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BACKGROUND: No-shows, or missed appointments, are a problem for many medical practices. They result in fragmented care and reduce access for all patients. OBJECTIVE: To determine whether telephone reminder calls targeted to patients at high risk of no-show can reduce no-show rates. DESIGN: Single-center randomized controlled trial. PARTICIPANTS: A total of 2247 primary care patients in a hospital-based primary care clinic at high risk of no-show (>15 % risk) for their appointment in 7 days. INTERVENTION: Seven days prior to their appointment, intervention arm patients were placed in a calling queue to receive a reminder phone call from a patient service coordinator. Coordinators were trained to engage patients in concrete planning. All patients received an automated phone call (usual care). MAIN MEASURES: Primary outcome was no-show rate. Secondary outcomes included arrival rate, cancellation rate, reschedule rate, time to cancellation, and change in revenue. KEY RESULTS: The no-show rate in the intervention arm (22.8 %) was significantly lower (absolute risk difference −6.4 %, p < 0.01, 95 % CI [−9.8 to −3.0 %]) than that in the control arm (29.2 %). Arrival, cancellation, and reschedule rates did not differ significantly. In the intervention arm, rescheduling and cancellations occurred further in advance of the appointment (mean difference, 0.35 days; 95 % CI [0.07-0.64]; p = 0.01). Reimbursement did not differ significantly. CONCLUSIONS: A phone call 7 days prior to an appointment led to a significant reduction in no-shows and increased reimbursement among patients at high risk of noshow. The use of targeted interventions may be of interest to practices taking on increased accountability for population health.KEY WORDS: access to care; applied informatics; primary care redesign; behavior change; population health.

BACKGROUND: A better understanding of the attributes of patients who require more effort to manage may improve risk adjustment approaches and lead to more efficient resource allocation, improved patient care and health outcomes, and reduced burnout in primary care clinicians. OBJECTIVE: To identify and characterize high-effort patients from the physician's perspective. DESIGN: Cohort study. PARTICIPANTS: Ninety-nine primary care physicians in an academic primary care network. MAIN MEASURES: From a list of 100 randomly selected patients in their panels, PCPs identified patients who required a high level of team-based effort and patients they considered complex. For high-effort patients, PCPs indicated which factors influenced their decision: medical/ care coordination, behavioral health, and/or socioeconomic factors. We examined differences in patient characteristics based on PCP-defined effort and complexity. KEY RESULTS: Among 9594 eligible patients, PCPs classified 2277 (23.7 %) as high-effort and 2676 (27.9 %) as complex. Behavioral health issues were the major driver of effort in younger patients, while medical/care coordination issues predominated in older patients. Compared to low-effort patients, high-effort patients were significantly (P < 0.01 for all) more likely to have higher rates of medical (e.g. 23.2 % vs. 6.3 % for diabetes) and behavioral health problems (e.g. 9.8 % vs. 2.9 % for substance use disorder), more frequent primary care visits (10.9 vs. 6.0 visits), and higher acute care utilization rates (25.8 % vs. 7.7 % for emergency department [ED] visits and 15.0 % vs. 3.9 % for hospitalization). Almost one in five (18 %) patients who were considered high-effort were not deemed complex by the same PCPs. CONCLUSIONS: Patients defined as high-effort by their primary care physicians, not all of whom were medically complex, appear to have a high burden of psychosocial issues that may not be accounted for in current chronic disease-focused risk adjustment approaches.KEY WORDS: primary care redesign; psychosocial; health services research; resource allocation; risk adjustment.

Internet sites could be enhanced for early detection and referral. The internet has become an important factor in clinical practice and physicians are increasingly explaining or responding to the information that their patients find on the internet. Our study shows that the information available to individuals with undiagnosed RA and SLE is likely to be of little help to them and could delay their seeking appropriate attention.

Identifying persons with early rheumatoid arthritis (RA) is a major challenge. The role of the Internet in making decisions about seeking care has not been studied. We developed a method for early diagnosis and referral using the Arthritis Foundation's website. A person with less than 3 months of joint pain symptom who has not yet sought medical attention was screened. Prescreened persons are linked to a self-scoring questionnaire and get a "likelihood" of RA statement. If "likely," the person is offered a free evaluation and biomarker testing performed by Quest Diagnostics. The system available only to Massachusetts's residents yielded a small steady flow of screen-positive individuals. Over 21 months, 43,244 persons took the Arthritis Foundation website prescreening questionnaire; 196 were from Massachusetts and 60 took the self-scoring algorithm. Of the 48 who screened positive, 29 set up an appointment for a free evaluation, but six never came in. Twenty-four subjects were evaluated and diagnosed independently by three rheumatologists. One met the 1987 American College of Rheumatology (ACR) criteria for RA and two met the 2010 ACR/EULAR RA criteria. The 24 examined individuals were contacted at a minimum of 1 year and asked to redo the case-finding questionnaire and asked about their health resource utilization during the interval. Seventeen of the 24 subjects responded, and 10 had seen a health professional. Three of the 17 had a diagnosis of RA; all were on at least methotrexate. Internet case finding was useful in identifying new potential RA cases. The system's performance characteristics are theoretically limited only by the number of study sites available. However, the major barrier may be that seeing a health professional is not a priority for many individuals with early symptoms.

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BACKGROUND/OBJECTIVES Trauma survivors with chronic post‐traumatic stress disorder (PTSD) have been found to have cognitive impairment. But little is known about these outcomes among Latino and Asians who comprise more than 80% of the U.S. immigrant population. They also experience disparities in PTSD and dementia care albeit increased exposure to trauma. This study aimed to (1) examine the association between trauma exposures and PTSD with cognitive impairment in a sample of Latino and Asian older adults; and (2) assess whether sleep quality attenuated the PTSD‐cognitive impairment association. DESIGN Cross‐sectional secondary analysis of baseline data from the Positive Minds‐Strong Bodies randomized controlled trial on disability prevention. SETTING Community‐based organizations serving minority or immigrant older adults in Massachusetts, New York, Florida, or Puerto Rico. PARTICIPANTS Hispanic/Latino and Asian/Pacific Islander adults aged 60 or older eligible per randomized controlled trial screening for elevated mood symptoms and minor‐to‐moderate physical dysfunction (n = 134 and n = 86, respectively). MEASUREMENTS Neuropsychiatric measures were cognitive impairment (Mini Montreal Cognitive Assessment (MoCA)), PTSD (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual‐5), trauma exposure (Brief Trauma Questionnaire), depression (Patient Health Questionnaire‐9), generalized anxiety (Generalized Anxiety Disorder Scale‐7), and daytime sleepiness (Epworth Sleepiness Scale). RESULTS Mean age was 72.8 years and 77.5 years for the Latino and Asian groups, respectively. The Asian group was 100% immigrant, whereas 70.2% (n = 92) of the Latino group was foreign‐born. In unadjusted models, higher Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual‐5 scores were associated with decreased odds of normal cognitive functioning (MoCA ≥25) in the Asian group (odds ratio (95% confidence interval) = .93 (.87, .99)), but not the Latino group (odds ratio (95% confidence interval) = .99 (.95, 1.05)). This association remained significant after adjusting for covariates. Daytime sleepiness did not moderate the association between PTSD and cognitive functioning in the Asian group. CONCLUSION Higher PTSD symptoms were associated with cognitive impairment in Asian, but not Latino, older adults. Clinicians serving older Asians should integrate trauma and cognitive screening to ensure this growing, underserved population receives appropriate evidence‐based treatments.