Sandra A. Ham

Background: Mental health conditions are often underdiagnosed and undertreated in primary care, particularly in underserved areas. Integrated behavioral health models can address this gap, but their reliance on mental health professionals may limit scalability. A multi-level intervention based on the chronic care model may enhance mental health care delivery in resource-limited settings. Objective: To evaluate the effectiveness of a chronic care model–based primary care behavioral health integration program for improving the diagnosis and management of mental health conditions in a primary care setting. Design: Quasi-experimental, pre-post observational study using interrupted time series analysis over a 10-year period (2010–2019). Participants: In total, 59,723 adult patients aged >18 who had at least two medical visits between 2010 and 2019. The patient population was 58% non-Hispanic Black, 29% non-Hispanic White, and 64% female. Interventions: Implementation of clinical decision support systems for common mental health conditions (e.g., depression, anxiety, ADHD), self-management support, delivery system re-design within integrated behavioral health services, and health system community support with weekly behavioral health tips. Main Measures: Changes in the rate of mental health diagnoses and follow-up care (including psychiatric medications, referrals to psychiatry or behavioral medicine, and primary care visits with a mental health diagnosis). Key Results: The rate of mental health diagnoses increased by 58.8 per 1000 person-years in the first year after intervention implementation ( p = 0.001). Follow-up care in primary care increased by 102.1 per 1000 person-years ( p = 0.03), while psychiatry referrals decreased by 59.8 per 1000 person-years annually after the intervention ( p = 0.004). Conclusions: This chronic care model-based system-level intervention was associated with significant increases in mental health diagnosis and treatment within primary care. Expanding the role of primary care in managing mental health conditions may offer a scalable solution to mental health professional shortages, especially in underserved areas.

Many physicians are blaming electronic health records for decreasing the time they spend with patients, increasing their documentation burden, and making them feel burned out. Some practices are us... Visual Productivity Requirements for Implementing Medical Scribes Many physicians are blaming electronic health records for decreasing the time they spend with patients, increasing their d... Background: Economic analyses of medical scribes have been limited to individual, specialty-specific clinics. Objective: To determine the number of additional patient visits various specialties wou...

Immunosuppressive regimens associated with organ transplantation increase the risk of developing cancer. Transplant candidates and recipients with prostate cancer are often treated, even if low-risk features would ordinarily justify active surveillance. Using SEER-Medicare, we identified 163 676 men aged 66 years and older diagnosed with nonmetastatic prostate cancer. History of solid organ transplant was identified using diagnosis or procedure codes. A propensity score-matched cohort was identified by matching transplanted men to nontransplanted controls by age, race, region, year, T-stage, grade, comorbidity, and cancer therapy. Fine-Gray competing risk models assessed associations between transplant status and prostate cancer-specific mortality (PCSM) and overall mortality (OM). We identified 620 men (0.4%) with transplant up to 10 years before (n = 320) or 5 years after (n = 300) prostate cancer diagnosis and matched them to 3100 men. At 10 years, OM was 55.7% and PCSM was 6.0% in the transplant cohort compared with 42.4% (P < .001) and 7.6% (P = .70) in the nontransplant cohort, respectively. Adjusted models showed no difference in PCSM for transplanted men (hazard ratio = 0.88, 95% confidence interval = 0.61 to 1.27, P = .70) or differences by prostate cancer therapy. Among 334 transplanted men with T1-2N0, well or moderately differentiated “low-risk” prostate cancer, PCSM was similar for treated and untreated men (hazard ratio = 0.92, 95% confidence interval = 0.47 to 1.81). Among men aged 66 years and older with prostate cancer, an organ transplant is associated with higher OM but no observable difference in PCSM. These findings suggest men with prostate cancer and previous or future organ transplantation should be managed per usual standards of care, including consideration of active surveillance for low-risk cancer characteristics.

