We conducted a qualitative study to elicit attitudes, attributions, and self-efficacy related to diabetes self-care in both English- and Spanish-speaking Hispanic men. Transcripts from six focus groups (three in English and three in Spanish) were reviewed by the authors to extract principal and secondary themes. Participants could describe their medication and lifestyle regimens and were aware of whether they were adherent or nonadherent to physician recommendations. Lack of skills on how to incorporate diet and regular physical activity into daily living, lack of will power, and reluctance to change culturally rooted behaviors emerged as significant barriers to diabetes self-management. Medication adherence is for some men the principal diabetes self-care behavior. Nonadherence appeared to fit two profiles: 1) intentional, and 2) nonintentional. In both instances low self-efficacy emerged as a significant influence on attainment and maintenance of diabetes self-care goals. Participants also expressed a strong sense of fatalism regarding the course of their disease, and seemed to have little motivation to attempt long-term dietary control. Educational and counseling messages should stress that a diagnosis of diabetes is not a death sentence, and full functional capacity can be maintained with good control.

Most colon cancer patients at a major VA medical center receive recommended therapy. Among rectal cancer patients, those presented at tumor board are most likely to receive recommended therapy.

Default options in health information technology exert a powerful effect on user behavior, an effect that can be leveraged to optimize decision making.

Objective: Most electronic health record (EHR) systems have the capability of generating a printed after-visit summary (AVS), but there has been little research on optimal content. We conducted a qualitative study and a randomized trial to understand the effect of AVS content on patient recall and satisfaction.Methods: Adult primary care patients (n ‫؍‬ 272) with at least 1 chronic condition were randomly assigned to 4 AVS content conditions: minimum, intermediate, maximum, or standard AVS. Demographics and health literacy were measured at an index clinic visit. Recall and satisfaction were measured by telephone 2 days and 2 to 3 weeks after the clinic visit.Results: Average age was 52 years; 75% of patients were female, 61% were Hispanic, and 21% were African American, and 64% had adequate health literacy. Average medication recall accuracy was 53% at 2 days and 52% at 3 weeks, with no significant difference among groups at either time. Satisfaction with AVS content was high and did not differ among groups. Recall of specific content categories was low and unrelated to group assignment. Health literacy was unrelated to recall and satisfaction. Supplying patients with printed instructions and information when they leave a medical encounter has become common practice. Before the availability of electronic health records (EHRs), patient educational materials often took the form of handouts and pamphlets and sometimes videos or interactive computer programs. Most EHRs enable clinicians to supply patients with individualized information in the form of an after visit summary (AVS) based on data available in patients' medical records. Recent legislation has all but required this feature to be included in the EHR for eligibility for financial incentives by meeting the Centers for Medicare and Medicaid Services' (CMS) Meaningful Use (MU) guidelines for the AVS.1 Core Measure 13 describes the objective to provide to patients clinical summaries about each office visit. According to §495.6(d)(13)(ii), the expectation is for, "Clinical summaries provided to patients for more than 50% of all office visits within 3 business days." 2The minimum set of elements recommended by CMS to achieve stage 1 of MU includes patient The EHR-generated AVS represents a potentially efficient and effective tool to support a variety of objectives for optimal patient outcomes in primary care. The majority of adult patients are followed for chronic conditions, such as hypertension and type 2 diabetes, which require long-term adherence to self-management behaviors. The concept of patient activation as a central factor in effective chronic disease self-management underlies many current behavioral interventions to improve outcomes. 3,4 In this conceptualization, the activated patient is provided with useful information about his or her condition(s), uses this information to undertake the recommended treatment plan, and engages with the provider in shared decision making to achieve desired health outcomes. The AVS can be viewed as a communication cha...

Background and Objective Patient-generated health data (PGHD) may help providers monitor patient status between clinical visits. Our objective was to describe our medical center's early experience with an electronic flowsheet allowing patients to upload self-monitored blood glucose to their provider's electronic health record (EHR). Methods An academic multispecialty practice enabled the portal-linked PGHD tool in 2012. We conducted a retrospective observational study of adult ambulatory patients using this tool between 2012 and 2016, comparing clinical and demographic characteristics of data uploaders with those of a group of patients with diabetes diagnoses and patient portal accounts seen by the same health care providers. Results Over four years, 16 providers chose to use the tool, and 53 adult patients used it to upload three or more blood glucose values within any 9-month period. Of these patients, 23 were pregnant women and 30 were nonpregnant adults with diabetes. Uploaders had more encounters and portal log-ins than comparison patients but did not differ in socioeconomic status. Among the chronic disease patients, uploaders' mean hemoglobin A1c and body mass index (BMI) both dropped significantly in the months after upload. Conclusion Despite the potential value of PGHD in health care, the rate of adoption of a tool allowing patients to upload PGHD to their provider's EHR has been slow. Among chronic disease patients, PGHD upload was associated with improvements in blood glucose control and BMI, but it is possible that the changes were because of increased motivation or intensive changes in medical management.

