Incorporating the Emergency Department in the Blueprint for Youth Suicide Prevention

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Implementation of an EHR-integrated web-based depression assessment in primary care: PORTAL-Depression

Objectives: To integrate a computerized adaptive test for depression into the electronic health record (EHR) and establish systems for administering assessments in-clinic and via a patient portal to improve depression care. Materials and methods: This article reports the adoption, implementation, and maintenance of a health information technology (IT) quality improvement (QI) project, Patient Outcomes Reporting for Timely Assessment of Life with Depression (PORTAL-Depression). The project was conducted in a hospital-based primary care clinic that serves a medically underserved metropolitan community. A 30-month (July 2017-March 2021) QI project was designed to create an EHR-embedded system to administer adaptive depression assessments in-clinic and via a patient portal. A multi-disciplinary team integrated 5 major health IT innovations into the EHR: (1) use of a computerized adaptive test for depression assessment, (2) 2-way secure communication between cloud-based software and the EHR, (3) improved accessibility of depression assessment results, (4) enhanced awareness and documentation of positive depression results, and (5) sending assessments via the portal. Throughout the 30-month observational period, we collected administrative, survey, and outcome data. Results: Attending and resident physicians who participated in the project were trained in depression assessment workflows through presentations at clinic meetings, self-guided online materials, and individual support. Developing stakeholder relationships, using an evaluative and iterative process, and ongoing training were key implementation strategies. Conclusions: The PORTAL-Depression project was a complex and labor-intensive intervention. Despite quick adoption by the clinic, only certain aspects of the intervention were sustained in the long term due to financial and personnel constraints.</p

The Impact of Unrelated Future Medical Costs on Economic Evaluation Outcomes for Different Models of Diabetes

Objective: This study leveraged data from 11 independent international diabetes models to evaluate the impact of unrelated future medical costs on the outcomes of health economic evaluations in diabetes mellitus. Methods: Eleven models simulated the progression of diabetes and occurrence of its complications in hypothetical cohorts of individuals with type 1 (T1D) or type 2 (T2D) diabetes over the remaining lifetime of the patients to evaluate the cost effectiveness of three hypothetical glucose improvement interventions versus a hypothetical control intervention. All models used the same set of costs associated with diabetes complications and interventions, using a United Kingdom healthcare system perspective. Standard utility/disutility values associated with diabetes-related complications were used. Unrelated future medical costs were assumed equal for all interventions and control arms. The statistical significance of changes on the total lifetime costs, incremental costs and incremental cost-effectiveness ratios (ICERs) before and after adding the unrelated future medical costs were analysed using t-test and summarized in incremental cost-effectiveness diagrams by type of diabetes. Results: The inclusion of unrelated costs increased mean total lifetime costs substantially. However, there were no significant differences between the mean incremental costs and ICERs before and after adding unrelated future medical costs. Unrelated future medical cost inclusion did not alter the original conclusions of the diabetes modelling evaluations. Conclusions: For diabetes, with many costly noncommunicable diseases already explicitly modelled as complications, and with many interventions having predominantly an effect on the improvement of quality of life, unrelated future medical costs have a small impact on the outcomes of health economic evaluations.</p

Association of Time-Based Billing with Evaluation and Management Revenue for Outpatient Visits

