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Study reveals lack of self-awareness among doctors when prescribing opioids

As health providers struggle to curb the epidemic of opioid abuse, researchers at the University of Colorado Anschutz Medical Campus and the University of Massachusetts Medical School have found that 65 percent of emergency department (ED) physicians surveyed underestimated how often they prescribed the highly addictive pain killers to patients.

Those rates dropped after they saw their actual data.

The year-long study, published this month in the journal Academic Emergency Medicine, focused on how doctors perceive themselves relative to their peers when it comes to prescribing opioids. Most felt they were restrained, but the results showed otherwise.

Dr. Sean Michael, assistant professor of emergency medicine and author of the study.
Dr. Sean Michael, assistant professor of emergency medicine and author of the study.

“We surveyed 109 emergency medicine providers at four different hospital EDs,” said study author Sean Michael, MD, MBA, assistant professor of emergency medicine at the University of Colorado School of Medicine. “We asked them to report their perceived opioid prescribing rates compared to their peers. Then we showed them where they actually were on that spectrum.”

Some 65 percent of those surveyed prescribed more opioids that they thought they did. Michael and his team found participants discharged 119,428 patients and wrote 75,203 prescriptions, of which 15,124 (or about 20 percent) were for opioids over the course of the 12-month study.

The researchers then monitored the doctors after they were shown their actual prescription rates.

“Everyone showed an overall decrease in prescribing opioids,” Michael said. “After seeing their real data, the people with inaccurate self-perceptions, on average, had 2.1 fewer opioid prescriptions per 100 patients six months later and 2.2 percent fewer prescriptions per 100 patients at 12 months.”

The study likened the physicians’ initial self-perceptions to the majority of drivers feeling they are above average – a statistical impossibility.

“Thus an intervention to identify and unmask inaccurate self-perception – and correct that perception using a provider’s actual data – appears to have enabled more robust behavior change for a subset of providers who may have otherwise had difficulty internalizing the need to change,” the study said.

The researchers believe the shock many felt upon seeing the reality of their actions versus their perceptions primed them to change their behavior.

Michael pointed out that this problem extends beyond emergency departments. In fact, only about 5-10 percent of all opioid prescriptions are generated by ED physicians.

“Despite making progress on the opioid epidemic, we can’t assume providers are behaving optimally and have all the information they need to do what we are asking of them,” Michael said. “Most believe they are doing the right thing, but we need to directly address this thinking to be sure they are not part of the problem.”

The other authors include Kavita Babu, MD, Christopher Androski Jr., MS, and Martin Reznek, MD, MBA, all from the University of Massachusetts Medical School, Worcester, MA.

 

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Shared decision-making between patients and clinicians can result in better choices

As more and more older patients are offered advanced treatments for chronic diseases, including surgeries and implantable devices, new questions have arisen over how these decisions are made.

In a study published Monday in JAMA Internal Medicine, researchers at the University of Colorado Anschutz Medical Campus examined this question by focusing on the decision-making that goes into whether a patient should proceed with a therapy called left ventricular assist device or LVAD.

They found that shared decision-making between patients and clinicians can improve the quality of the final decision in these often high-risk interventions.

Dr. Larry Allen, associate professor of medicine-cardiology at the CU School of Medicine.
Dr. Larry Allen, associate professor of medicine-cardiology at the CU School of Medicine. Allen co-authored the study.

“LVAD is growing rapidly among people dying from end-stage heart failure who are unable to get a heart transplant,” said study co-author Dr.Larry Allen, MD, associate professor of medicine-cardiology at the University of Colorado School of Medicine. “These patients decide to live out the remainder of their lives dependent on a partial artificial heart—so-called destination therapy (DT). Although patients may live longer with a DT LVAD, it also poses many risks, including stroke, serious infection, and bleeding, and comes with big lifestyle changes.”

Deciding whether to go forward with LVAD is often difficult for patients. Yet until recently, there were few tools available for patients and health care providers to use in LVAD shared decision-making.

“Because of this, the Colorado Program for Patient Centered Decisions spent years developing unbiased pamphlet and video decision aids for patients and caregivers, and paired them with training for doctors and nurses,” said study co-author Jocelyn Thompson, MA, of the CU School of Medicine.

The researchers set out to see how well these decision aids worked in routine care to help patients make quality choices around DT LVAD.

Six hospitals across the United States participated in a trial called the Decision Support Intervention for Patients and Caregivers Offered Destination Therapy Heart Assist Device (DECIDE-LVAD).

They switched from their current pre-LVAD education practices—usually consisting of locally made documents and pamphlets from the companies that make the LVADs—to using the formal decision aids and providing decision support training for the staff.

Patients were surveyed during the hospitals’ usual process, called the control period, and during the time the formal decision aids were used, called the intervention period. Researchers wanted to see how the new process changed LVAD decision-making.

A total of 248 patients were enrolled in the study. Some 95 percent of those in the intervention period received the formal decision aids. When compared to those in the control period, patients exposed to the decision aids had an improved understanding of the DT LVAD decision. This was demonstrated by a 5.5% increase in correct answers on a knowledge test.

The decision aids also improved values-choice agreement. In the intervention period, patients who said they were willing to undergo risky surgery for a chance to extend life were more likely to get an LVAD while those who didn’t want to be dependent on a machine were more likely to turn down LVAD.

Overall, patients who received the decision aids were more likely not to get an LVAD.

