A Time-Motion Study of Primary Care Physicians' Work in the Electronic Health Record Era

Young RA, Burge SK, Kumar KA, Wilson JM, Ortiz DF. Fam Med. 2018 Feb;50(2):91-9. [CrossRef] [PubMed]

Electronic health records (EHRs) have lengthened the time required to care for patients in primary care clinics with EHRs. The authors directly observed family physician (FP) attendings, residents, and their ambulatory patients in 982 visits in clinics affiliated with 10 residencies of the Residency Research Network of Texas. The FPs were purposely chosen to reflect a diversity of patient care styles. We measured total visit time, previsit chart time, face-to-face time, non-face time, out-of-hours EHR work time, and total EHR work time. The mean (SD) visit length was 35.8 (16.6) minutes, not counting resident precepting time. The mean time components included 2.9 (3.8) minutes working in the EHR prior to entering the room, 16.5 (9.2) minutes of face-to-face time not working in the EHR, 2.0 (2.1) minutes working in the EHR in the room (which occurred in 73.4% of the visits), 7.5 (7.5) minutes of non-face time (mostly EHR time), and 6.9 (7.6) minutes of EHR work outside of normal clinic operational hours (which occurred in 64.6% of the visits). The total time and total EHR time varied only slightly between faculty physicians, third-year and second-year residents. The authors conclude that primary care physicians spent more time working in the EHR than they spent in face-to-face time with patients in clinic visits.

Impact of Temporary Methotrexate Discontinuation for 2 Weeks on Immunogenicity of Seasonal Influenza Vaccination in Patients with Rheumatoid Arthritis: A Randomised Clinical Trial

Park JK, Lee YJ, Shin K, Ha YJ, et al.  Ann Rheum Dis. 2018 Mar 23. pii: annrheumdis-2018-213222. [CrossRef]  [PubMed]

Rheumatoid arthritis (RA) is a common disease and methotrexate (MTX) is often used to treat RA. The present study examined whether a 2-week methotrexate (MTX) discontinuation after vaccination improves the efficacy of seasonal influenza vaccination in patients with rheumatoid arthritis (RA). In this prospective randomized parallel-group multicenter study, patients with RA on stable dose of MTX were randomized to continue MTX or to hold MTX for 2 weeks after seasonal influenza vaccination. The primary outcome was frequency of satisfactory vaccine response defined as greater than or equal to fourfold increase of hemagglutination inhibition antibody titer at 4 weeks after vaccination against ≥2 of four vaccine strains. The intention-to-treat population included 156 patients in the MTX-continue group and 160 patients in the MTX-hold group. More patients in MTX-hold group achieved satisfactory vaccine response than the MTX-continue group (75.5% vs 54.5%, p<0.001). Although it is late in influenza season in the US, this study suggests that a temporary MTX discontinuation for 2 weeks after vaccination improves the immunogenicity of seasonal influenza vaccination in patients with RA without increasing RA disease activity.

Quantifying Population-Level Health Benefits and Harms of E-Cigarette Use in the United States

Soneji SS, Sung HY, Primack BA, Pierce JP, Sargent JD. PLoS One. 2018 Mar 14;13(3):e0193328. [CrossRef] [PubMed]

Electronic cigarettes (e-cigarettes) may help cigarette smokers quit smoking, yet they may also facilitate cigarette smoking for never-smokers. The authors quantified the balance of health benefits and harms associated with e-cigarette use at the population level using a Monte Carlo stochastic simulation model. Model parameters drawn from census counts, national health and tobacco use surveys, and published literature were used to calculate the expected years of life gained or lost from the impact of e-cigarette use on smoking cessation and transition to long-term cigarette smoking among never smokers.  The model estimated that 2,070 additional current cigarette smoking adults would quit smoking and remain continually abstinent from smoking for ≥7 years. However, the model also estimated 168,000 additional never-cigarette smoking adolescents would initiate cigarette smoking and eventually become daily cigarette smokers. Overall, the model estimated that e-cigarette use would lead to 1,510,000 years of life lost. The authors conclude that effective national, state, and local efforts are needed to reduce e-cigarette use among youth and young adults if e-cigarettes are to confer a net population-level benefit in the future.

Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial

Krebs EE, Gravely A, Nugent S, et al. JAMA. 2018 Mar 6;319(9):872-82. [CrossRef] [PubMed]

Opioids are usually considered more efficacious than nonopioids for acute pain. Based on this, opioids have been assumed to be better pain relievers than nonopioids for chronic pain. The authors challenged that assumption in 240 patients with moderate to severe chronic back pain or hip or knee osteoarthritis. Patients were randomized to either opioids (immediate-release morphine, oxycodone, or hydrocodone/acetaminophen) or non-opioids (acetaminophen or a nonsteroidal anti-inflammatory). Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response. The primary outcome was pain-related function (Brief Pain Inventory [BPI] interference scale) over 12 months and the main secondary outcome was pain intensity (BPI severity scale). Groups did not significantly differ on pain-related function over but pain intensity was significantly better in the nonopioid group. These results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.

Adolescent Exposure to Toxic Volatile Organic Chemicals from E-Cigarettes

Rubinstein ML, Delucchi K, Benowitz NL, et al. Pediatrics. 2018;141(4):e20173557. [CrossRef]

The authors sought to identify the presence of chemical toxicants contained in cigarette smoke in adolescent e-cigarette users. E-cigarette users and dual users (use of cigarettes in the past 30 days in addition to e-cigarettes) were compared to never-using controls. Urine excretion of metabolites of benzene, ethylene oxide, acrylonitrile, acrolein, and acrylamide was significantly higher in dual users versus e-cigarette–only users (all P < .05). Excretion of metabolites of acrylonitrile, acrolein, propylene oxide, acrylamide, and crotonaldehyde were significantly higher in e-cigarette–only users compared with controls (all P < .05). E-cigarette vapor may be less hazardous than tobacco smoke, but e-cigarette vapor contains many of the volatile carcinogens found in cigarette smoke. The authors encourage warnings about the potential risk from toxic exposure to carcinogenic compounds generated by these products.