Margaret M. Paul

Introduction/Objectives: The rise in screening for social drivers of health (SDoH) in primary care settings has led to questions about effective intervention design. A large primary care practice at Mayo Clinic developed a model centered on a full-time Health Equity Coordinator (HEC) to facilitate clinic-community partnerships in 2022. The goal of this analysis was to assess the model on process outcomes, resolution of SDoH needs, and changes in healthcare utilization. Methods: Using a cohort study design, we identified primary care patients with unmet SDoH needs at the intervention clinic and two comparator clinics from March 2022 to December 2023. We assessed process outcomes descriptively and resolution of SDoH needs and healthcare utilization using multivariable regression. Results: The HEC contacted 348 patients and conducted 748 meetings with community-based organization staff. While there were decreases for SDoH needs and missed or late cancelled appointments in intervention group, there were no significant difference in resolution of SDoH and healthcare utilization relative to comparator groups. Conclusions: The HEC model for multi-stakeholder coordination showed promise in referring patients to services and engaging key stakeholders in a primary care setting. Longer term follow up may be needed to identify changes in SDoH needs and healthcare utilization.

Introduction: Community health workers (CHWs) help patients navigate community resources. CHW programs can improve health outcomes and reduce healthcare utilization, but identifying eligible patients is challenging. We developed an electronic health record (EHR)‐based algorithm trained to predict referrals to a CHW program. Our objective was to evaluate whether an algorithm trained on historical referrals identifies a subgroup of patients that differs from the subgroup identified through questionnaire‐based health‐related social needs (HRSN) screening alone. Methods: This analysis used data from Mayo Clinic primary care patients in Southeast Minnesota. We developed a gradient boosted time‐to‐event model that incorporated demographics, diagnoses, HRSN questionnaire responses, and HRSNs derived from clinical notes using natural language processing. We compared the characteristics of algorithm‐identified patients with those identified through questionnaires and assessed the variable importance of model features. Results: The algorithm had AUC: 0.87 in the training and 0.92 in the hold out set. Patients flagged by the algorithm tended to use interpreter services more commonly (12.6% vs. 1.3%), have a non‐English preferred language (14.1% vs. 2.3%), and have more instances of health literacy documented (5.36 vs. 1.29) compared to patients identified by the HRSN questionnaire. Only 47.0% of patients flagged by the algorithm had responded to the HRSN questionnaire within 2 years. Variable importance was highest for health literacy and financial strain from unstructured notes. Conclusions: The algorithm is a chart‐review prioritization tool for referral to the CHW program for patients that may overcome challenges to identifying patients with HRSNs, especially when questionnaire data is incomplete.

Introduction: Video visits in primary care have decreased significantly since their surge early in the COVID-19 pandemic. Methods: Clinicians including physicians, nurse practitioners, and physician assistants in the Mayo Clinic Department of Family Medicine were invited to dedicate one to two half-days per month exclusively to video visits. Schedules for these half-day sessions remained restricted to video appointments until the day prior. If at least 80% of slots were not filled by then, remaining openings were converted to in-person visits. If the half-day sessions were at least 80% full with video visits, clinicians had the option of performing these sessions remotely. Results: Of 155 eligible clinicians, 34 (22%) participated voluntarily in this scheduling intervention. For the participating clinicians, the average video visit rate increased from 6.3% per month preintervention to 11.5% postintervention ( p < 0.001). On a departmental level, the trend line for the percent of outpatient visits via video visit was decreasing by −0.1% per month preintervention. The postintervention slope of the trend line was 0.3% per month ( p < 0.001). The majority (65%) of the time the half-day video visit schedules filled at least 80% and did not require conversion to allow in-person visits allowing clinicians to work remotely if they chose. Conclusion: Allowing family medicine clinicians to perform 1–2 half-day schedules dedicated to only video visits increases the percentage of video visit performed per month both for individual clinicians and on a departmental level.