Allen said the DECIDE-LVAD trial shows that the use of formal, unbiased, patient decision aids for LVADs can help patients dying from heart failure improve the quality of decision-making. It may also change the rate at which they decide to proceed with such high-risk, high-reward treatment.

The study was funded by the Patient-Centered Outcomes Research Institute (PCORI).

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Honor Society: A small dose of compassion goes a long way

In the end, his patient died. But as Ajay Major, MD, MBA, then an intern, flipped through the old veteran’s medical record, he found comfort in the memories the notes inspired.

Now Major, a second-year internal-medicine resident on the University of Colorado Anschutz Medical Campus, calls up those memories of the witty old man with terminal cancer who always asked for bourbon (and his devoted wife who always rolled her eyes in response) as a continual reminder of the importance of compassion in health care.

“Medicine is hard,” Major said. “We see a lot of patients with a lot of difficult medical issues, and I think burnout stems not just from feeling overworked, but also from feeling that we’re not truly caring for our patients on a human level.”

Major, co-president of the CU Anschutz School of Medicine (SOM) Resident Chapter of the Gold Humanism Honor Society, spread his message during the society’s annual Solidarity Week Feb. 12-16 by encouraging his colleagues to take part in the week’s centerpiece program, Tell Me More (TMM).

Changing the conversation

Dr. Griff with Cory
Megan Griff, MD, chats with University of Colorado Hospital patient Frances Cory as part of a program aimed at teaching the value of compassion in medicine.

Armed with a TMM questionnaire and a smile, second-year internal-medicine resident Megan Griff, MD, entered her patient’s room, finding Betty Redwine, 77, wrapped in a light blanket and relaxing in a chair. “Is it OK to talk and find out about your life?” Griff asked, after explaining the program and introducing Major and attending physician, Jeannette Guerrasio, MD.

“OK,” Betty Redwine said, returning her doctor’s smile. “But it’s nothing exciting,” she said, grinning up from beneath a black-suede, shower-like cap she informed her guests was taming her unruly hair.

Prompted by four TMM questions, Redwine soon was sharing pieces of her past. Topics of capillaries and high blood pressure gave way to children’s feats and life’s treasures, sounding more like tea-time chatter than hospital-room discussion. When Redwine let a little secret slip, the room exploded in utterances of disbelief.

“What?” Guerrasio said, after Redwine revealed she worked as a registered nurse for 35 years. “Why didn’t you tell us?” asked Griff. “My mom is a nurse, too,” Griff said, when the commotion subsided. “You guys are hard-workers,” she said, patting Redwine’s hand.

Staying centered on the cause

While it might seem miniscule, a small dose of compassion can result in an array of benefits, Major said.  “It allows the patient to feel that the care team really cares about them, but it also brings some catharsis for providers. Just finding out a little bit more about our patients’ lives outside of the hospital can help re-center us in the work that we are doing as physicians and, I believe, help prevent burnout.”

On the patient side, studies show compassionate healthcare results in higher patient satisfaction, a higher pain threshold, reduced anxiety and better outcomes, according to the Gold Foundation, which cites supporting studies on its website.

TMM team meets with nurse
Ajay Major, MD, MBA, left, and Jeannette Guerrasio, MD, right, talk with Anne Marie Fleming, RN, about the Tell Me More program.

“People develop diseases for lots of reasons, and everyone’s lives really affect the way they respond to health problems,” said SOM Chair of Medicine David Schwartz, MD. It makes sense that trusted patient-provider relationships result in better care, he said. “We need to know how their lives might be contributing to the development of disease, and how their lives might contribute to our ability to effectively treat their disease,” he said.

Remembering: ‘I’m a person’

Looking up from her bed as the TMM trio walked into her room, Frances Cory, 79, had them laughing before even agreeing to chat. “You want to talk beyond my medical condition? You mean you don’t care about my medical condition anymore?” said the mother and grandmother, who later responded to a question about her biggest strength: “My sense of humor.”

Cory, who shared with her visitors that she had served more than 5,000 volunteer hospital hours during her lifetime, said she thought the program was important. “It’s nice to know that you take the time to talk to your patients. I’m a person.”

The TMM program offers a valuable reminder for medical students that their patients are people, and not just medical mysteries to solve, Guerrasio said. “I actually, as a doctor, find these conversations really helpful. And it’s what makes me come to work every day.”

Notes about the patient-doctor chat are jotted down on the TMM questionnaire, which is then displayed on the wall so that everyone involved in that patient’s stay, from therapists and nurses to doctors and janitors, can use it as conversation fodder, Major said.

‘The more passionate individuals are about their profession, and the more they enjoy what they are doing, the more engaged they become. These things feed on each other in very positive ways.’   ̶   David Schwartz, SOM Chair of Medicine  

Seeing nothing as too small

By getting to know his end-stage cancer patient and his wife as an intern, Major learned not just about his patient’s bourbon routine, but that he was a strong war veteran who had “always been a fighter.” That helped Major, when the man opted for a late chemo-treatment that was questionable at his stage and age. While the patient fared well through therapy, he developed an infection afterward that ended his fight.

When his patient was transferred to hospice, Major told his palliative caregivers about the bourbon. As he looked through his patient’s medical record after learning of his death, Major was jolted by one caretaker directive: Bourbon, one ounce at bed time as needed.

