Browsing by Author "Michaels, Kenan C."

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    Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study
    Rockwell, Michelle S.; Michaels, Kenan C.; Epling, John W. (2022-01-06)
    Background The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. Methods Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. Results Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05). Conclusions In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings.
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    Nonsyndromic bilateral second branchial cleft fistulae: A case report
    Worden, Cameron P.; Michaels, Kenan C.; Magdycz, William P. (Elsevier, 2021-04-27)
    Branchial cleft anomalies are rare congenital malformations that result from the abnormal persistence of branchial clefts during embryogenesis and manifest clinically as cysts, sinuses, or fistulae. In greater than 95% of cases, branchial cleft anomalies originate from remnants of the second branchial cleft. Identification of branchial cleft anomalies, particularly branchial cleft fistulae, are clinically important as these findings may be part of a larger syndromic clinical presentation such as the branchiootorenal syndrome, which necessitates further workup. Branchial cleft anomalies are bilateral in approximately one percent of cases; however, bilateral second branchial cleft fistulae are, for unknown reasons, much rarer. To the best of our knowledge, there have been less than ten cases of nonsyndromic, bilateral second branchial cleft fistulae recorded in the literature. In this report, we present the CASE of a 50-year-old woman with recent left-sided pain, drainage, and swelling in the lower one-third of her neck. The patient reported a history of bilateral “cysts” in the lower one-third of her neck for most of her adult life, which frequently become infected. She denied a personal or family history of renal anomalies or hearing loss. Computed tomography scan with intravenous contrast of the soft tissues of the neck revealed bilateral soft tissue tracts beginning in the region of the tonsillar fossae and extending bilaterally along the anterior borders of the sternocleidomastoid muscle (SCM) down to the skin surface near the level of the thyroid gland, consistent with bilateral second branchial cleft fistulae.