Preventable delays in lung cancer diagnosis arose mostly from failure to recognize documented abnormal imaging results and failure to complete key diagnostic procedures in a timely manner. Potential solutions include EHR-based strategies to improve recognition of abnormal imaging and track patients with suspected cancers.

Background-Inadequate follow-up of abnormal fecal occult blood test (FOBT) results occurs in several types of practice settings. Our institution implemented multifaceted quality improvement (QI) activities in 2004-2005 to improve follow-up of FOBT positive results. Activities addressed pre-colonoscopy referral processes and system-level factors such as electronic communication and provider education and feedback. We evaluated their effects on timeliness and appropriateness of positive FOBT follow-up and identified factors that affect colonoscopy performance.

OBJECTIVES: Electronic health records (EHR) enable transmission and tracking of referrals between primarycare practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronic referral communication in a large multispecialty VA facility. METHODS: We retrieved outpatient referrals to five subspecialties between October 2006 and December 2007, and queried the EHR to determine their status: completed, discontinued (returned to PCP), or unresolved (no action taken by subspecialist). All unresolved referrals, and random samples of discontinued and completed referrals were reviewed to determine whether subspecialists took follow-up actions (i.e., schedule appointments anytime in the future) within 30 days of referral-receipt. For referrals without timely follow-up, we determined whether inaction was supported by any predetermined justifiable reasons or associated with certain referral characteristics. We also reviewed if PCPs took the required action on returned information. RESULTS: Of 61,931 referrals, 22,535 were discontinued (36.4%), and 474 were unresolved (0.8%). We selected 412 discontinued referrals randomly for review. Of these, 52% lacked follow-up actions within 30 days. Appropriate justifications for inaction were documented in 69.8% (150/215) of those without action and included lack of prerequisite testing by the PCP and subspecialist opinion that no intervention was required despite referral. We estimated that at 30 days, 6.3% of all referrals were associated with an unexplained lack of follow-up actions by subspecialists. Conversely, 7.4% of discontinued referrals returned to PCPs were associated with an unexplained lack of follow-up. CONCLUSIONS: Although the EHR facilitates transmission of valuable information at the PCP-subspecialist interface, unexplained communication breakdowns in the referral process persist in a subset of cases.

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Background The COVID-19 pandemic caused widespread changes to healthcare, but few studies focus on ambulatory care during the early phase of the pandemic. We characterize veterans’ ambulatory care experience, specifically access and satisfaction, early in the pandemic. Methods We employed a semi-structured telephone interview to capture quantitative and qualitative data from patients scheduled with a primary care provider between March 1 – June 30, 2020. Forty veterans were randomly identified at a single large urban Veterans Health Administration (VHA) medical center. The interview guide utilized 56 closed and open-ended questions to characterize veterans’ perceptions of access to and satisfaction with their primary care experience at VHA and non-VHA primary care sources. We also explored the context of veterans' daily lives during the pandemic. We analyzed quantitative data using descriptive statistics and verbatim quotes using a matrix analysis. Results Veterans reported completing more appointments (mean 2.6 (SD 2.2)) than scheduled (mean 2.3 (SD 2.2)) mostly due to same-day or urgent visits, with a shift to telephone (mean 2.1 (SD 2.2)) and video (mean 1.5 (SD 0.6)). Among those who reported decreased access to care early in the pandemic (n = 27 (67%)), 15 (56%) cited administrative barriers (“The phone would hang up on me”) and 9 (33%) reported a lack of provider availability (“They are not reaching out like they used to”). While most veterans (n = 31 (78%)) were highly satisfied with their VHA care (mean score 8.6 (SD 2.0 on a 0–10 scale), 9 (23%) reported a decrease in satisfaction since the pandemic. The six (15%) veterans who utilized non-VHA providers during the period of interest reported, on average, higher satisfaction ratings (mean 9.5 (SD 1.2)). Many veterans reported psychosocial effects such as the worsening of mental health (n = 6 (15%)), anxiety concerning the virus (n = 12 (30%)), and social isolation (n = 8 (20%), “I stay inside and away from people”). Conclusions While the number of encounters reported suggest adequate access and satisfaction, the comments regarding barriers to care suggest that enhanced approaches may be warranted to improve and sustain veteran perceptions of adequate access to and satisfaction with primary care during times of crisis.