“It seems like such a small detail,” said Major, who published an article in JAMA Oncology about the patient experience. “But when his fighting wasn’t working anymore, he started thinking about things he really enjoyed in life. And having his little bit of bourbon was kind of important to him. So we made sure he could have that to the end.”

 

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CU’s AIDS Clinical Trials Unit celebrates 25 years of progress

Diagnosed in 1991, David Dillon was sure his HIV-positive test was a death sentence. He’d watched friends die, struggling on the only drugs available at the time, medications that had intense side effects and were barely effective, with the rapidly evolving AIDS virus building resistance to them often within months.

But then the words of a social worker resonated in his mind. Experts, she had told him soon after hearing his diagnosis, were on the verge of turning the once always-deadly affliction into a chronic but manageable disease. “That’s what I grabbed on to right away,” Dillon said. “And that’s what I’ve hung on to ever since.”

Dillon was one of the first HIV-positive patients to volunteer for studies with the AIDS Clinical Trials Unit (ACTU) at the now University of Colorado Anschutz Medical Campus. Today, as the ACTU celebrates 25 years of major contributions in revolutionizing HIV/AIDS treatment, Dillon is still alive, grateful for CU and content knowing he helped make a difference.

Creating a top-notch program

The human-immunodeficiency virus (HIV), which spread fear and bias throughout the country in the ‘80s, killing people from actor Rock Hudson to writer Isaac Asimov, had no treatment until 1987, and no effective drugs until the mid-‘90s. CU eventually became one of the top research universities for HIV/AIDS research in the world, but not until netting a major new faculty recruitment.

AIDS patient David Dillon
David Dillon has set a goal of outliving his new pup, Finn.

“It was a big deal,” Thomas Campbell, MD, principal investigator of CU’s ACTU, said of the 1989 recruitment of Robert “Chip” Schooley. A Harvard Medical School professor and prominent, internationally-recognized HIV researcher, Schooley established CU as an AIDS Clinical Trials Center, bringing front-line drugs to the region.

“I remember sitting on my back porch and reading about his recruitment on the front page of The Denver Post,” said Campbell, who was an infectious disease fellow at the time. “Bringing him to Colorado was like recruiting John Elway to the Denver Broncos. It’s bringing a superstar to Colorado, which helps elevate the whole team.”

By 1991, when Dillon, a Housing Department employee at CU Boulder at the time, was learning of his infection, the National Institutes of Health was tapping Schooley to lead a new ACTU, injecting $4.8 million in adult AIDS research and $3 million in pediatric AIDS research into CU’s coffers. CU’s unit joined a growing number of national sites within the AIDS Clinical Trials Group (ACTG), formed in 1986 as the urgency for new drugs intensified.

“Schooley was the key person that made that happen, and so all of the great HIV/AIDS research capacity that we have today is largely possible because of the groundwork that he laid and the foundation that he built in the early ‘90s,” said Campbell, who had joined CU as an infectious disease fellow that year and is now medical director of the adult Clinical and Translational Research Center (CTRC) of the Colorado Clinical Translational Science Institute at CU, where clinical trials are conducted.

For many Colorado HIV patients, including Dillon, the move was a life-saving boon.

Road past resistance is long

Wearing a beeper, which interrupted him every four hours to take his arsenal of pills, Dillon, now 65, was one of the lucky ones in that the regimen’s side effects didn’t make him so sick he ditched the AZT (azidothymidine), choosing to accept HIV’s fate. But he knew the drug’s effects were waning.

‘It seemed like I was already at the cusp, so when a drug came into testing, I was ready for it. Dr. Steven Johnson saved my life more than once.’ – patient David Dillon

Dillon found Graham Ray, RN, still a study coordinator with CU’s ACTU, and signed up for one of the first of what would exceed 177 clinical trials in the unit’s 25 years, with more than 2,500 participants coming forward to help scientists in their search for a more effective treatment.

The study involved spending some nights in the hospital, and Dillon recalled a trial patient in a nearby bed. “He had pretty much run the gamut of drugs available. He’d run out of options, so this trial was one of his last hopes,” Dillon said. “I lost several friends that were in the same boat. There just wasn’t new treatment coming fast enough to help them.”

Few drugs and rapid resistance were major problems for patients in those days,” Campbell said. “We could only give one or two drugs at the most together, and drug resistance developed very rapidly. The medicines lost their effectiveness.”

For Dillon, who estimates he tried upwards of 20 single experimental drugs, the trials always came right in time, with Ray and his CU doctor, Steven Johnson, MD, of the Division of Infectious Diseases, regularly alerting him to new studies.

“It just seemed like I was already right at the cusp, so when a drug came into testing, I was ready for it,” said Dillon, who still travels to CU Anschutz from his Loveland home, indebted to his caregivers. “Dr. Johnson saved my life more than once,” said Dillon, who has AIDS, the end-stage disease of an HIV infection.

HIV attacks patients’ immune systems by binding to and killing CD4 cells, which are largely responsible for fighting infections. Doctors monitor CD4-cell counts, assessing the progression of the disease. If a patient’s count falls below 200, then they are diagnosed with AIDS, and their risk of deadly infections rises. Dillon’s counts were once as low as five.

Trial volunteers join mission

AIDS patient Patrick Terry
Patrick Terry has been an integral member of the International Gay Rodeo Association for 30 years.

