Association of Self-reported Primary Care Physician Tolerance for Uncertainty With Variations in Resource Use and Patient Experience.

Importance: Inappropriate variations in clinical practice are a known cause of poor quality and safety, with variations often associated with nonclinical factors, such as individual differences in cognitive processing. The differential response of physicians to uncertainty may explain some of the variations in resource use and patient experience.

Objective: To examine the association of physician tolerance for uncertainty with variations in resource use and patient experience.

Comparing neighborhood-based indices of socioeconomic risk factors and potentially preventable emergency department utilization.

Background: Neighborhood stress score (NSS) and area deprivation index (ADI) are two neighborhood-based composite measures used to quantify an individual's socioeconomic risk based on home location. In this analysis, we compare the relationships between an individual's socioeconomic risk, based on each of these measures, and potentially preventable acute care utilization.

Methods: Using emergency department (ED) visit data from two academic medical centers in Boston, Massachusetts, we conducted adjusted Poisson regressions of ADI decile and NSS decile with counts of low acuity ED visits, admissions for ambulatory care sensitive conditions (ACSCs), and patients with high frequency ED utilization at the census block group (CBG) level within the greater Boston area.

Predictors of MRI Leakage Among Patients Attributed to an Academic Medical Center Commercial Risk-Shared Insurance Contract.

Purpose: For health care organizations engaged in risk-shared insurance contracts, leakage of advanced diagnostic imaging to imaging sites not affiliated with the risk-sharing organization may undermine performance on financial and quality metrics. The goal of this study was to identify factors that are predictive of leakage of MRI examinations among patients attributed to an academic health care organization's risk-shared commercial insurance contract.

Methods: Administrative claims data from 2015 through 2016 for patients attributed to a single risk-shared commercial insurance contract at a large academic medical center (AMC) were analyzed.

Reduction in pediatric gastroenterology ED visits can be sustained through physician accountability and financial incentives.

Objective: There have been various interventions to reduce ED utilization. Little is known about the sustainability of outcomes of interventions to reduce ED overcrowding. We sought to investigate whether the outcomes from one of successful interventions to reduce ED utilization, specialist physician level reporting were sustained over time and how this practice change was sustained over time.

Development of an electronic health record-based chronic kidney disease registry to promote population health management.

Background: Electronic health record (EHR) based chronic kidney disease (CKD) registries are central to population health strategies to improve CKD care. In 2015, Partners Healthcare System (PHS), encompassing multiple academic and community hospitals and outpatient care facilities in Massachusetts, developed an EHR-based CKD registry to identify opportunities for quality improvement, defined as improvement on both process measures and outcomes measures associated with clinical care.

Methods: Patients are included in the registry based on the following criteria: 1) two estimated glomerular filtration rate (eGFR) results < 60 ml/min/1.

Measuring individual physician clinical productivity in an era of consolidated group practices.

Background: As physician groups consolidate and value-based payment replaces traditional fee-for-service systems, physician practices have greater need to accurately measure individual physician clinical productivity within team-based systems. We compared methodologies to measure individual physician outpatient clinical productivity after adjustment for shared practice resources.

Methods: For cardiologists at our hospital between January 2015 and June 2016, we assessed productivity by examining completed patient visits per clinical session per week.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population.

Objective: This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use.

Methods: Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits.

Optimizing the Use of Electronic Health Records to Identify High-Risk Psychosocial Determinants of Health.

Background: Care coordination programs have traditionally focused on medically complex patients, identifying patients that qualify by analyzing formatted clinical data and claims data. However, not all clinically relevant data reside in claims and formatted data. Recently, there has been increasing interest in including patients with complex psychosocial determinants of health in care coordination programs.

Variation in the Echocardiographic Surveillance of Primary Mitral Regurgitation.

Background: Clinical outcomes after surgical treatment of mitral regurgitation are worse if intervention occurs after deterioration of left ventricular size and function. Transthoracic echocardiographic (TTE) surveillance of patients with mitral regurgitation is indicated to avoid adverse ventricular remodeling. Overly frequent TTEs can impair patient access and reduce value in care delivery.

Utilization Management of High-Cost Imaging in an Outpatient Setting in a Large Stable Patient and Provider Cohort over 7 Years.