Background: Identification and modification of cardiovascular risk factors is paramount to reducing cardiovascular disease morbidity and mortality. Hypertension is a major risk factor for cardiovascular disease, but its association with height remains largely underrecognized. Objectives: The objective of this manuscript is to review the evidence examining the association between blood pressure and human stature and to summarize the plausible pathophysiological mechanisms behind such an association. Methods: A systematic review of adult human height and its association with hypertension and coronary artery disease was undertaken. The literature evidence is summarized and tabulated, and an overview of the pathophysiological basis for this association is presented. Results: Shorter arterial lengths found in shorter individuals may predispose to hypertension in a complex hemodynamic interplay, which is explained predominantly by summated arterial wave reflections and an elevated augmentation index. Our systemic review suggests that an inverse relationship between adult height and blood pressure exists. However, differences in the studied populations and heterogeneity in the methods applied across the various studies limit the generalizability of these findings and their clinical application. Conclusion: Physiological studies and epidemiological data suggest a potential inverse association between adult height and blood pressure. Further research is required to define the relationship more clearly between adult height and blood pressure and to assess whether antihypertensive therapeutic approaches and goals should be modified according to patients’ heights.

Background The COVID-19 pandemic caused widespread practice changes to healthcare in all settings, but little is known about veterans’ experience with primary care during the early phase of the pandemic. Objective To characterize how COVID-induced changes affected the ambulatory care experience, specifically access and satisfaction, among Veteran users of primary care at a large urban Veterans Health Administration (VHA) medical center. Design: We employed a semi-structured telephone interview consisting of 56 questions to capture quantitative and qualitative data. We randomly selected potential participants from among patients who were scheduled to see any of 31 primary care physicians between March 1 – June 30, 2020 at a single location. We evaluated quantitative data using descriptive statistics and categorized open-ended qualitative responses using a matrix analysis. Participants: The study sample of 40 veterans largely consisted of men, almost equally split between non-Hispanic Whites and African Americans. The majority (22, 55%) of the veterans were members of Priority Group 1, the VHA eligibility group that requires either a greater than 50% disability rating or deemed unemployable. Many of the veterans had other insurance coverage, including TRICARE (21, 52.5%), Medicare (8, 20%), and private insurance (5, 12.5%). Main Measures/Approach: We sought to characterize veterans’ perceptions of access to and satisfaction with their primary care experience at VHA and their non-VHA primary care source. We also explored the context of veterans' daily lives during the pandemic, knowing that many people’s mental health, relationships, and employment were impacted. Key Results: Veterans completed (mean 2.6) more appointments than scheduled (mean 2.3) due to urgent or ‘sick’ visits with a shift to virtual modalities like telephone (mean: 2.1) and video (mean: 1.5). Those who reported decreased access to care (27, 67%) as compared to before the pandemic cited administrative barriers (15, 56%) and lack of physician availability (9, 33%) as key factors. While most veterans (31, 84%) were highly satisfied with their care, 9 (24%) reported a decrease in satisfaction since the pandemic. The few veterans who utilized non-VHA physicians were slightly more satisfied with their care. None of the veterans interviewed contracted COVID-19 during the study period, but many experienced indirect psychosocial effects such as the worsening or development of mental health conditions (6, 15%), anxiety concerning the virus (12, 30%), social isolation (8, 20%). Conclusions While the quantitative data suggests continued adequate access and satisfaction, the numerous comments regarding barriers to care illustrate a disconnect between veterans’ perceived experience and the quantitative findings. Given the VHA system’s efforts to scale up virtual care and pandemic-related messaging, the comments of this sample of veterans suggest that enhanced or different approaches may be warranted to maintain perceptions of access and satisfaction with primary care during times of crisis.