For Patrick Terry, a former Colorado rodeo staple and Denver-area native, who has done “probably a dozen” trials with CU since 2000, taking part in trials is about staving off AIDS (his CD4 count has never fallen below 500), and putting an end to the epidemic. “To me, it’s so important that we find out more about it, and if there’s any chance that there could be a cure, then I’d like to be a part of it.”

Helping science isn’t always easy, said Dillon and Terry, 60, who calls himself a go-to volunteer for ACTU research nurse Cathi Basler, RN, because of his dedication to the trial process. Although he said he’s “lucky” to have apparently always received the active drug in the double-blind studies, Dillon recalled a nearly five-year trial that required injecting a drug in his abdominal muscles twice a day.  “It just hurt, and you had to just keep doing it.”

“You know when you are on the real drug,” said Terry, who has volunteered for clinical trials with Basler for years after being diagnosed with HIV in 1995. “I’ve had some very difficult studies,” he said, noting one in which the drug was so strong, it caused hallucinations, and another in which he had to have lymph nodes removed.

But the pair’s dedication has paid off, for them, and for many of the more than 30 million people worldwide living with HIV.

Treatment only works with adherence

In 1996, a CU ACTU-led research study played a key role in the development and widespread use of what was commonly termed “drug cocktails.” That was a major turning point in HIV/AIDS treatment, Campbell said.

“When we first really had the ability to put three drugs together to make an effective combination, it greatly reduced the risk of drug resistance. It did so by having much more effective suppression of viral replication,” he said. “We suddenly had a way to effectively treat HIV and prevent all the damage it does to the body.”

AIDS patient David Dillon at CU Anschutz
David Dillon, one of the first HIV-positive patients to volunteer for studies with the AIDS Clinical Trials Unit, is indebted to his caregivers at the CU Anschutz Medical Campus. He still travels regularly to CU Anschutz from his home in Loveland.

Part of a two-drug combination trial today, Terry’s CD4 counts hover around 1,000, and his viral load is undetectable. For, Dillon, although his CD4 counts aren’t quite so high, and his “cocktail” includes five drugs, his viral load is also undetectable.

But Terry, emphasizing that the effective drugs are still not a cure, advocates for medication adherence. “I’ve never missed a dose, and that’s probably one of the most important things,” said Terry, , who watched his “little brother” die in 2005, after living in denial with an HIV infection for years and succumbing to AIDS within 18 days of hospitalization.

“Take it seriously,” Terry said. “Don’t skip your medicine. That’s a problem with so many people. The medicine doesn’t work if you don’t take it. And take care of yourself,” he said, adding that he stopped drinking at diagnosis and keeps an eye on fitness.

Workload for researchers still great

While noting the great scientific achievements, which would not have been possible without dedicated volunteers, Campbell, too, emphasized that HIV remains a serious virus with no cure. “Yes, a person diagnosed today who seeks treatment early and adheres to it should live a near-normal lifespan,” Campbell said. “But near normal is not normal. There’s still a lot of work that needs to be done.”

The to-do list for HIV/AIDS researchers remains long, with vaccine trials still underway, and development of a cure feasible but probably not within close reach, Campbell said. Continuing efforts to treat HIV patients in developing countries remains a priority, as does boosting prevention education.

For instance, use of an antiretroviral drug combination called PrEP in high-risk individuals who are not yet infected can reduce their chances of contracting HIV, and early treatment in patients already infected can not only boost their chances of success; it reduces the virus’s spread, Campbell said. “So we not only help them, but we help the rest of the community.”

Dillon said he’s grateful for that first social worker’s hopeful words and for finding the ACTU at CU at the right time. “It saved my life, and it saved a lot of other lives.”

Photo at top: Constance Benson, MD, Robert “Chip” Schooley, MD, and Thomas Campbell, MD, attended a recent Zimbabwe Art and Sculpture Auction in the Fulginiti Pavilion.

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New service offers fast, standardized results for eating disorder experts

Eating disorder researchers at the University of Colorado Anschutz Medical Campus have developed a new procedure that takes detailed patient questionnaires and generates a fast, standardized score for mental health professionals.

The service is available free to doctors, psychologists and other health professionals working with patients who have eating disorders.

Dr. Guido Frank, associate professor of psychiatry, is an expert in eating disorders

“Despite all the research, the fact is we still have limited treatments available in the field of eating disorders,” said Guido Frank, MD, eating disorder expert and associate professor of psychiatry and neuroscience at the University of Colorado School of Medicine. “But if we clinicians use similar validated assessments across disciplines and providers, the field of eating disorders will be more cohesive and more evidence-based.”

Frank and his fellow researchers, developed a web-based service where therapists can sign in patients. The patients fill out questionnaires developed for those with disorders like anorexia nervosa, bulimia and binge eating. Using a computer program, the questionnaire is automatically scored with a number that health care providers can use to understand the nature of the illness. The scoring process keeps the patients anonymous.

“The therapist receives the results and can discuss them with the patient,” Frank said. “It is purely a free service in the hopes that it will help.”

Frank said the system is unique in offering a standardized scoring method while bringing the latest science to practitioners in the field.

“Sometimes the work we do is hard to translate into the real world so we trying to close that research gap,” he said. “This shared knowledge, I believe, will help us  personalize treatment and provide evidence-based interventions that are tailored to individual needs.”

Here is the general /primary link to the service portal: Know Your Client/Know Your Patient

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Program reduces high ED use, increases primary care visits for most vulnerable patients

Researchers at the University of Colorado Anschutz Medical Campus  have found that a community-based program aimed at high users of hospital emergency departments (EDs), reduced ED visits and hospital admissions,  while increasing use of primary care providers.