INTRODUCTION: Ongoing surveillance after successful endoscopic eradication therapy for Barrett's esophagus (BE)-related neoplasia is essential to detect and manage recurrence. Despite established surveillance interval recommendations after complete eradication of intestinal metaplasia (CE-IM), patient compliance with repeat endoscopy is frequently suboptimal. Understanding patient drivers to adherence is essential to inform interventions that address the high rates of overdue surveillance and loss to follow-up. METHODS: Patients with BE-related neoplasia who achieved CE-IM were eligible for inclusion and classified as delayed or on-time for endoscopic surveillance. Patients were prospectively enrolled and participated in structured virtual interviews designed to explore barriers and facilitators to on-time care. A rapid qualitative analysis approach was applied, continuing until thematic saturation was reached. RESULTS: Thirty-nine patients were interviewed: 22 (56.4%) were delayed, and 17 (43.6%) were on-time for surveillance. Patients in the delayed group had longer mean BE segment lengths and a higher prevalence of tobacco use. Geographic distance from the treatment center was the most frequently cited barrier to follow-up (n = 17; 43.5%). Other common barriers were access limitations, financial concerns, misunderstanding of disease course, and test-related anxiety. DISCUSSION: Patient-related drivers of delay in postendoscopic eradication therapy surveillance are largely logistical, socioeconomical, and psychological in nature. Solutions to reduce the significant burden on the patient and achieve timely surveillance may include transitioning patients back to their local endoscopists after CE-IM or incorporating nonendoscopic surveillance methods through patient centered approaches.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Menopause symptoms are common but often inadequately addressed by primary care clinicians due to limited time for discussions and resources. Mobile health apps can play a crucial role in symptom identification and management; yet, many existing menopause-focused apps lack evidence-based content and medical expertise. Objective: The aim of this study is to describe the protocol study design and methodology of a randomized controlled trial to evaluate the effectiveness of the emmii mobile app for improving menopause-related knowledge and shared decision-making compared to a traditional menopause education pamphlet. Methods: This randomized controlled trial will recruit women aged 45-55 years with upcoming primary care appointments at Mayo Clinic within 3 weeks of the date of initial outreach. Eligible patients must be English-speaking, able to provide informed consent, and report a Menopause Rating Scale score ≥5, which indicates that they are experiencing significant menopause-related symptoms. Patients will be randomized to have access to either the emmii app (intervention, n=200) or an evidence-based menopause education pamphlet (control, n=200). The emmii app is developed with direct input from primary care clinicians certified by The Menopause Society and offers symptom tracking, personalized treatment recommendations based on a protocol, and a discussion guide to support communication between patients and their primary care clinicians. Outcomes will include a postappointment survey sent to the patients and their primary care clinicians within 1-3 weeks of the appointment, and assessment of patient knowledge, clinical treatment plans, and both the patient and clinician experience. The study will also compare prescribing rates of hormonal and nonhormonal therapies for menopause symptoms between the emmii intervention and control groups to assess for influence on treatment patterns. Data will be analyzed using descriptive statistics, including chi-square tests, Wilcoxon rank sum tests, and multivariable modeling. Results: Data collection is scheduled to begin in April 2025. Conclusions: This protocol outlines the design and methodology of a randomized controlled trial that aims to assess the impact of the emmii app in facilitating menopause care through primary care clinician–patient communication and shared decision-making. Trial Registration: ClinicalTrials.gov NCT06919887; https://clinicaltrials.gov/ct2/show/NCT06919887

Despite progress to define primary care practice transformation models, there remain gaps in translating evidence-based guidelines into routine clinical care. Primary care providers (MD, DO, NP, PA) and researchers need tools to assess modifiable factors that improve practice performance to inform practice transformation efforts. We aimed to develop a pragmatic tool for assessing practice-level primary care structures and processes that are associated with better care quality and clinical outcomes. We generated 314 candidate items for the Tool for Advancing Practice Performance (TAPP) using data from a comprehensive literature review, Delphi study, and qualitative interviews with high-performing practices. We used empirical criteria and expert review to eliminate redundancy and improve clarity via removing and retaining items. The retained items were formatted into a survey tool, and we further revised the tool based on feedback elicited from cognitive interviews and pilot testing with primary care providers and staff. The final candidate pool comprised 126 items after refinement and expert review. For the survey tool, we adapted and developed survey questions for each of the 126 items. Eight cognitive interview participants reviewed the tool and provided feedback on its content and language. Based on this feedback, we eliminated 13 items because they were poorly or incorrectly understood by participants, resulting in a 113-item tool. Fifteen participants pilot tested the tool and no additional items were eliminated. The TAPP is a novel, low-burden tool that researchers and primary care providers can use to identify areas for improvement at the practice-level. Practices and health systems could use the TAPP to assess their own performance and identify gaps in their structures and processes, and practice networks and health systems can use the tool to assess structures and processes at individual clinics, track this information over time, and evaluate its relationship to care quality and clinical outcomes.

