Objectives

While 3T breast magnetic resonance imaging has increased in use over the past decade, there is little data comparing its use for assessing ductal carcinoma in situ (DCIS) versus 1.5 T. We sought to compare the accuracies of DCIS extent of disease measures on pre-operative 3T versus 1.5 T MRI.

Methods

This institutional review board-approved prospective study included 20 patients with ductal carcinoma in situ diagnosed by core needle biopsy (CNB) who underwent pre-operative breast MRI at both 3T (resolution=0.5 mm×0.5 mm×1.3 mm) and 1.5 T (0.85 mm×0.85 mm×1.6 mm). All patients provided informed consent, and the study was HIPPA compliant. Lesion sizes and imaging characteristics (morphologic and kinetic enhancement) were recorded for the 3 T and 1.5 T examinations. Lesion size measures at both field strengths were correlated to final pathology, and imaging characteristics also were compared.

Results

Of the initial cohort of 20 patients with CNB-diagnosed DCIS, 19 underwent definitive surgery. Median DCIS sizes of these 19 patients were 6mm (range: 0-67 mm) on 3T, 13 mm (0-60 mm) on 1.5 T, and 6mm (0-55 mm) on surgical pathology. Size correlation between MRI and pathology was higher for 3T (Spearman's ρ=0.66, p=0.002) than 1.5 T (ρ=0.36, p=0.13). In 10 women in which a residual area of suspicious enhancement was identified on both field strengths, there was agreement of morphologic description (NME vs. mass) in nine, and no significant difference in dynamic contrast enhanced kinetics at 3T compared to 1.5 T.

Conclusions

Pre-operative breast MRI at 3T provided higher correlation with final pathology size of DCIS lesions compared to 1.5 T, and may be more accurate for assessment of disease extent prior to definitive surgery.

BACKGROUND: Patient portals are expanding as a means to engage patients and have evidence for benefit in the outpatient setting. However, few studies have evaluated their use in the inpatient setting, or with vulnerable patient populations. OBJECTIVE: This article assesses an intervention to teach hospitalized vulnerable patients to access their discharge summaries using electronic patient portals. METHODS: Patients at a safety net hospital were randomly assigned to portal use education or usual care. Surveys assessed perceptions of discharge paperwork and the electronic portal. RESULTS: Of the 202 prescreened eligible patients (e.g., deemed mentally competent, spoke English, and had a telephone), only 43% had working emails. Forty-four percent of participants did not remember receiving or reading discharge paperwork. Patients trained in portal use (n = 47) or receiving usual care (n = 23) preferred hospitals with online record access (85 and 83%, respectively), and felt that online access would increase their trust in doctors (85 and 87%) and satisfaction with care (91% each). Those who received training in portal use were more likely to register for the portal (48% vs. 11%; p < 0.01). CONCLUSION: Patients had positive perceptions of portals, and education increased portal use. Lack of email access is a notable barrier to electronic communication with vulnerable patients.

BACKGROUND: Patients are increasingly offered electronic access to their doctors notes, and many consistently receive paper After-Visit Summaries. Specific feedback from patients about notes and summaries are lacking, particularly within safety-net settings. DESIGN: A mixed methods study SETTING AND PARTICIPANTS: Patients with poorly controlled diabetes attending two urban safety-net primary care clinics in Washington State. METHODS: Patients read their own most recent clinic note and After-Visit Summary, then completed a brief survey followed by a focus group discussion (3 groups in a large general medicine teaching clinic and 1 in an HIV/AIDS clinic) about their perceptions of the clinic note and After-Visit Summary. RESULTS: Twenty-seven patients participated; 70% were male, 41% were Black, 48% were unemployed or disabled, 56% reported fair/poor health, and 37% had accessed the electronic patient portal. A majority of patients felt their note content was useful (89%); a minority reported that their notes were not accurate (19%), had too much medical jargon (29%), or were too long (26%). Themes identified from the discussions included reliance on the provider to explain confusing content; a desire for more rather than less detail; and perceived inaccuracies, particularly in heavily templated notes. In each focus group, one or more portal users were enthusiastically willing to teach other patients. CONCLUSIONS: The majority of focus group participants at this safety-net site had not accessed the electronic patient portal, but those who had were willing to promote the portal benefits and assist others. Patients identified specific opportunities to improve clinic notes and After-Visit Summaries.

Objective

Chronic disease management can require daily attention, and increased levels of patient activation and engagement. We examined whether patients with diabetes perceive a greater benefit to having electronic access to their doctors' clinic notes compared to patients without diabetes. We hypothesized that easy electronic access to these notes may help patients with self-care by improving education and communication.

Methods

Survey of patients with and without diabetes in Massachusetts and Pennsylvania about perceptions of potential benefits and risks of reading their visit notes via an electronic patient information portal. Administrative data were used to identify patients with diabetes; we compared their perceptions to those of patients without diabetes.

Results

The majority of patients (both with and without diabetes) perceived a positive impact of using the portal. Patients with diabetes were significantly more likely to believe that having access to and reading their notes would help them take their medication better and take better care of themselves.

Conclusions

Patients with chronic diseases such as diabetes might receive an even greater benefit from access to their doctors' notes than the general patient population.

Practice implications

Doctors should encourage their patients with diabetes (or other chronic diseases) to use patient portals.

There are concerns regarding whether patients with mental illness should be provided with access to their electronic medical records. This study compared perceptions of patients with (n = 400) and without (n = 2,134) a mental health diagnosis regarding access to primary care clinic notes through secure online portals. Eligible participants viewed at least 1 clinic note during a 12-month period. Administrative data were used to stratify patients by mental health diagnosis. As we hypothesized, patients with and without mental health diagnoses had similar perceptions about online access to notes.

Background

Although treatment guidelines exist for melanoma in situ and invasive melanoma, guidelines for other melanocytic skin lesions do not exist.

Objective

To examine pathologists' treatment suggestions for a broad spectrum of melanocytic skin lesions and compare them with existing guidelines.

Methods

Pathologists (N = 187) completed a survey and then provided diagnoses and treatment suggestions for 240 melanocytic skin lesions. Physician characteristics associated with treatment suggestions were evaluated with multivariable modeling.

Results

Treatment suggestions were concordant with National Comprehensive Cancer Network guidelines for the majority of cases interpreted as melanoma in situ (73%) and invasive melanoma (86%). Greater variability of treatment suggestions was seen for other lesion types without existing treatment guidelines. Characteristics associated with provision of treatment suggestions discordant with National Comprehensive Cancer Network guidelines were low caseloads (invasive melanoma), lack of fellowship training or board certification (melanoma in situ), and more than 10 years of experience (invasive melanoma and melanoma in situ).

Limitations

Pathologists could not perform immunohistochemical staining or other diagnostic tests; only 1 glass side was provided per biopsy case.

Conclusions

Pathologists' treatment suggestions vary significantly for melanocytic lesions, with lower variability for lesion types with national guidelines. Results suggest the need for standardization of treatment guidelines for all melanocytic lesion types.