“Many programs have tried to tackle the problem of high utilizers of hospital emergency departments. These are usually people who are on Medicaid,” said the study’s first author Roberta Capp, MD, an assistant professor of emergency medicine at the University of Colorado School of Medicine. “But this is the first program to show that care coordination actually works.”

The study was published October 2, 2017 in the journal Health Affairs http://bit.ly/2fJUIaq.

Dr. Roberta Capp, assistant professor of emergency medicine, is the first author on the study.
Dr. Roberta Capp, assistant professor of emergency medicine, is the first author on the study.

Capp and her fellow researchers implemented and evaluated Bridges to Care (B2C), an ED-initiated, community-based program. It was one of four sites funded by a Center for Medicare and Medicaid Innovations grant.

The program was led by Rutgers University Center for State Health Policy and developed in collaboration with four Colorado stakeholders including an urban academic hospital, a network of 13 local federally qualified health centers, a mental health clinic and a community advocacy organization.

Researchers compared participants in the B2C program, which focused on Medicaid eligible high ED users, with patients who had received standard care with respect to ED utilization, hospital admission and primary care use.

High ED users were identified as adults who had two or more ED visits or hospital admissions within the last 180 days.

During the six months after B2C enrollment, the participants had 29.7 percent fewer ED visits and 30 percent less hospitalizations. At the same time, they had 123 percent more primary care visits than the control subjects.

“There is a perspective from multiple stakeholders that high users of the ED are difficult patients,” Capp said. “But this study shows that patients use the ED because of there are serious barriers to care.

ED care makes up 5 – 6 percent of all healthcare expenses.

Previous studies have shown that providing care-coordination services and better access to primary care can reduce waste in healthcare spending. A number of programs addressing low-income, high users of EDs have been implemented with mixed results. Most were hospital-based with little community involvement.

But Capp said the B2C intervention is the first aimed at high users of EDs to combine active outreach in the ED with multidisciplinary, community-based services.

It offers intensive medical, behavioral health and social care coordination services. That includes providing a care coordinator, a health coach, a behavioral health specialist, a community health worker and frequent home visits.

Each patient was given a personally tailored, 60-day care plan that included, but was not limited to assistance with getting housing resources, refugee services, access to transportation, help with applying for insurance and disability benefits, setting up primary and specialty care and filling prescriptions.

“We believe that our success stems from bringing together different healthcare systems, breaking down silos between disciplines and focusing on continuity of care in the outpatient setting,” Capp said.

The study shows just how intense the services offered to this population must be to reduce their reliance on EDs. One reason is that they often have chronic diseases, including mental illness.

“We learned that active outreach in the ED is key to ensuring successful high utilizer and enrollment and engagement,” the study said.

For example, early in the study, the team used call back lists and enrolled only 80 patients in seven to eight months, but when a community health worker was embedded in the ED, enrollment over the same period of time tripled.

“For a program like B2C to be effective, behavioral health services must be provided to high utilizers to ensure comprehensive, multidisciplinary care,” Capp said.

She hopes federal lawmakers examining the Affordable Care Act will evaluate the program as a more cost efficient way of providing high quality care to the most vulnerable.

Co-authors of the study from CU Anschutz include Benjamin Honigman, MD, professor of emergency medicine; Jennifer Wiler, MD, associate professor of emergency medicine and Richard Lindrooth, PhD, professor in the department of health systems, management and policy.

 

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An Epic Sprint to aid clinics

In February 2011, the University of Colorado Anschutz Medical Campus took a major step toward fundamentally changing its health care delivery. The change would eventually affect every provider, researcher and staff member on the campus and beyond – and the reverberations continue today.

The revolution began with a handful of ambulatory clinics at University of Colorado Hospital that began using the Epic electronic health record (EHR). The aim: shelve dozens of discrete applications and towering paper stacks in favor of a single system that would allow all providers to view a patient’s entire medical record online.

Sprint Team Conference Room
Sprint team at work near the end of its four weeks of work in the OB/Gyn Clinic.

The Epic implementation included a massive training effort and a phased, multi-year rollout that ensconced the EHR on the Anschutz Medical Campus and at UCH satellite clinics. With the formation and growth of UCHealth, Epic now links hospitals and clinics up and down the Front Range and beyond.

But the challenges of ­working efficiently and effectively with an EHR remain. Memorizing sequences of clicks in record charting can be frustrating for providers focused on patient care. Patients now have an electronic conduit to their providers through My Health Connection; figuring out how best to route and respond to questions can be challenging and time-consuming for clinics. The basic Epic framework requires ongoing customization to meet the needs of dozens of specialists and subspecialists – most them with the CU School of Medicine – and their UCHealth patients.

These challenges help to explain why Epic training, in the form of tip sheets, webinars, emails, and other support, has never ended. The past year has produced a new twist: a dedicated team that gives clinic providers and staff focused, face-to-face help with making the most of the EHR.

On the run

The Sprint team, as it’s called, consists of Epic analysts, trainers, and a project manager, as well as a nurse and physicians who combine clinical and information technology skills. Together they help to define the clinical and operational needs of providers and staff and collaborate with IT, clinical and other experts to meet them. Their guiding principle: people learn best when they have face-to-face help from people who are interested in listening to them, answering their questions and solving their problems.

