The Impact of Medical or Health-Related Internet Searches on Patient Compliance

Health-related Internet searches have been associated with cyberchondria and can impact how patients receive and react to medical advice. The purpose of this study was to analyze the relationships between patient compliance and the experiences of 191 Internet information seekers from >12 countries and 27 occupations, surveyed online between 2015 and 2016 using the ‘Dr. Net' questionnaire. After Internet search, 75% agreed with the diagnosis given by their doctor and 83% remained compliant with their doctor's orders. Statistical analysis using Kruskal-Wallis H test (“one-way ANOVA on ranks”) and Spearman correlation coefficient revealed strong positive correlations (p < 0.001) between compliance and each of the following: finding the search helpful (86%), being satisfied with Internet information (71%), becoming more cautious about health (60%), finding the information provided by their doctor comprehensible (71%), and agreement with physician. Recommendations are discussed for increasing ehealth literacy and patient-physician trust with improved online medical information.

Barriers to and Recommendations for Research Recruitment of Individuals Affected by Serious Illness

Researchers are encountering increasing challenges in recruiting participants for healthcare research. We conducted semi-structured individual interviews to identify participant barriers to research and recommendations for overcoming these challenges. We recruited 17 patients and eight caregivers who were approached to participate in a randomized control trial. We also recruited 31 primary care physicians. Using grounded theory, three researchers independently coded the transcripts and then met to compare codes and reconcile discrepancies. Themes from patient and caregiver interviews included time constraints, privacy concerns, lack of research familiarity, disconnect with research institution, self-perceived health status, and concerns with study randomization and repetitive questions. Physician-identified barriers focused on time constraints and study randomization. Patient and caregiver recommendations for study recruitment included various recruitment techniques. Physician recommendations were related to incentives. Although patients and caregivers prefer that their physicians recruit them for health-related research studies, physicians identified time constraints as a barrier to research involvement.

Physician Diagnosis and Knowledge of Mild Cognitive Impairment

Background: Older adults with mild cognitive impairment (MCI) receive fewer guideline-concordant treatments for multiple health conditions than those with normal cognition. Reasons for this disparity are unclear. Objective: To better understand this disparity, we describe physician understanding and experience with patient MCI, particularly physician identification of MCI, ability to distinguish between MCI and dementia, and perspectives on education and training in MCI and dementia. Methods: As part of a mixed-methods study assessing the influence of patient MCI on physician recommendations for acute myocardial infraction and stroke treatments, we conducted a descriptive qualitative study using semi-structured interviews of physicians from three specialties. Key question topics included participants’ identification of MCI, impressions of MCI and dementia awareness within their practice specialty, and perspectives on training and education in MCI. Results: The study included 22 physicians (8 cardiologists, 7 neurologists, and 7 internists). We identified two primary themes: There is 1) a lack of adequate understanding of the distinction between MCI and dementia; and 2) variation in physician approaches to identifying whether an older adult has MCI. Conclusion: These findings suggest that physicians have a poor understanding of MCI. Our results suggest that interventions that improve physician knowledge of MCI are needed.

QOLP-01. EXPERIENCES FROM PATIENT, CAREGIVER, AND PHYSICIAN SURVEYS ON DIAGNOSIS AND TREATMENT OF BRAIN METASTASES

The development of brain metastases (BM) is one of the most feared complications of cancer due to the substantial neuro-cognitive morbidity and grim prognosis. In the past decade, targeted therapies and checkpoint inhibitors have demonstrated remarkable intracranial response rates for tumors of multiple histologies. As overall survival for these patients improves, there is a growing need to identify issues surrounding patient survivorship and to standardize physician practice patterns for these patients. To date, there has not been an adequate study to specifically explore these questions of survivorship and practice standardization for patients with advanced cancer and BM. Here, we present results from a cross-sectional survey in which we analyze responses from 237 patients, 209 caregivers, and 239 physicians to identify areas of improvement in the clinical care of BM. In comparing physician and patient/caregiver responses, we found a disparity in the perceived discussion of topics pertaining to important aspects of BM clinical care. We identified variability in practice patterns for this patient population between private practice and academic physicians. Many physicians continue to have patients with BM excluded from clinical trials. Finally, we obtained patient/physician recommendations on high-yield areas for federal funding to improve patient quality of life. Therefore, by identifying potential areas of unmet need, we anticipate this wealth of actionable information will translate into tangible benefits for both patients and caregivers. Future studies are needed to validate our findings.

