25 research outputs found

    Effect of a Clinical Evidence Technology on Patient Skin Disease Outcomes in Primary Care: A Cluster-Randomized Controlled Trial

    Get PDF
    Objective: Providers’ use of clinical evidence technologies (CETs) improves their diagnosis and treatment decisions. Despite these benefits, few studies have evaluated the impact of CETs on patient outcomes. Investigators evaluated the effect of one CET, VisualDx, on skin problem outcomes in primary care. Methods: The cluster-randomized controlled pragmatic trial was set in outpatient clinics at an academic medical center in the Northeast. Participants were Primary Care Providers (PCPs) and adult patients seen for skin problems. The intervention was VisualDx as used by PCPs. Outcomes were patient-reported time from index clinic visit to problem resolution, and the number of follow-up visits to any provider for the same problem. PCPs assigned to intervention agreed to use VisualDx as their primary evidence source for skin problems. Control group PCPs agreed not to use VisualDx. Investigators collected outcome data from patients by phone at 30 day intervals. Cox proportional hazards models assessed time to resolution. Wilcoxon-rank sum tests and logistic regression compared return appointments. Results: Thirty-two PCPs and 433 patients participated. In proportional hazards modelling adjusted for provider clusters, the days from index visit to skin problem resolution were similar in both groups (HR 0.92; CI 0.70, 1.21 P= 0.54). Patient follow-up appointments did not differ significantly between groups (OR 1.26 95% CI 0.94, 1.70 P =0.29). Conclusion: This pragmatic trial tested the effectiveness of VisualDx on patient reported skin disease outcomes in a generalizable clinical setting. There was no difference in skin problem resolution or number of follow-up visits when PCPs used VisualDx

    Barriers and Facilitators to Use of a Clinical Evidence Technology for Management of Skin Problems in Primary Care: Insights from Mixed Methods

    Get PDF
    Background: A previous cluster-randomized controlled trial tested the effectiveness of a clinical evidence technology (CET), VisualDx, for skin problems seen by Primary Care Providers (PCPs). Based on patient report, there was no effect on time to problem resolution or return appointments. Objective: To explain, from the provider perspective, why the CET did not make a difference in the clinical trial and to identify barriers and facilitators to use. Methods: Mixed methods study design. Providers from both arms completed a survey about their use of VisualDx and information-seeking during and after the trial. Active arm providers participated in interviews to explore their opinions and experiences using VisualDx. Behavioral steps of the evidence-based medicine (EBM) paradigm informed the 6 step model. Results: PCPs found VisualDx easy to use (median 3 on a 1-4 scale), but found it only somewhat useful (median 2 on a 1-4 scale). PCPs with fewer years in practice used it more often and found it easier to use. Interviews identified facilitators and barriers to using VisualDx. Facilitators included diagnostic uncertainty, positive attitude, easy access, utility for diagnosis and therapy decisions, and utility for patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulty, and retrieval of irrelevant diagnoses and images. Some PCPs reported positive impacts on patient treatment and fewer referrals; others saw no difference. PCPs found VisualDx easy to access, but some found the interface difficult to use. They found it useful and relevant at times, but also frustrating and time-consuming. They used other sources in addition to, or instead of, VisualDx. Conclusion: PCPs did not perceive VisualDx as “useful” often enough for them to use it frequently or exclusively, thereby reducing the likelihood of its making a difference in patient-level outcomes such as problem resolution and return appointments

    Barriers and Facilitators to Use of a Clinical Evidence Technology in the Management of Skin Problems in Primary Care: Insights from Mixed Methods

    Get PDF
    Objective: Few studies have examined the impact of a single clinical evidence technology (CET) on provider practice or patient outcomes from the provider’s perspective. A previous cluster-randomized controlled trial with patient-reported data tested the effectiveness of a CET (i.e., VisualDx) in improving skin problem outcomes but found no significant effect. The objectives of this follow-up study were to identify barriers and facilitators to the use of the CET from the perspective of primary care providers (PCPs) and to identify reasons why the CET did not affect outcomes in the trial. Methods: Using a convergent mixed methods design, PCPs completed a post-trial survey and participated in interviews about using the CET for the management of patients’ skin problems. Data from both methods were integrated. Results: PCPs found the CET somewhat easy to use but only occasionally useful. Less experienced PCPs used the CET more frequently. Data from interviews revealed barriers and facilitators at four steps of evidence-based practice: clinical question recognition, information acquisition, appraisal of relevance, and application with patients. Facilitators included uncertainty in dermatology, intention for use, convenience of access, diagnosis and treatment support, and patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulties, presence of irrelevant information, and lack of decision impact. Conclusion: PCPs found the CET useful for diagnosis, treatment support, and patient communication. However, the barriers of interface difficulties, irrelevant search results, and preferred use of other sources limited its positive impact on patient skin problem management