“It’s a collaborative effort,” said Christine Gonzalez, the Sprint team’s project manager. “When you need to make rapid changes, nothing beats live help. Providers and staff feel safe with working one-on-one.”

The Sprint team is a response to a problem that is both local and national, said Amber Sieja, MD, a physician informaticist for the Anschutz Medical Campus and an internist with the CU School of Medicine. Maintaining paper medical records might have been cumbersome, but for many providers meeting the demands of an electronic system has made practicing medicine more difficult than ever.

“The problem we face is that providers are burned out with their clinical practice,” Sieja said. She noted that in national surveys, providers routinely identify EHRs as a major contributor to that problem. “Locally, our providers have told us the EHR takes up too much time,” she added. “That’s our problem to solve.”

That’s a tall order, however. Epic is a dynamic tool that receives annual upgrades as well as ongoing customized changes for specific clinical areas. How to communicate the changes to the couple of thousand providers with the School of Medicine and UCHealth Medical Group? The Epic team has tried spreading the word with regularly scheduled Skype videos, newsletters, tip sheets, and open training sessions. It’s all fallen well short of reaching anywhere near most providers, Sieja said.

“The message we got is ‘we want somebody in our clinics,’” she said.

Face time

Sprint Team
Members of the Epic Sprint team outside the OB/Gyn Clinic at University of Colorado Hospital. Left to right, back row: Amber Sieja, MD – physician informaticist; Todd Andrews – lead analyst; Dan Golightly – analyst; Rob Lewis – analyst; Dan Kroening – trainer; Diane Pruitt, RN – clinical informaticist. Left to right, front row: Scott Carpenter – lead trainer; Barbara Noble – trainer; Christine Gonzalez – project manager; Megan Cortez – analyst; Tally Talyai, PA – physician informaticist.

That demand spurred the creation of the first “Sprint” in 2016. Sieja, fellow physician informaticist Katie Markley, MD, and UCHealth Chief Medical Information Officer CT Lin, MD, put together a team that parachuted into the Endocrinology Clinic at UCH for a two-week, hands-on helping stint. Their work drew praise from both providers and staff for helping to decrease burnout, reduce charting time and improve patient care.

The Endocrinology pilot wasn’t perfect, Sieja said. Most importantly, it showed that future Sprint projects would need more lead time to prioritize clinic needs, schedule rooms and meeting times, identify potential new EHR builds, and so on. They settled on 90 days of preparation, said Sieja, who used that time to develop a curriculum for the Neurology Clinic at UCH.

The Sprint project in Neuro, which began in January 2017, represented a major challenge. Its nearly 100 providers handled more than 26,000 patient visits in 2016. It also includes eight subspecialties, all with specific patient care needs. A major part of the work involved meeting with “clinical content leaders” to identify priorities for new Epic builds, such as flowsheets to help ensure that patients with neuromuscular diseases like ALS (amyotrophic lateral sclerosis, or Lou Gehrig’s disease) and other complex neurologic conditions receive evidence-based standards of care.

“These are tools that allow us to track patients over time,” said Laura Strom, MD, an epilepsy specialist who helped to lead the Sprint effort in the Neurology Clinic. “They are invaluable in Epic.” The flowsheets, however, had to be built from scratch, a time-consuming process, she added. All told, seven subspecialties requested and received customized builds as part of the Sprint project.

The Sprint team spent a pair of two-week stints, separated by a one-week break, in the Neurology Clinic, wrapping up the work in February. Much of the effort focused on helping providers use Epic more efficiently for their basic work: pulling needed information from patient charts; ordering labs, imaging studies and other tests; responding to patient questions and referral requests; and preparing to address patients’ chief complaints in advance of the visit. Providers learned to use templates, preference lists, keywords and phrases, and other shortcuts to reduce the number of clicks – and therefore time – they spend at the keyboard, Sieja said.

Making work simpler

The key is to reduce frustration with practical help, said Gonzalez, who handles the planning, coordination and other logistical details of each Sprint mission.

“I feel we come in to take a good tool [Epic] that we already have and make it better,” Gonzalez said. Many providers on the Anschutz Medical Campus, she noted, have not had additional guidance in using Epic since the first go-live six-plus years ago.

“Who doesn’t need more training?” Gonzalez asked. She cited the example of a UCHealth Colorado Springs provider who was surprised when she found how much time she could save by using Epic’s Dragon voice-recognition software for her progress notes instead of typing. The shortcut helped her get home to her family earlier.

“She told us the change helped her to become a better mother,” Gonzalez said.

Strom said more than 90 percent of the Neurology Clinic’s providers received the Sprint training in some form. The attention generally helped to increase individuals’ confidence in using shortcuts in Epic to trim their documentation time, she said. One example: “dictionaries” Epic uses to translate shorthand for frequently used terms into the real word.

“People applauded the one-on-one teaching,” Strom said. Some critics of Epic who had viewed it as nothing more than a “billing tool,” she added, changed their minds after the Sprint initiative.

“They saw that Epic could be used to take better care of patients and to help to improve the growth of understanding about their disease,” Strom said. A post-intervention survey showed that both providers and staff viewed Epic in a more favorable light than they had before the Sprint team worked with them. For example, the percentages of those who agreed that the clinic improved its use of the EHR and the patient care it provided increased significantly in both groups.

