VA Center for Clinical Management Research

Background:Carpal tunnel syndrome is the most common entrapment neuropathy. Prior studies have documented racial and ethnic disparities in use of carpal tunnel release (CTR), but few have examined differences in the use of both operative and nonoperative treatments and differences in an equal-access healthcare system.Methods:We conducted a retrospective cohort study of 366,009 veterans diagnosed with carpal tunnel syndrome across the Veterans Health Administration from 2010 to 2020. We assessed the association of race/ethnicity with receipt of CTR, surgical consultation, nonoperative management modalities, and time to treatment using multilevel logistic regression and Cox proportional hazards models. Predictors included demographic, clinical, structural, and care process variables.Results:Among the study cohort, 12.7% underwent CTR within 2 years. After adjustment, Black and Hispanic veterans had significantly lower odds of receiving CTR compared with White veterans (Black: odds ratio 0.61; Hispanic: odds ratio 0.80). Similar trends were observed for surgical consultation, although the magnitude of disparity was attenuated. Time-to-event analyses showed prolonged time to surgical consultation and CTR for Black and Hispanic veterans compared with White veterans. Black and Hispanic patients were more likely to receive nonoperative treatments, including splinting and specific therapeutic modalities.Conclusions:Despite the Veterans Health Administration’s equal-access model, significant racial and ethnic differences exist in surgical consultation, receipt of CTR, and timeliness of care. These differences seem to emerge across the surgical care continuum and are not fully explained by clinical or structural factors. Interventions targeting pre- and perioperative processes are needed to ensure equitable surgical care delivery.

Mobile health (mHealth) apps are widely available, and some have proven safe and effective for management of specific chronic conditions. Despite a high degree of interest, the potential of these technologies has yet to be realized. Patient and clinician attitudes are key factors that influence the adoption of mHealth apps but remain poorly understood, particularly in the United States. This study aimed to identify both patient and clinician attitudes that can influence recommending and adopting mHealth apps. Using well-established technology adoption and implementation science frameworks, this study included a deductive content analysis using a rapid qualitative analytic method. Semistructured interviews were conducted with patients and clinicians to identify technical and material, social and personal, and policy and organizational factors that can influence the recommendation or adoption of mHealth apps. The interviews and data analysis were performed between September 2023 and August 2024. Participants included 20 clinicians (n=12, 60% general internists) with a mean time in practice of 17 (SD 11.6) years, and 28 patients with a mean age of 59 (SD 12.1) years. A total of 7 categories related to patients' and clinicians' attitudes toward mHealth apps emerged: (1) apps as tools to improve health by extending care, (2) the role of apps in enhancing the patient-clinician relationship, (3) the need for simplicity and efficiency in app design, (4) the influence of prior experience with mHealth apps, (5) comfort with technology, (6) recommendations from trusted sources, and (7) education and hands-on experience. Although similar factors were considered by patients and clinicians, their views about older adults' interest and ability to use mHealth apps differed. Understanding patient and clinician views about mHealth apps provides critical insights for developing approaches to facilitate their use. These findings suggest patients and clinicians share similar views about the benefits of mHealth apps. Nonetheless, clinicians' perceptions about older patients' interest and ability to use mHealth apps may negatively impact recommendation of mHealth apps and subsequent adoption by older adults.

Urinary tract infection (UTI) is common in ambulatory care settings and the primary reason for antibiotic prescribing. Despite several guidelines focused on the type and duration of antibiotics prescribed for treating UTI, there is limited outpatient guidance on how to best triage patients with presumed UTI. To assess the appropriateness of different triage and management recommendations involving empiric antibiotics, urine testing strategies, and visit types and how these recommendations vary by patient sex, age, presenting symptoms, and clinical history. Using the RAND/UCLA Appropriateness Method, a 13-member multidisciplinary panel (physicians, advanced practice providers, and nurses) performed a scoping review of the literature publications from 2009 to June 2024 and rated the appropriateness of 136 clinical scenarios (48 for women, 49 for men, and 39 scenarios not specific to sex) with up to 9 management strategies per scenario for a total of 1094 scenarios. For each scenario, experts rated the appropriateness of empiric treatment, types of urine testing, and triage to visit type (in-person, virtual, or none) as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. Appropriateness ratings were summarized into 2 groups: nonpregnant adult women and adult men. Major recommendations based on symptoms included (1) same-day in-person evaluation if symptoms were concerning for pyelonephritis, complicated cystitis, or urinary obstruction; (2) a visit if additional nonurinary symptoms were present (ie, diarrhea, genital discharge, or cough); (3) neither urine testing nor empiric treatment solely due to a change in urine color or appearance without other bladder (cystitis) symptoms; (4) empiric treatment without testing or a visit, for women, if there were new classic cystitis symptoms of dysuria, urinary frequency, urgency, or suprapubic pain without risks for antibiotic resistance; (5) urinalysis with culture (ideally reflexed to culture) before taking first antibiotic dose for women at risk of antibiotic resistance (eg, recent antibiotic treatment for UTI or recurrent UTIs) and all men; and (6) empiric treatment considered for patients with barriers to obtaining timely urine testing or visits. The appropriateness of empiric antibiotics, urine testing, and different clinical evaluation options were defined for adults presenting with concerns for UTI in common ambulatory triage settings, including telehealth. These criteria for ambulatory triage of suspected UTI symptoms in adults are anticipated to help standardize and improve the appropriateness of empiric antibiotic prescribing, urine testing, and visit type triage.

