Dataset Information

Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests.

ABSTRACT: Importance:Early cancer detection can lead to improved outcomes, but cancer screening tests are often underused. Objective:To evaluate the association of an active choice intervention in the electronic health record directed to medical assistants with changes in clinician ordering and patient completion of breast and colorectal cancer screening tests. Design, Setting, and Participants:A retrospective quality improvement study was conducted among 69?916 patients eligible for breast or colorectal cancer screening at 25 primary care practices at the University of Pennsylvania Health System between September 1, 2014, and August 31, 2017. Data analysis was conducted from January 21 to July 8, 2019. Interventions:From 2016 to 2017, 3 primary care practices at the University of Pennsylvania Health System implemented an active choice intervention in the electronic health record that prompted medical assistants to inform patients about cancer screening during check-in and template orders for clinicians to review during the visit. Main Outcomes and Measures:The primary outcome was clinician ordering of cancer screening tests. The secondary outcome was patient completion of cancer screening tests within 1 year of the primary care visit. Results:The sample eligible for breast cancer screening comprised 26?269 women with a mean (SD) age of 60.4 (6.9) years; 15?873 (60.4%) were white and 7715 (29.4%) were black. The sample eligible for colorectal cancer screening comprised 43?647 patients with a mean (SD) age of 59.4 (7.5) years; 24?416 (55.9%) were women, 19?231 (44.1%) were men, 29?029 (66.5%) were white, and 9589 (22.0%) were black. For breast cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (22.2 percentage points; 95% CI, 17.2-27.6 percentage points; P?

SUBMITTER: Hsiang EY

PROVIDER: S-EPMC6902810 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests.

Hsiang Esther Y EY Mehta Shivan J SJ Small Dylan S DS Rareshide Charles A L CAL Snider Christopher K CK Day Susan C SC Patel Mitesh S MS

JAMA network open 20191101 11

<h4>Importance</h4>Early cancer detection can lead to improved outcomes, but cancer screening tests are often underused.<h4>Objective</h4>To evaluate the association of an active choice intervention in the electronic health record directed to medical assistants with changes in clinician ordering and patient completion of breast and colorectal cancer screening tests.<h4>Design, setting, and participants</h4>A retrospective quality improvement study was conducted among 69 916 patients eligible for ...[more]

PMID: 31730186

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Project description:ImportanceMany health systems are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration.ObjectiveTo test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year.Design, setting, and participantsThe Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions.InterventionsInpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record.Main outcomes and measuresPrimary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees.ResultsThe sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.05 tests ordered per patient-day; 95% CI, -0.002 to 0.09; P = .06) or associated fees ($0.24 per patient-day; 95% CI, -$0.42 to $0.91; P = .47). Exploratory subset analyses found small but significant differences in tests ordered per patient-day based on patient intensive care unit (ICU) stay (patients with ICU stay: -0.16; 95% CI, -0.31 to -0.01; P = .04; patients without ICU stay: 0.13; 95% CI, 0.08-0.17; P < .001) and the magnitude of associated fees (top quartile of tests based on fee value: -0.01; 95% CI, -0.02 to -0.01; P = .04; bottom quartile: 0.03; 95% CI, 0.002-0.06; P = .04). Adjusted analyses of tests that were performed found a small but significant overall increase in the intervention group relative to the control group over time (0.08 tests performed per patient day, 95% CI, 0.03-0.12; P < .001).Conclusions and relevanceDisplaying Medicare allowable fees for inpatient laboratory tests did not lead to a significant change in overall clinician ordering behavior or associated fees.Trial registrationclinicaltrials.gov Identifier: NCT02355496.