The Sprint team followed the Neurology Clinic assignment with a regular schedule of visits to UCHealth facilities in Northern and Southern Colorado as well as the Anschutz Medical Campus. For example, they worked with the respective Hematology/Oncology practices at UCHealth’s Memorial Hospital in Colorado Springs and Poudre Valley Hospital in Fort Collins. They wrapped up a four-week stint with the OB/Gyn Clinic at UCH – another with close to 100 providers and several subspecialties – on July 21. They are booked on a two-week on, one-week off schedule through June 2018 (with some extra time off for the next Epic upgrade this October), Gonzalez said.

Important challenges remain, including how to ensure that the positive changes in clinics visited by Sprint continue. Sieja points to the importance of super users and clinical content leaders to “carry the improvements forward.” Sprint success also brings to light questions of “scalability,” said Chief Medical Information Officer Lin, noting that it could be increasingly difficult for a single Sprint team to meet clinic demand. For now, the team splits to work with clinics with fewer providers and subspecialists.

“We need people to bring along others at the basic level,” Strom agreed. “But the sense of what is possible with Epic is now much more keen. More people are saying, ‘We really can use this tool.’”

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Researchers find creosote bush could treat Giardia and brain-eating amoeba infections

Compounds produced by the creosote bush, a desert shrub common to American Southwest, exhibit potent anti-parasitic properties against two deadly parasites responsible for Giardia infections (Giardia lamblia) and the amoeba that causes an often-lethal form of encephalitis (Naegleria fowleri), according to researchers at the Skaggs School of Pharmacy and Pharmaceutical Sciences at CU Anschutz and UC San Diego.

Daniel LaBarbera, PhD, associate professor of drug discovery and medicinal chemistry at Skaggs School of Pharmacy and Pharmaceutical Sciences.
Daniel LaBarbera, PhD, associate professor of drug discovery and medicinal chemistry at Skaggs School of Pharmacy and Pharmaceutical Sciences.

The findings, published online this month in PLOS Neglected Tropical Diseases, may give scientists the chance to widen their arsenal of antimicrobial agents effective against deadly parasitic infections. The current standard treatment for both infections involve antibiotics and anti-parasitic drugs.

The World Health Organization estimates giardiasis, a diarrheal illness, is linked to approximately 846,000 deaths worldwide each year. Infection usually occurs through ingestion of contaminated water or food. Though rarely lethal in the United States, it’s estimated there are more than a million cases of giardiasis in the country annually. Infections due to N. fowleri, sometimes called the `brain eating amoeba,’ are much less common than Giardia.

Compounds from the creosote bush may fight two deadly parasitic infections.
Compounds from the creosote bush may fight two deadly parasitic infections.

“However, it is a far deadlier parasite that is found in warm fresh waters and infects the central nervous systems of their victims through the nasal passages causing lethal brain damage known as primary amoebic meningoencephalitis (PAM),” said principal investigator Dan LaBarbera, PhD, associate professor of drug discovery and medicinal chemistry at the Skaggs School of Pharmacy and Pharmaceutical Sciences at CU Anschutz.

Due to its rapid infection cycle and high mortality rate, the CDC has been given special approval to provide the drug miltefosine to clinicians as a treatment option for N. fowleri infection. But it is still not FDA approved and has limited availability in the U.S. This new compound potentially provides a less expensive, more effective treatment option.

Scientists from CU Anschutz and UC San Diego collaborated as part of the Skaggs Scholars program, which matches investigators from Skaggs-funded schools of pharmacy with complementary expertise to discover potential drug breakthroughs. UC San Diego scientists provided expertise in parasitology, while the CU Skaggs School of Pharmacy provided expertise in natural products, compound libraries and active compounds from plants. The researchers investigated these tropical diseases because of their occurrence in Mexico and South America and found indigenous peoples treating infections with creosote compounds.

“The significance and intrigue about our study is that it shows the value of prospecting for new medicines from plants traditionally used by indigenous people as medicine,” said co-principal investigator Anjan Debnath, Ph.D., an assistant adjunct professor at Skaggs School of Pharmacy and Pharmaceutical Sciences at UC San Diego.

The creosote bush (Larrea tridentata), is a tough evergreen bush with small waxy leaves, yellow flowers and a distinctive turpentine-like scent. Native Americans in both the United States and Mexico have long used the plant for a variety of ailments, including intestinal complaints. There is also an existing body of scientific work documenting the plant’s pharmacologically active compounds, notably nordihydroguaiaretic acid (NDGA). NDGA has antiviral, antibacterial, anti-inflammatory and anticancer properties.  The study is the first to show that NDGA and five other compounds are active against both pathogenic parasites.

In other studies, NDGA has been shown to be a neuroprotective agent. It protects human monocytes and other cells and tissues through its powerful antioxidant activity.

“In our study the creosote natural product, NDGA, proved to be a more potent anti-parasitic agent against N. fowleri compared to miltefosine,” LaBarbera said. “Therefore, NDGA may lead to a more effective drug therapy option for N. fowleri infection.”

This research was funded in part, by a grant from The ALSAM Foundation and National Institutes of Health.

 

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Major communication gaps between doctors and home health care nurses revealed

Researchers at the University of  Colorado Anschutz Medical Campus have found serious gaps in communication between physicians and home health care agencies (HHC) responsible for caring for often elderly patients discharged from hospitals. The problem, the study said, can contribute to hospital readmissions.