OBJECTIVE To examine for a legacy effect of early glycemic control on diabetic complications and death. RESEARCH DESIGN AND METHODS This cohort study of managed care patients with newly diagnosed type 2 diabetes and 10 years of survival (1997–2013, average follow-up 13.0 years, N = 34,737) examined associations between HbA_1c 1c. RESULTS Compared with HbA_1c 1c levels ≥6.5% (≥48 mmol/mol) were associated with increased microvascular and macrovascular events (e.g., HbA_1c 6.5% to 1c levels ≥7.0% (≥53 mmol/mol) were associated with increased mortality (e.g., HbA_1c 7.0% to 1c levels ≥8.0% (≥64 mmol/mol) were associated with increasing microvascular event and mortality risk. CONCLUSIONS Among patients with newly diagnosed diabetes and 10 years of survival, HbA_1c levels ≥6.5% (≥48 mmol/mol) for the 1st year after diagnosis were associated with worse outcomes. Immediate, intensive treatment for newly diagnosed patients may be necessary to avoid irremediable long-term risk for diabetic complications and mortality.

Background: Physicians often receive feedback on their quality of diabetes care. However, it is unclear what performance measures (e.g., blood pressure targets) are used in this feedback, whether these measures correspond with diabetes care guideline recommendations, and whether feedback affects their clinical practice. Methods: In 2016, we mailed a national survey to 1,200 U.S. primary care physicians and endocrinologists. We excluded physicians who did not provide longitudinal care to patients with type 2 diabetes (adjusted response rate, 41% (N=356)). Physicians were asked to report whether they received feedback on their quality of diabetes care, the hemoglobin A_1c (A1C), cholesterol, and blood pressure (BP) goals they were encouraged to reach, and the usual A1C, cholesterol, and BP goals they recommend to their patients. Results: In total, 56% of physicians reported receiving feedback. Among those who received feedback, the most frequent goals were an A1C, 53%; cholesterol, 51%; systolic BP, 45%; diastolic BP, 47%). Only 22% of physicians reported that receiving feedback on their quality of diabetes care affected their treatment decisions “most of the time”/“almost always,” compared to 40% and 38% reporting “sometimes” and “never”/“rarely,” respectively. Conclusions: Many U.S. physicians are being measured on their quality of diabetes care using performance measures that are inconsistent with diabetes care guidelines and national quality standards. Further, many physicians may not be strongly influenced by diabetes performance measurement. These discrepancies suggest that the impact of physician feedback on quality of diabetes care may be limited. Disclosure P. Zarei: None. S.A. Ham: None. A. Nathan: None. L. Sepulveda: None. R.M. Sargis: Advisory Panel; Self; CVS/Caremark. M.T. Quinn: None. E. Huang: None. N. Laiteerapong: None.

Background: In recent clinical trials, some SGLT2is and GLP-1 receptor agonists have been shown to reduce cardiovascular events, leading to their prioritization for patients with cardiovascular disease in diabetes care guidelines. However, because these medications are costly, oftentimes medication access is limited by insurance companies. Objectives: To determine the frequency that physicians encounter cost-related barriers to prescribing new diabetes medications. Methods: We mailed a survey to a national sample of 720 primary care physicians (PCPs) and 480 endocrinologists in 2016 (adjusted response rate, 41%). Physicians were asked how often their patients were unable to start a new diabetes medication in general, and, specifically, an SGLT2i, because it was too expensive. Physicians also reported the frequency of completing a prior authorization (PA) for a new diabetes medication. Results: In 2016, 28% (N=101) and 37% (N=129) of physicians reported that their patients were unable to start medications in general, and specifically, SGLT2is, due to costs “most of the time”/“always.” More PCPs (45%, N=86) than endocrinologists (26%, N=43) were unable to start SGLT2is due to costs. Daily PA were reported by 43% of physicians (N=151); 62% (N=101) endocrinologists completed PAs daily. Adjusting for specialty and panel size, physicians with >50% of patients age >65 were more likely to report that patients were unable to start a new medication or SGLT2i due to costs (OR=2.25, 95% CI=1.38-3.67; p=0.001 and OR=1.63, CI=1.02-2.60, p=0.04). Endocrinologists (OR=5.03, CI=3.09-8.18; p1000 patients in their panel (OR=2.69, CI=1.61-4.49; p<0.001) were more likely to complete PAs daily. Conclusions: U.S. physicians experience significant cost-related barriers to prescribing new diabetes medication classes. Pharmacy benefit management strategies will need to be updated to facilitate access to glucose-lowering medications with clear cardiovascular benefit. Disclosure: S.A. Ham: None. A. Nathan: None. N. Laiteerapong: None. R.M. Sargis: Advisory Panel; Self; CVS/Caremark. M.T. Quinn: None. E. Huang: None.