Project description:ObjectiveAvailable studies on implementation of evidence-based psychotherapy (EBP) for patients attending Department of Veterans Affairs (VA) residential post-traumatic stress disorder (PTSD) programs rely on therapist self-report of EBP delivery. Patient-level data on receipt of EBP are needed both to corroborate therapist self-report and to understand patient factors that predict receipt of EBPs for PTSD.Materials and methodsWe identified 159 therapists from 38 VA residential PTSD programs who responded to a survey about EBP implementation during the 2015 fiscal year (FY15). Therapists self-reported their use of two EBPs, including prolonged exposure delivered in an individual format (PE-I) and cognitive processing therapy delivered in individual and group formats (CPT-I and CPT-G). Using electronic medical record (EMR) templates mandated for EBP documentation in FY15, we measured contemporaneous patient-level receipt of EBPs for PTSD. We assessed the degree of correlation between therapist self-reported EBP delivery and patient receipt of EBT as measured by EMR templates using polychoric correlation coefficients. We determined patient and therapist factors that predicted the receipt of EBPs with multivariable logistic regression, using random effects and robust standard error estimation, and controlling for site. The Veterans IRB of Northern New England provided a waiver of informed consent; as this was a retrospective review, no patients or therapists were contacted, and all data were stored, transmitted, and analyzed on secure VA servers. The VA Connecticut Health Care System Human Research Protection Program approved secondary use of therapist survey data for this project.ResultsWhen EMR template use became mandated in FY15, the proportion of patients in residential PTSD programs who received at least one EBP session that was recorded with an EMR template increased dramatically from 8.8% to 33.9%. There was adequate correlation and between survey-based and EMR-based measures of EBP receipt, with polychoric correlation values of 0.77 for PE-I, 0.69 for CPT-I, and 0.82 for CPT-G. Multiple patient factors were positive (e.g., female gender) and negative (e.g., depressive disorders) predictors of receipt of EBPs, even after controlling for site. Among therapist factors, only EBP consultant or trainer status was a positive predictor of EBP provision and only therapist race was a negative predictor of EBT provision after controlling for site.ConclusionFollowing a FY15 mandate, EMR templates documenting EBP delivery were widely used by therapists working in VA residential PTSD programs. EBP receipt measured using EMR templates was consistent with therapist self-report of EBT delivery. There were several patient-level predictors of EBP receipt and therapist-level predictors of EBP delivery. However, therapists most likely to deliver EBPs were clustered at a limited number of sites.

Project description:ImportanceAs the clinic day progresses, clinicians may fall behind schedule and experience decision fatigue. However, the association of time of day with cancer screening rates is unknown.ObjectiveTo evaluate the association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening.Design, setting, and participantsRetrospective, quality improvement study of 33 primary care practices in Pennsylvania and New Jersey from September 1, 2014, to August 31, 2016. Participants included adults eligible for breast or colorectal cancer screening. Data analysis was conducted from April 24, 2018, to November 8, 2018.ExposuresClinic appointment time during each patient's first primary care physician visit in the study period.Main outcomes and measuresPrimary outcome was clinician ordering of the screening test during the visit. Secondary outcome was patient completion of the tests within 1 year of the visit.ResultsAmong the 19 254 patients eligible for breast cancer screening, the mean (SD) age was 60.2 (6.9) years; 19 254 (100%) were female, 11 682 (60.7%) were white, and 5495 (28.5%) were black. Screening test order rates were highest at 8 am at 63.7%, decreased throughout the morning to 48.7% at 11 am, increased to 56.2% at noon, and then decreased to 47.8% at 5 pm (adjusted odds ratio [OR] for overall trend, 0.94; 95% CI, 0.93-0.96; P < .001). Trends in screening test completion rates were similar beginning at 33.2% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.95; 95% CI, 0.94-0.97; P < .001). Among the 33 468 patients eligible for colorectal cancer screening, the mean (SD) age was 59.6 (7.4) years; 18 672 (55.8%) were female, 22 157 (66.2%) were white, and 7296 (21.8%) were black. Screening test order rates were 36.5% at 8 am, decreased to 31.3% by 11 am, increased at noon to 34.4%, and then decreased to 23.4% at 5 pm (adjusted OR, 0.94; 95% CI, 0.93-0.95; P < .001). Trends in screening test completion rates were similar beginning at 28.0% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.97; 95% CI, 0.96-0.98; P < .001).Conclusions and relevanceClinician ordering of cancer screening tests significantly decreased as the clinic day progressed. Patient completion of cancer screening tests within 1 year of the visit was also lower as the primary care appointment time was later in the day. Future interventions targeting improvements in cancer screening should consider how time of day may influence these behaviors.

Dataset Information

Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests.

Publications

Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests.

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