Introduction: The population in need of primary care is rapidly growing and increasingly complex with respect to chronic disease burden. We must develop alternative and more efficient approaches to managing patients if we are to increase access to care without sacrificing continuity; however, there is little guidance for innovation strategies at the practice level. Methods: The Mayo Clinic Department of Family Medicine engaged in a 2-year multistage planning process to develop plans for the Family Medicine Learning and Experience (FLEX) Lab to identify opportunities for innovation to improve daily practice. The purpose of the FLEX Lab is to drive continuous advancements within the context of our health system with the goal of delivering high-quality care to a greater number of patients while working within the constraints of limited staffing. Results: Key lessons from the planning stage led to the development of a contextualized, incremental, and continuous approach to design and innovation. In its first phase, the FLEX Lab implemented a set of interventions that were novel to the unit itself, including nurse-led hypertension management, task-shifting rooming responsibilities, incorporating telehealth visits into routine clinician schedules, and ambient documentation to replace clinician-generated visit notes. We present a description of the overall FLEX Lab approach including early-stage findings and future work. Conclusions: The FLEX Lab is an adaptable and generalizable example of how health systems can strategically implement practice improvements informed by real-time input from clinicians and staff to support continuous and phased evolution.

Remote patient monitoring (RPM) increased exponentially during the COVID-19 pandemic. RPM programs commonly incorporate tools to capture and transmit health-relevant data from the home to the clinical space to augment the clinical decision-making process of health care providers. Given the potential to improve patient health outcomes, health care systems around the world are actively engaged in fashioning, implementing, and exploring the outcomes of various RPM program models. However, new challenges to health care systems include increasing RPM program enrollment, optimizing condition-specific RPM programs to best address the needs of specific patient groups, integrating new RPM-derived data streams into existing IT infrastructure, overcoming limited availability of desired remote monitoring technologies, and quantifying the health outcomes produced by RPM use. Herein, we identify stakeholders for RPM in the United States, summarize the landscape of RPM tools available for chronic disease management, discuss the current regulatory environment, delve into the benefits and challenges of integrating these tools into clinical practice, summarize aspects of coverage and reimbursement, and examine the knowledge and policy gaps regarding sustained use of RPM in clinical practice, along with associated opportunities.

Qualitative interviews and focus groups are commonly used methods to elicit participants’ voices in program evaluations. However, the use of these data-gathering methods can fall short of the goal; even with open-ended questions, the protocols guiding and shaping interviews and focus groups heavily reflect the evaluators’ understanding and experience of the program or intervention under consideration and its target population(s). In this paper, we describe three cases that employed a method of inquiry that is underutilized in evaluation but one that we believe holds great potential as a method to enhance interpersonal reflexivity, namely participant-generated photo-elicitation interviewing (PEI). Across three diverse settings and interventions, we readily added participant-generated PEI to our mixed methods evaluations. We found participant-generated PEI to add great value to the evaluations by complementing our other data collection methods, allowing for greater participant voice, challenging evaluators’ assumptions, enhancing dissemination efforts, and fostering our reflexivity.

BACKGROUND Menopause symptoms are common but often inadequately addressed by primary care clinicians due to limited time for discussions and resources. Mobile health apps can play a crucial role in symptom identification and management; yet, many existing menopause-focused apps lack evidence-based content and medical expertise. OBJECTIVE The aim of this study is to describe the protocol study design and methodology of a randomized controlled trial to evaluate the effectiveness of the emmii mobile app for improving menopause-related knowledge and shared decision-making compared to a traditional menopause education pamphlet. METHODS This randomized controlled trial will recruit women aged 45-55 years with upcoming primary care appointments at Mayo Clinic within 3 weeks of the date of initial outreach. Eligible patients must be English-speaking, able to provide informed consent, and report a Menopause Rating Scale score ≥5, which indicates that they are experiencing significant menopause-related symptoms. Patients will be randomized to have access to either the emmii app (intervention, n=200) or an evidence-based menopause education pamphlet (control, n=200). The emmii app is developed with direct input from primary care clinicians certified by The Menopause Society and offers symptom tracking, personalized treatment recommendations based on a protocol, and a discussion guide to support communication between patients and their primary care clinicians. Outcomes will include a postappointment survey sent to the patients and their primary care clinicians within 1-3 weeks of the appointment, and assessment of patient knowledge, clinical treatment plans, and both the patient and clinician experience. The study will also compare prescribing rates of hormonal and nonhormonal therapies for menopause symptoms between the emmii intervention and control groups to assess for influence on treatment patterns. Data will be analyzed using descriptive statistics, including chi-square tests, Wilcoxon rank sum tests, and multivariable modeling. RESULTS Data collection is scheduled to begin in April 2025. CONCLUSIONS This protocol outlines the design and methodology of a randomized controlled trial that aims to assess the impact of the emmii app in facilitating menopause care through primary care clinician–patient communication and shared decision-making. CLINICALTRIAL ClinicalTrials.gov NCT06919887; https://clinicaltrials.gov/ct2/show/NCT06919887 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/76536