The research, published today in the Journal of General Internal Medicine, cites an array of communication challenges between HHC agencies and physicians following hospital discharge.

Dr. Christine Jones, assistant professor of medicine and lead author of the study.
Dr. Christine Jones, MD, MS, assistant professor of medicine and lead author of the study.

The study cited frequent discrepancies in medication lists, confusion over who was responsible to write patient care orders, inaccessible hospital records and resistance from clinicians and staff for accountability.

Led by Christine D. Jones, MD, MS, assistant professor at the University of Colorado School of Medicine, the researchers conducted six focus groups with HHC nurses from six different agencies in Colorado to ask about their general experience with caring for patients after discharge from any of their referring hospitals.

“We found that communication breakdowns can have consequences for patients,” said Jones, lead author of the study. “These are some of our most fragile patients, most are over 65, and more seamless communication is needed.”

Some of the HHC nurses interviewed complained of a lack of accountability, medical errors and difficulty in reaching doctors.

“As a general rule, I’ve been told you’re not to contact the hospitals. I actually got in trouble for contacting the hospital, trying to find out, get more information, trying to track a doctor down,” one nurse said in a focus group.

Another nurse said even if they reach a primary care physician, they often say they didn’t know the patient was in the hospital and they don’t have a report on them.

“The communication between the hospital and the primary care providers is just as bad as it is for us because the PCP’s don’t have the information,” the nurse said.

Dr. Jones said another complicating factor is that insurance often requires doctors to order HHC services. So if a nurse practitioner is providing primary care for a patient, obtaining HHC immediately becomes more difficult.

The researchers found another serious problem when it came to ordering medication. HHC nurses and staff said most of the medication lists they receive are incorrect due to the number of doctors and specialties involved.

“As hospitalists, we need to think about what happens beyond the hospital walls and how we can support our patients after discharge, especially when it comes to home health care patients who can be very vulnerable.” Jones said.

She noted that the study did not focus on any one specific hospital, but hospitals in general.

The study proposes a series of solutions to these problems including the following:

  • Hospitals and primary care physicians could provide HHC agencies direct access to Electronic Medical Records and direct phone lines to doctors.
  • Enact laws allowing nurse practitioners and physician’s assistants to write HHC orders. A bill was under consideration to do this but was not acted upon by Congress.
  • Clearly establishing accountability for hospital clinicians to manage HHC orders until a primary care physician can see a patient and help HHC nurses with questions.
  • Create better communication methods with PCPs to ensure safer transitions

“Our findings suggest that improvements to accountability and communication could address patient needs and goals, avoid medication discrepancies and ultimately improve safety for patients and HHC nurses,” Dr. Jones said.

 

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Senior Executives from Film and Virtual Reality Industries Join NBHIC

The National Behavioral Health Innovation Center announced today that Rick Rekedal, a former senior executive with DreamWorks Animation, and Dr. Walter Greenleaf, a pioneer and leading authority on virtual reality for medical use, have joined its staff.

Rick Rekedal joins NBHIC as Senior Creative Advisor
Rick Rekedal joins NBHIC as Senior Creative Advisor

“Walter and Rick are recognized internationally as leaders in their fields,” said Matt Vogl, executive director of NBHIC at the University of Colorado Anschutz Medical Campus. “Their knowledge and insight are powerful assets to our mission of finding bold new solutions to the country’s mental health crisis.”

In 2016, Rekedal completed over 20 years with DreamWorks as Chief Creative of franchise development and the global franchise director of the hit movie “Trolls.” Rekedal has also worked on properties such as “How To Train Your Dragon,” “Shrek,” “Kung Fu Panda,” and “The Lost World: Jurassic Park,” developing merchandising, interactive and licensing programs. Rekedal’s work has been recognized with two Annie Awards, two Kids Choice Awards and Toy of the Year. He is a frequent speaker and serves on advisory boards for The Wedgwood Circle; Michael W. Smith Group and Seabourne Pictures; and Belmont University’s film school.

Dr. Walter Greenleaf is NBHIC’s new Director of Technology Strategy
Dr. Walter Greenlef joins NBHIC as Director of Technology Strategy

Rekedal joins NBHIC as Senior Creative Advisor, consulting on how to elevate an open and urgent national conversation on mental health.

Greenleaf is a behavioral neuroscientist and a medical product developer who has been on the cutting edge of virtual reality and augmented reality applications in healthcare for more than 30 years.

In his role as NBHIC’s Director of Technology Strategy, Greenleaf brings his considerable knowledge to the Center’s approach to digital initiatives. He continues to work as a Visiting Scholar at the Stanford University Virtual Human Interaction Lab.

He has developed several clinical product streams, founded medical companies, and served as a scientific advisor and reviewer for the U.S. Public Health Service, National Science Foundation, National Institutes of Health, NASA and the U.S. Department of Education. He holds a PhD in Neuro and Bio-behavioral Sciences from Stanford University.

“Our approach is to seek out unexpected partners as we look beyond the current mental health system for new solutions,” said Vogl. “Walter and Rick fit that approach. Walter’s depth of knowledge in virtual reality and Silicon Valley are leading us to work with new technology partners in developing cutting edge tools for mental health treatments. Rick’s extraordinary creative abilities can help steer powerful human connections to combat the awful stigma that is so harmful to many people in need.”

Guest contributor: Lauren Baker, marketing and communications strategist for the National Behavioral Health Innovation Center at CU Anschutz.

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