Comparison of Diagnostic Recommendations from Individual Physicians versus the Collective Intelligence of Multiple Physicians in Ambulatory Cases Referred for Specialist Consultation

Background Studies report higher diagnostic accuracy using the collective intelligence (CI) of multiple clinicians compared with individual clinicians. However, the diagnostic process is iterative, and unexplored is the value of CI in improving clinical recommendations leading to a final diagnosis. Methods To compare the appropriateness of diagnostic recommendations advised by individual physicians versus the CI of physicians, we entered actual consultation requests sent by primary care physicians to specialists onto a web-based CI platform capable of collecting diagnostic recommendations (next steps for care) from multiple physicians. We solicited responses to 35 cases (12 endocrinology, 13 gynecology, 10 neurology) from ≥3 physicians of any specialty through the CI platform, which aggregated responses into a CI output. The primary outcome was the appropriateness of individual physician recommendations versus the CI output recommendations, using recommendations agreed upon by 2 specialists in the same specialty as a gold standard. The secondary outcome was the recommendations’ potential for harm. Results A total of 177 physicians responded. Cases had a median of 7 respondents (interquartile range: 5–10). Diagnostic recommendations in the CI output achieved higher levels of appropriateness (69%) than recommendations from individual physicians (45%; χ2 = 5.95, P = 0.015). Of the CI recommendations, 54% were potentially harmful, as compared with 41% of individuals’ recommendations (χ2 = 2.49, P = 0.11). Limitations Cases were from a single institution. CI was solicited using a single algorithm/platform. Conclusions When seeking specialist guidance, diagnostic recommendations from the CI of multiple physicians are more appropriate than recommendations from most individual physicians, measured against specialist recommendations. Although CI provides useful recommendations, some have potential for harm. Future research should explore how to use CI to improve diagnosis while limiting harm from inappropriate tests/therapies.

Cross-sectional survey of patients, caregivers, and physicians on diagnosis and treatment of brain metastases

Background The development of brain metastases (BM) is one of the most feared complications of cancer due to the substantial neuro-cognitive morbidity and grim prognosis. In the past decade, targeted therapies and checkpoint inhibitors have demonstrated promising intracranial response rates for tumors of multiple histologies. As overall survival for these patients improves, there is a growing need to identify issues surrounding patient survivorship and to standardize physician practice patterns for these patients. To date, there has not been an adequate study to specifically explore these questions of survivorship and practice standardization for patients with advanced cancer and BM. Methods Here, we present results from a cross-sectional survey in which we analyze responses from 237 patients, 209 caregivers, and 239 physicians to identify areas of improvement in the clinical care of BM. Results In comparing physician and patient/caregiver responses, we found a disparity in the perceived discussion of topics pertaining to important aspects of BM clinical care. We identified variability in practice patterns for this patient population between private practice and academic physicians. Many physicians continue to have patients with BM excluded from clinical trials. Finally, we obtained patient/physician recommendations on high-yield areas for federal funding to improve patient quality of life. Conclusion By identifying potential areas of unmet need, we anticipate this wealth of actionable information will translate into tangible benefits for both patients and caregivers. Future studies are needed to validate our findings.

Abstract P027: Individualized Protein Based Cardiovascular Risk Stratification: Impact On Patient And Physician Decision Making In Patients With Real World Cardiovascular Disease

