Publications
Department of Medicine faculty members published more than 3,000 peer-reviewed articles in 2022.
2017
CONTEXT
Advance care planning (ACP) is valued by patients and clinicians, yet documenting ACP in an accessible manner is problematic.
OBJECTIVES
In order to understand how providers incorporate electronic health record (EHR) ACP documentation into clinical practice, we interviewed providers in primary care and specialty departments about ACP practices (n = 13) and analyzed EHR data on 358 primary care providers (PCPs) and 79 specialists at a large multispecialty group practice.
METHODS
Structured interviews were conducted with 13 providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology departments. The EHR problem list data on Advance Health Care Directives (AHCDs) and Physician Orders for Life-Sustaining Treatment (POLST) were used to calculate ACP documentation rates.
RESULTS
Examining seriously ill patients ≥65 years with no preexisting ACP documentation seen by providers during 2013 to 2014, 88.6% (AHCD) and 91.1% (POLST) of 79 specialists had zero ACP documentations. Of 358 PCPs, 29.1% (AHCD) and 62.3% (POLST) had zero ACP documentations. Interviewed PCPs often believed ACP documentation was beneficial and accessible, while specialists more often did not. Specialists expressed more confusion about documenting ACP, whereas PCPs reported standard clinic workflows. Problems with interoperability between outpatient and inpatient EHR systems and lack of consensus about who should document ACP were sources of variations in practices.
CONCLUSION
Results suggest that providers desire standardized workflows for ACP discussion and documentation. New Medicare reimbursement for ACP and an increasing number of quality metrics for ACP are incentives for health-care systems to address barriers to ACP documentation.
View on PubMed2017
BACKGROUND
Cardiac rehabilitation (CR) is linked to reduced mortality and morbidity, including improvements in cardiorespiratory fitness, psychosocial state, and quality of life in patients with heart failure (HF). However, little is known about CR utilization among patients with HF.
OBJECTIVE
We sought to determine (a) the proportion of patients with HF who participated in CR and (b) patient characteristics associated with participation.
METHODS
A retrospective study was conducted with the use of national data from the Centers for Medicare and Medicaid Services and the Veterans Health Administration. We used primary discharge ICD-9 codes to identify patients hospitalized for HF during 2007-2011 and identified CR participation with the use of current procedure terminology codes from claims data. Multivariate logistic regression was used to identify patient characteristics associated with CR participation.
RESULTS
There were 66,710 veterans and 243,208 Medicare beneficiaries hospitalized for HF and 1554 (2.3%) and 6280 (2.6%), respectively, who attended ≥1 sessions of outpatient CR. Among Medicare beneficiaries, men were more likely than women to participate in CR (3.7% vs 1.8%; P < .001), but there was no gender difference among veterans (2.3% vs 2.8%; P = .40). Characteristics associated with participation in CR in both groups included younger age, white race, and history of ischemic heart disease.
CONCLUSIONS
Very few HF patients participated in CR, with lower rates among older non-white women with a history of depression or other chronic medical conditions. Because Medicare has recently introduced coverage for CR in patients with systolic HF, we must increase efforts to improve CR participation, especially among these vulnerable groups.
View on PubMed2017
BACKGROUND
Celiac disease is a chronic inflammatory condition with wide ranging effects on individual's lives caused by a combination of symptoms and the burden of adhering to a gluten-free diet (GFD).
OBJECTIVES
To further understand patients' experience of celiac disease, the impact it has on health-related quality of life (HRQOL), and to develop a conceptual model describing this impact.
METHODS
Adults with celiac disease on a GFD reporting symptoms within the previous 3 months were included; patients with refractory celiac disease and confounding medical conditions were excluded. A semistructured discussion guide was developed exploring celiac disease symptoms and impact on patients' HRQOL. An experienced interviewer conducted in-depth interviews. The data set was coded and analyzed using thematic analysis to identify concepts, themes, and the inter-relationships between them. Data saturation was monitored and concepts identified formed the basis of the conceptual model.
RESULTS
Twenty-one participants were recruited, and 32 distinct gluten-related symptoms were reported and data saturation was reached. Analysis identified several themes impacting patients' HRQOL: fears and anxiety, day-to-day management of celiac disease, physical functioning, sleep, daily activities, social activities, emotional functioning, and relationships. The conceptual model highlights the main areas of impact and the relationships between concepts.
CONCLUSIONS
Both symptoms and maintaining a GFD have a substantial impact on patient functioning and HRQOL in adults with celiac disease. The conceptual model derived from these data may help to design future patient-reported outcomes as well as interventions to improve the quality of life in an individual with celiac disease.
View on PubMed2017
Association Between Use of a Scalp Cooling Device and Alopecia After Chemotherapy for Breast Cancer.
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