Importance: Time-based billing options for physicians have expanded, enabling many physicians to bill according to time spent instead of medical decision-making (MDM) level for fee-for-service outpatient visits. However, no study to date has estimated the revenue changes associated with time-based billing. Objective: To compare evaluation and management (E/M) reimbursement for physicians using time-based billing vs MDM-based billing for outpatient visits of varying lengths. Design, Setting, and Participants: This economic evaluation used 2019 billing data for outpatient E/M codes and 2021 reimbursement rates from the Centers for Medicare & Medicaid Services. Modeling of generic clinic templates was performed to estimate expected yearly E/M revenues for a single full-time physician working in an outpatient clinic using fee-for-service billing. Main Outcomes and Measures: Yearly E/M revenues for different patient visit templates were modeled. The standardized length of return patient visits was 10 to 45 minutes, and new patient visits were twice as long in duration. Results: Under MDM-based billing, increased visit length was associated with decreased E/M revenue (564 188 US dollars for 30-minute new patient visit/15-minute return patient visit vs 423 137 US dollars for 40-minute new patient visit/20-minute return patient visit). Under time-based billing, yearly E/M revenue remained similar across increasing visit lengths (400 432 US dollars for 30-minute new patient visit/15-minute return patient visit vs $458 718 for 40-minute new patient visit/20-minute return patient visit). Compared with time-based billing, MDM-based billing was associated with higher E/M revenue for 10- to 15-minute return patient visits (400 432 US dollars vs 564 188 US dollars). Time-based billing was associated with higher E/M revenue for return patient visits lasting 20 minutes or longer. The highest modeled E/M revenue of 846273 US dollars occurred for 10-minute return patient visits under MDM-based billing. Conclusions and Relevance: Results of this study showed that the relative economic benefits of MDM-based billing and time-based billing differed and were associated with the length of patient visits. Physicians with longer patient visits were more likely to experience revenue increases from using time-based billing than physicians with shorter patient visits.</p

Evaluation of Faculty Parental Leave Policies at Medical Schools Ranked by <i>US News & World Report</i> in 2020

Importance: Physician parents, particularly women, are more likely to experience burnout, poor family-career balance, adverse maternal and fetal outcomes, and stigmatization compared with nonparent colleagues. Because many physicians delay child-rearing due to the rigorous demands of medical training, favorable parental leave policies for faculty physicians are crucial to prevent physician workforce attrition. Objective: To evaluate paid and unpaid parental leave policies at medical schools ranked by US News & World Report in 2020 and identify factors associated with leave policies. Design, setting, and participants: This cross-sectional national study was performed at US medical schools reviewed from December 1, 2019, through May 31, 2020, and February 1 through March 31, 2021, due to the COVID-19 pandemic. All medical schools ranked by US News & World Report in 2020 were included. Main outcomes and measures: The primary outcome was the number of weeks of paid and unpaid leave for birth, nonbirth, adoption, and foster care physician parents. Institutional policies for the number of weeks of leave and requirements to use vacation, sick, or disability leave were characterized. Institutional factors were evaluated for association with the duration of paid parental leave using χ2 tests. Results: Among the 90 ranked medical schools, 87 had available data. Sixty-three medical schools (72.4%) had some paid leave for birth mothers, but only 13 (14.9%) offered 12 weeks of fully paid leave. While 11 medical schools (12.6%) offered 12 weeks of full paid leave for nonbirth parents, 38 (43.7%) had no paid leave for nonbirth parents. Adoptive and foster parents had no paid leave in 35 (40.2%) and 65 (74.7%) medical schools, respectively. Median paid parental leave was 4 (IQR, 0-8) weeks for birth parents, 4 (IQR, 0-6) weeks for adoptive parents, 3 (IQR, 0-6) weeks for nonbirth parents, and 0 (IQR, 0-1) weeks for foster parents. About one-third of medical schools required birth mothers to use vacation (29 [33.3%]), sick leave (31 [35.6%]), or short-term disability (9 [10.3%]). Among institutional characteristics, higher ranking (top vs bottom quartile: 30.4% vs 4.0%; P = .03) and private designation (private vs public, 23.5% vs 9.4%; P Conclusions and relevance: In this cross-sectional national study of medical schools ranked by US News & World Report in 2020, many physician faculty receive no or very limited paid parental leave. The lack of paid parental leave was associated with higher rates of physician burnout and work-life integration dissatisfaction and may further perpetuate sex, racial and ethnic, and socioeconomic disparities in academic medicine.</p