There is a growing population of patients with established cardiovascular disease and residual cardiovascular risk. Identification of patients who would benefit most from more advanced risk reduction strategies would be ideal. Hypothesis: Identification of secondary risk of MACE may change both physician recommendations and patient choices regarding goal directed therapy (GDT). Methods: Retrospective review of 244 patients with established CAD with traditional assessment of secondary cardiovascular risk and SomaScan proteomic risk assessment followed over 3 years. Patients were evaluated for GDT and standard measurements were made at baseline. SomaScan protein risk score was obtained. Patients received advice regarding risk and offered GDT with established secondary prevention goals. Willingness to change, physician recommendations to change therapy and therapy changes were recorded. Patients were followed over three years. Results: 244 patients were included in the cohort; 186 males (76%), 58 females (24%). Mean age of 66, range 32-84. Diagnosis of coronary artery disease was made based on imaging in 121 patients (49%) and clinical events including CABG, MI, PCI in 123 patients (51%). Secondary cardiovascular risk of MACE by SomaScan was assessed in 5 predefined risk classes. There were 70 patients in class I (0-9.9%), 116 patients in Class II (10-19.9%), 41 patients in Class III (20-29.9%), 12 patients in Class IV (30-59%) and I patient in Class V (60-100%). GDT was already present in 143 patients including statin therapy, ACE inhibition and daily aspirin. In the cohort, 101 patients were sub-optimally treated. After reviewing results of SomaScan results, 20 patients initiated GDT, 52 patients intensified GDT. This included addition of second lipid lowering agent, initiation of PCSK-9 inhibitors, ACE-inhibition and intense lifestyle management. Overall, 30% of the overall cohort had a change in therapy: 39 patients were advised to alter therapy and did not, 17 patients would not begin goal directed therapy, 22 patients would not intensify management to meet accepted goals. Two deaths occurred during the study period. There were 14 episodes of MACE. Conclusions: In this population of patients with established cardiovascular disease only 58% were on guideline-based therapy. Use of SomaScan results in conjunction with standard assessment allowed an additional 30% of patients to change therapy with initiation of GDT and intensification of GDT to meet current guidelines.

Exploring intentional medication nonadherence in patients with systemic lupus erythematosus: the role of physician-patient interactions

Objective Medication nonadherence contributes to worse health outcomes among systemic lupus erythematosus (SLE) patients. The underlying mechanisms which drive medication nonadherence are poorly understood. The purpose of this study is to explore possible mechanisms of medication nonadherence through eliciting patient experiences. Methods Consented adult patients with American College of Rheumatology- or Systemic Lupus International Collaborating Clinics-classified SLE were recruited. Ten semi-structured interviews were conducted across six participants. Interviews were audio recorded, transcribed, and analyzed using an iterative process. Findings were presented to an interactive public forum with SLE patients, family members and friends of patients, and health care professionals to assess validity and elaboration of the concepts developed. Results Three interrelated themes emerged from the interviews: (1) Why do rheumatologists not know more about lupus or share what they do know with their patients?; (2) Why do I have to take so many drugs and why do the drug not work?; and (3) If my rheumatologist cannot communicate with me, why should I follow the prescribed medication regime? Conclusions Our exploratory findings layout a possible underlying logic by which patients may choose to intentionally engage with medication nonadherence behaviors. Patients suggested that poor communication with their rheumatologists along with a lack of validation of their symptoms contributed to them not valuing physician recommendations. This also contributed to development of a cynical outlook and little belief that medication would improve their condition. While further work is needed to validate these findings, our preliminary work suggests that interventions focusing on developing communication skills among both patients and rheumatologists are necessary to reduce medication nonadherence.

Direct-to-Consumer Chat-Based Remote Care Before and During the COVID-19 Outbreak

Objective. To compare the patient population, common complaints, and physician recommendations in direct-to-consumer chat-based consults, before and during the COVID-19 outbreak. Data sources. Data on patient characteristics, patient complaints, and physician recommendations from 36,864 chat-based telemedicine consults with physicians in an online-clinic by patients from across the United States between April 2019 and April 2020. Study Design. We perform a retrospective analysis comparing patient characteristics, visit characteristics, and physician recommendation before and after the COVID-19 outbreak. We examine patient age and gender, visit time, patient chief complains, and physician medical recommendation (including prescription drugs, reassurance, and referrals). Principal Findings. Before March 2020, most patients were female (75 percent) and 18-44 years old (89 percent). Common complaints such as abdominal pain, dysuria, or sore throat suggested minor acute conditions. Most cases (67 percent) were resolved remotely, mainly via prescriptions; a minority were referred. Since March 2020, the COVID-19 emergency has led to a sharp (fourfold) increase in case volume, including more males (from 25 to 29 percent), patients aged 45 and older (from 11 to 17 percent), and more cases involving mental health complaints and complaints related to COVID-19. Across all symptoms, significantly more cases (78 percent) have been resolved remotely. Conclusions. The COVID-19 outbreak in the United States has been associated with a sharp increase in the use of chat-based telemedicine services, including by new patient demographics, an increase in both COVID-19 and mental health complains, and an increase in remote case resolutions.