    The use of insulin declines as patients live farther from their source of care: results of a survey of adults with type 2 diabetes

    Get PDF
    BACKGROUND: Although most diabetic patients do not achieve good physiologic control, patients who live closer to their source of primary care tend to have better glycemic control than those who live farther away. We sought to assess the role of travel burden as a barrier to the use of insulin in adults with diabetes METHODS: 781 adults receiving primary care for type 2 diabetes were recruited from the Vermont Diabetes Information System. They completed postal surveys and were interviewed at home. Travel burden was estimated as the shortest possible driving distance from the patient's home to the site of primary care. Medication use, age, sex, race, marital status, education, health insurance, duration of diabetes, and frequency of care were self-reported. Body mass index was measured by a trained field interviewer. Glycemic control was measured by the glycosolated hemoglobin A1C assay. RESULTS: Driving distance was significantly associated with insulin use, controlling for the covariates and potential confounders. The odds ratio for using insulin associated with each kilometer of driving distance was 0.97 (95% confidence interval 0.95, 0.99; P = 0.01). The odds ratio for using insulin for those living within 10 km (compared to those with greater driving distances) was 2.29 (1.35, 3.88; P = 0.02). DISCUSSION: Adults with type 2 diabetes who live farther from their source of primary care are significantly less likely to use insulin. This association is not due to confounding by age, sex, race, education, income, health insurance, body mass index, duration of diabetes, use of oral agents, glycemic control, or frequency of care, and may be responsible for the poorer physiologic control noted among patients with greater travel burdens

    Observation of gravitational waves from the coalescence of a 2.5−4.5 M⊙ compact object and a neutron star

    Get PDF

    Ultralight vector dark matter search using data from the KAGRA O3GK run

    Get PDF
    Among the various candidates for dark matter (DM), ultralight vector DM can be probed by laser interferometric gravitational wave detectors through the measurement of oscillating length changes in the arm cavities. In this context, KAGRA has a unique feature due to differing compositions of its mirrors, enhancing the signal of vector DM in the length change in the auxiliary channels. Here we present the result of a search for U(1)B−L gauge boson DM using the KAGRA data from auxiliary length channels during the first joint observation run together with GEO600. By applying our search pipeline, which takes into account the stochastic nature of ultralight DM, upper bounds on the coupling strength between the U(1)B−L gauge boson and ordinary matter are obtained for a range of DM masses. While our constraints are less stringent than those derived from previous experiments, this study demonstrates the applicability of our method to the lower-mass vector DM search, which is made difficult in this measurement by the short observation time compared to the auto-correlation time scale of DM

    Driving Distance as a Barrier to Glycemic Control in Diabetes

    No full text
    BACKGROUND: Despite advances in treatment of diabetes, many barriers to good glycemic control remain. OBJECTIVE: To determine the relationship between glycemic control and the driving distance from home to the site of primary care. DESIGN: Cross-sectional analysis of data from the Vermont Diabetes Information System. PARTICIPANTS: Nine-hundred and seventy-three adults with diabetes in primary care. The mean age was 64.9 years, 57% were female, and 18.4% used insulin. MEASUREMENTS: Hemoglobin A1c, shortest driving distance from a patient's home to the site of primary care calculated by geographic software, self-reported gender, age, education, income, marital status, race, insurance coverage, diabetic complications, and use of insulin and oral hypoglycemic agents. RESULTS: Controlling for social, demographic, seasonal, and treatment variables, there was a positive, significant relationship between glycemic control and driving distance (β=+0.07%/10 km, P <.001, 95% confidence interval [CI]=+0.03, +0.11). Driving distance had a stronger association with glycemic control among insulin users (β=+0.22%/10 km, P =.016, 95% CI=+0.04, +0.40) than among noninsulin users (β=+0.06%/10 km, P =.006, 95% CI=+0.02, +0.10). CONCLUSION: Longer driving distances from home to the site of primary care were associated with poorer glycemic control in this population of older, rural subjects. While the mechanism for this effect is not known, providers should be aware of this potential barrier to good glycemic control

    Searches for gravitational waves from known pulsars at two harmonics in the second and third LIGO-Virgo observing runs