Postoperative opioid and benzodiazepine use often extends beyond recovery, yet research on surgical prescribing tends to focus on opioid-naive patients. Less is known about those already using these medications preoperatively, who face different risks and care needs. Using a national US claims database (PearlDiver, 2010 to 2022), we identified insured adults receiving 1 of 18 common surgeries. We examined patterns of filled prescriptions for opioids and benzodiazepines before and after surgery, including (1) opioids without benzodiazepines (opioid monotherapy), (2) benzodiazepines without opioids (benzodiazepine monotherapy), (3) exposure to both, and (4) exposure to neither. Preoperative prescriptions were assessed between 6 months and 1 week before surgery. Postoperative prescriptions between 1 and 3 months after surgery were assessed. Using multivariable logistic regression, we analyzed relationships between preoperative and postoperative opioid and benzodiazepine medication fills. Among 14.9 million adults, 62% and 80% were opioid- and benzodiazepine-naive preoperatively. Among opioid and benzodiazepine-naive patients, 21.4% initiated these medications postoperatively. In contrast, 51% of preoperative opioid and benzodiazepine users filled prescriptions after surgery. Although >80% of patients on preoperative benzodiazepine monotherapy no longer received benzodiazepines postoperatively, benzodiazepine monotherapy strongly predicted exposure to benzodiazepine monotherapy (adjusted odds ratio 24.10 [23.88 to 24.32]) and both opioid and BZDs (adjusted odds ratio 15.59 [15.51 to 15.88]). Postoperative prescribing may reflect patients' preexisting opioid and benzodiazepine use more than new surgical indications. Understanding these trajectories is key for developing surgery-specific interventions, especially for patients with preoperative opioid and benzodiazepine exposure.

Inappropriate prescribing of Direct Oral Anticoagulants (DOACs) is a leading cause of adverse outcomes. Electronic health record (EHR)-based notification strategies may support evidence-based prescribing and reduce adverse events. Engaging clinical pharmacists (vs. prescribers) through EHR-based notifications that review inappropriate DOAC prescribing may be an effective strategy for ensuring evidence-based medication prescribing. We conducted a pragmatic, single-center, parallel-group, randomized implementation trial using notifications (asynchronous EHR-based notifications) to prompt correction of inappropriate DOAC prescriptions that had arisen after the initial prescription of the DOAC (e.g., due to changes in patient condition). Notifications were sent for adult ambulatory patients with DOAC prescriptions not adhering to the package insert instructions or having significant drug-drug interactions. Notifications directed either to the prescribing clinician or to the clinical anticoagulation pharmacist, randomized at the prescriber level. The primary outcome was the proportion of notifications adopting any prescription change within 7 days. Moderator analyses examined the influence of prescriber, patient, and prescription characteristics. From May 2023 to December 2024, 388 notifications for potentially inappropriate DOAC prescriptions among 183 prescribers were analyzed. Overall, 23.2% of notifications led to a prescription change within 7 days, 26% among prescriber-directed and 21% among pharmacist-directed notifications (p = 0.36). Nearly all (97.8%) changes made were clinically appropriate changes aligned with notification recommendations. Subgroup and moderator analyses showed that pharmacists made more changes than prescribers when errors were further from dosing cutoffs and managed cases with polypharmacy or complex thresholds more consistently. Clinical pharmacists spent an average of 7.9 min per notification. Prescribers and clinical pharmacists both responded similarly and consistently to correct inappropriate DOAC prescriptions in response to EHR asynchronous notifications. While pharmacists did not outperform prescribers overall, they demonstrated more nuanced application of medication prescribing guidelines in complex cases. Engaging clinical pharmacists directly may be an efficient implementation strategy for addressing medication prescribing issues. Optimal EHR-based implementation strategies for complex prescribing guidelines should consider both workflow integration and recipient expertise. (ClinicalTrials.gov: NCT05351749).

BackgroundMedications such as proton pump inhibitors (PPIs), antihistamines, and nonsteroidal anti‐inflammatory drugs have been linked to immune checkpoint inhibitor (ICI) efficacy in patients with non–small cell lung cancer (NSCLC), but these associations may reflect unmeasured confounding rather than true pharmacologic effects. This study evaluated whether commonly prescribed medications influence ICI outcomes, using a national patient sample and a negative control cohort.MethodsThe authors identified Veterans Health Administration (VHA) patients with stage IV NSCLC treated with first‐ or second‐line ICI therapy (n = 3739) or chemotherapy (n = 6585) from 2005 to 2023. Baseline use of 20 common medication classes and an immunomodulatory drug score were assessed. Propensity‐weighted Cox regression evaluated associations between each medication class and overall survival (OS) or time‐to‐next treatment (TTNT) in the ICI group. For any medication with a nominally significant association (p < .05), the same analysis was repeated in the chemotherapy group to test for nonspecific effects.ResultsAfter propensity weighting, 14 of 20 medication classes showed no association with OS or TTNT in the ICI cohort. Loop diuretics, anticoagulants, opioids, penicillin antibiotics, and fluoroquinolone antibiotics were associated with worse outcomes, but similar effects were seen in the chemotherapy group. A higher immunomodulatory drug score was also associated with inferior outcomes among ICI patients, but this association was likewise present in the chemotherapy cohort.ConclusionIn this study, commonly prescribed medications did not appear to alter ICI efficacy in stage IV NSCLC. Prior associations reported in the literature may be attributable to unmeasured confounding rather than true drug–immunotherapy interactions.