. Approaches to improving effectiveness against A(H3N2) viruses are needed.

Improving diabetes self-care with a PDA in ambulatory care.

Background:While the transformation of a primary care practice into a patient-centered medical home (PCMH) has the potential to improve care, there is a dearth of data on patient perspectives. This study was conducted to assess patients’ opinions related to current patient-centeredness, focusing on aspects of coordinated care, communication, accessibility, and management of care. Methods:A cross-sectional survey of English-speaking patients aged >18 years who had a scheduled appointment to see a primary care provider (PCP) at four Baylor Scott & White Health (BSWH) primary care clinics was conducted. The survey instrument included Likert-scale questions based on 5-item choices and data analysis focused on descriptive statistics. The study was approved by the BSWH Institutional Review Board. Results:Of 316 patients approached, 204 (64.6%) returned completed surveys. Their mean age was 47.4 years (SD=16.0; range 18-89) and they were predominantly white (84.4%), female (67.0%), employed (60.2%), and married (57.0%). More than half had at least some college education. Most of the positive responses pertained to patient-provider communication (e.g., provider and staff treating patient with courtesy and respect; provider and staff listening to patient’s questions and answering them directly) and management of patient healthcare (e.g., patient thinking it is important to be proactive in their own healthcare; patient belief in playing an active role in their healthcare). Conclusions:A PCMH model appears to be an attainable goal that can better meet the needs of our patients in the ambulatory setting of our integrative healthcare system. Our patient sample endorsed survey items related to satisfactory patient-provider communication as well as those related to quality of participation in their treatment planning and self-management, concepts compatible with the tenants of the PCMH model. In addition, the study suggests that eliciting patient opinions can provide guidance for the initial planning and execution of PCMHs specific to a patient population.