Background Several national initiatives aim to teach high-value care to residents. While there is a growing body of literature on cost impact of physicians' therapeutic decisions, few studies have assessed factors that influence residents' prescribing practices. Objective We studied factors associated with intensive health care utilization among internal medicine residents, using brand name statin prescribing as a proxy for higher-cost care. Methods We conducted a retrospective, cross-sectional analysis of statin prescriptions by residents at an urban academic internal medicine program, using electronic health record data between July 1, 2010, and June 30, 2011. Results For 319 encounters by 90 residents, patients were given a brand name statin in 50% of cases. When categorized into quintiles, the bottom quintile of residents prescribed brand name statins in 2% of encounters, while the top quintile prescribed brand name statins in 98% of encounters. After adjusting for potential confounders, including patient characteristics and supervising attending, being in the primary care track was associated with lower odds (odds ratio [OR], 0.38; P  =  .02; 95% confidence interval [CI], 0.16–0.86), and graduating from a medical school with an above-average hospital care intensity index was associated with higher odds of prescribing brand name statins (OR, 1.70; P  =  .049; 95% CI, 1.003–2.88). Conclusions We found considerable variation in brand name statin prescribing by residents. Medical school attended and residency program type were associated with resident prescribing behavior. Future interventions should raise awareness of these patterns in an effort to teach high-value, cost-conscious care to all residents.

Background Multiple policy initiatives encourage more cautious prescribing of opioids in light of their risks. Electronic health record (EHR) redesign can influence prescriber choices, but some redesigns add to workload. Objective To estimate the effect of an EHR prescribing redesign on both opioid prescribing choices and keystrokes. Design Quality improvement quasi-experiment, analyzed as interrupted time series. Participants Adult patients of an academic multispecialty practice and a federally qualified health center (FQHC) who received new prescriptions for short-acting opioids, and their providers. Intervention In the redesign, new prescriptions of short-acting opioids defaulted to the CDC-recommended minimum for opioid-naïve patients, with no alerts or hard stops, such that 9 keystrokes were required for a guideline-concordant prescription and 24 for a non-concordant prescription. Main Measures Proportion of guideline-concordant prescriptions, defined as new prescriptions with a 3-day supply or less, calculated per 2-week period. Number of mouse clicks and keystrokes needed to place prescriptions. Key Results Across the 2 sites, 22,113 patients received a new short-acting opioid prescription from 821 providers. Before the intervention, both settings showed secular trends toward smaller-quantity prescriptions. At the academic practice, the intervention was associated with an immediate increase in guideline-concordant prescriptions from an average of 12% to 31% of all prescriptions. At the FQHC, about 44% of prescriptions were concordant at the time of the intervention, which was not associated with an additional significant increase. However, total keystrokes needed to place the concordant prescriptions decreased 62.7% from 3552 in the 6 months before the intervention to 1323 in the 6 months afterwards. Conclusions Autocompleting prescription forms with guideline-recommended values was associated with a large increase in guideline concordance in an organization where baseline concordance was low, but not in an organization where it was already high. The redesign markedly reduced the number of keystrokes needed to place orders, with important implications for EHR-related stress. Trial Registration www.ClinicalTrials.gov protocol 1710018646

BackgroundStatins are generally well tolerated and effective at reducing a patient’s risk of both primary and secondary cardiovascular events. Many patients who would benefit from statin therapy either do not adhere to or stop taking their statin medication within the first year. We developed an audio booklet targeted to low health literacy patients to teach them about the benefits and risks of statins to help the patients adhere to their statin therapy.MethodsThrough focus groups and an iterative design, an audio booklet was developed for both English-speaking and Spanish-speaking patients. We then compared the booklet with standard of care in 132 patients from our target patient population to measure its impact on knowledge and understanding of statins.ResultsThe patients enjoyed the audio booklet and showed significant increases in knowledge after listening to it when compared with those who received the standard of care materials.ConclusionThe audio booklet shows promise as a tool that can be used effectively in clinical practice to teach patients about statin therapy.