Purpose To quantify the effect of a comprehensive, long-term, provider-led utilization management (UM) program on high-cost imaging (computed tomography, magnetic resonance imaging, nuclear imaging, and positron emission tomography) performed on an outpatient basis. Materials and Methods This retrospective, 7-year cohort study included all patients regularly seen by primary care physicians (PCPs) at an urban academic medical center. The main outcome was the number of outpatient high-cost imaging examinations per patient per year ordered by the patient's PCP or by any specialist.

Images of imaging: how to process and display imaging utilization for large populations.

Objective: We propose a method of processing and displaying imaging utilization data for large populations.

Conclusion: The comprehensive and finely grained picture of imaging utilization yielded by our methods is a first step toward population-based imaging utilization management. We believe that our methods for the categorization and display of imaging utilization will prove to be widely useful.

Provider Feedback about Imaging Appropriateness by Using Scores from Order Entry Decision Support: Raw Rates Misclassify Outliers.

Purpose: To determine the relevant physician- and practice-related factors that jointly affect the rate of low-utility imaging examinations (score of 1-3 out of 9) ordered by means of an order entry system that provides normative appropriateness feedback.

Materials And Methods: This HIPAA-compliant study was approved by the institutional review board under an expedited protocol for analyzing anonymous aggregated administrative data. This is a retrospective study of approximately 250 000 consecutive scheduled outpatient advanced imaging examinations (computed tomography, magnetic resonance imaging, nuclear medicine) ordered by 164 primary care and 379 medical specialty physicians from 2008 to 2012.

An electronic health records study of long-term weight gain following antidepressant use.

Importance: Short-term studies suggest antidepressants are associated with modest weight gain but little is known about longer-term effects and differences between individual medications in general clinical populations.

Objective: To estimate weight gain associated with specific antidepressants over the 12 months following initial prescription in a large and diverse clinical population.

Design, Setting, And Participants: We identified 22,610 adult patients who began receiving a medication of interest with available weight data in a large New England health care system, including 2 academic medical centers and affiliated outpatient primary and specialty care clinics.

Face time versus test ordering: is there a trade-off?

Background: As clinician-patient face time comes under pressure, clinicians might consider substituting testing for time spent in diagnostic reasoning, history, and physical exam.

Objectives: To explore the relationship between clinician-patient time and medical resource utilization.

Methods: In the Massachusetts General Hospital/Massachusetts General Physician Organization outpatient radio frequency identification project, clinicians and patients wore real-time location system (RTLS) tags.

Use of imaging in the emergency department: physicians have limited effect on variation.

Purpose: To quantify interphysician variation in imaging use during emergency department (ED) visits and examine the contribution of factors to this variation at the patient, visit, and physician level.

Materials And Methods: This study was HIPAA compliant and approved by the institutional review board of Partners Healthcare System (Boston, Mass), with waiver of informed consent. In this retrospective study of 88 851 consecutive ED visits during 2011 at a large urban teaching hospital, a hierarchical logistic regression model was used to identify multiple predictors for the probability that low- or high-cost imaging would be ordered during a given visit.

QT interval and antidepressant use: a cross sectional study of electronic health records.

Objective: To quantify the impact of citalopram and other selective serotonin reuptake inhibitors on corrected QT interval (QTc), a marker of risk for ventricular arrhythmia, in a large and diverse clinical population.

Design: A cross sectional study using electrocardiographic, prescribing, and clinical data from electronic health records to explore the relation between antidepressant dose and QTc. Methadone, an opioid known to prolong QT, was included to demonstrate assay sensitivity.

Antidepressant response in patients with major depression exposed to NSAIDs: a pharmacovigilance study.

OBJECTIVE It has been suggested that there is a mechanism by which nonsteroidal anti-inflammatory drugs (NSAIDs) may interfere with antidepressant response, and poorer outcomes among NSAID-treated patients were reported in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. To attempt to confirm this association in an independent population-based treatment cohort and explore potential confounding variables, the authors examined use of NSAIDs and related medications among 1,528 outpatients in a New England health care system. METHOD Treatment outcomes were classified using a validated machine learning tool applied to electronic medical records.

Determinants of diagnostic imaging utilization in primary care.

Objectives: To examine patient and physician factors affecting utilization of diagnostic imaging in primary care.

Data Sources/study Setting: Patient-level data from a large academic group practice over the period July 1, 2007, through June 30, 2009.

Study Design: This is a retrospective cohort study of 85,277 patients cared for by 148 primary care physicians (PCPs).