Physician practice patterns and variation in the delivery of preventive services

Emergency Provider Use of Plain Radiographs in the Evaluation of Pediatric Constipation

BACKGROUND

More than half of children evaluated as outpatients for abdominal pain are diagnosed with constipation. X-ray use in this scenario is variable: less than 5% in clinic settings, greater than 70% in emergency departments. X-rays increase misdiagnosis rate, remain costly, and involve radiation exposure.

OBJECTIVES

The aim of this study was to assess the use of plain radiographs by pediatric emergency medicine (PEM) providers in the diagnostic evaluation and management of pediatric constipation.

METHODS

A cross-sectional survey of PEM providers was performed. Survey participants were subscribers to the American Academy of Pediatrics Section on Emergency Medicine Listserv. To assess diagnostic and therapeutic approaches, participants were presented a case of pediatric constipation meeting Rome III clinical criteria. Participants also categorized frequency of x-ray use, reasons for obtaining, estimated diagnostic utility, and elements of institutional standard approach. Descriptive statistical analyses were performed.

RESULTS

Three hundred five of 1272 Listserv members (24%) responded. Ninety-nine percent elected to treat for constipation in a case meeting Rome III clinical criteria; one third (31%) would obtain plain radiographs for this same scenario. Plain radiographs were viewed as somewhat (59%) or minimally (29%) value-added in the evaluation of suspected pediatric constipation. Obtaining family buy-in (44%) was the most common reason for utilizing plain radiographs. Frequency of use varied across geographic regions and with participant and hospital characteristics.

CONCLUSIONS

This survey suggests that many PEM providers obtain radiographs to convince families of the diagnosis of constipation. This is not a viable management plan given the risks of radiation as well as costs. There remains room for improvement as we attempt to reduce use of radiation in the evaluation of common pediatric illnesses.

Accountable care organizations and the use of cancer screening

Cancer preventive services, when used appropriately, result in improved health, better quality of life and decreased costs. For these reasons, cancer preventive services represent important priorities within the Affordable Care Act (ACA). Among the many provisions to improve access to preventive services the ACA introduced Accountable Care Organizations (ACOs) as trajectory to deliver coordinated, high-quality care. In order to evaluate this benchmark, we analyzed (in 2016/Boston) screening prevalence of breast cancer, a recommended screening test according to the United States Preventive Services Task Force (USPSTF), and prostate cancer, for which screening is no longer recommended by the USPSTF, among traditional Medicare beneficiaries and those enrolled in ACOs. We used propensity-score weighting to adjust for baseline confounders. We found that the prevalence of breast cancer screening (35.0% vs. 25.2%, p<0.001) and prostate cancer screening (54.6% vs. 41.7%, p<0.001) is higher among ACO enrollees. Our results suggest increased utilization of cancer preventive care within ACOs, regardless of whether the test is recommended or not. Better efforts may be needed within the ACO infrastructure to encourage recommended preventive care, but also penalize unnecessary use of low value services.

Preventive Care Quality of Medicare Accountable Care Organizations: Associations of Organizational Characteristics With Performance

BACKGROUND

Accountable Care Organizations (ACOs) are a delivery and payment model aiming to coordinate care, control costs, and improve quality. Medicare ACOs are responsible for 8 measures of preventive care quality.

OBJECTIVES

To create composite measures of preventive care quality and examine associations of ACO characteristics with performance.

DESIGN

This is a cross-sectional study of Medicare Shared Savings Program and Pioneer participants. We linked quality performance to descriptive data from the National Survey of ACOs. We created composite measures using exploratory factor analysis, and used regression to assess associations with organizational characteristics.

RESULTS

Of 252 eligible ACOs, 246 reported on preventive care quality, 177 of which completed the survey (response rate=72%). In their first year, ACOs lagged behind PPO performance on the majority of comparable measures. We identified 2 underlying factors among 8 measures and created composites for each: disease prevention, driven by vaccines and cancer screenings, and wellness screening, driven by annual health screenings. Participation in the Advanced Payment Model, having fewer specialists, and having more Medicare ACO beneficiaries per primary care provider were associated with significantly better performance on both composites. Better performance on disease prevention was also associated with inclusion of a hospital, greater electronic health record capabilities, a larger primary care workforce, and fewer minority beneficiaries.

CONCLUSIONS

ACO preventive care quality performance is related to provider composition and benefitted by upfront investment. Vaccine and cancer screening quality performance is more dependent on organizational structure and characteristics than performance on annual wellness screenings, likely due to greater complexity in eligibility determination and service administration.

Knowledge, attitudes, and practice patterns of recurrent urinary stones prevention in Saudi Arabia

The purpose of this study is to assess the knowledge, attitudes, and practice patterns of urologists in Saudi Arabia regarding prevention of recurrent stone formation and how much they follow preventive stone disease management guidelines. A questionnaire about knowledge, attitudes, and practice patterns of urologists in Saudi Arabia regarding prevention of recurrent stone formation was used. The survey comprised three domains: knowledge, attitudes, and practice patterns. Data about gender, duration of experience and health care sector were also collected. Individual responses were recorded, tabulated and compared using descriptive statistics. The overall response rate was 38.8%. All respondents were male urologists. Most of them (62, 71.3%) had an experience of 5-20 years in management of stone disease patients and the majority (74, 85.1%) belonged to the governmental health care sector. A total of 51% of the respondents answered in concordance with the best practice guidelines in at least half of the questions and 40% in all of the questions. Overall, practice patterns of 58% of the respondents were in concordance with the best practice guidelines in all the questions except for the question of practices regarding stone analysis. As regards to attitude domain, a total of 58.7% respondents expressed their agreement or strong agreement with the questions. Urologists' knowledge of stone recurrence preventive programs is suboptimal. They do not apply effectively the best stone prevention practice guidelines in their daily practice as well. Efforts to increase knowledge and enforce its application in daily practice are strongly warranted.

Cognitive testing in older primary care patients: A cluster-randomized trial

Introduction

This study investigated whether neuropsychological testing in primary care (PC) offices altered physician-initiated interventions related to cognitive impairment (CI) or slowed the rate of CI progression.

Methods

This 24-month, cluster-randomized study included 11 community-based PC practices randomized to either treatment as usual (5 practices) or cognitive report (CR; 6 practices) arms. From 2005 to 2008, 533 patients aged ≥65 years and without a diagnosis of CI were recruited; 423 were retested 24 months after baseline.

Results

CR physicians were significantly more likely to order cognitive-related interventions (P = .02), document discussions about cognition (P = .003), and order blood tests to rule out reversible CI (P = .002). At follow-up, significantly more CR patients had a medication for cognition listed in their chart (P = .02). There was no difference in the rate of cognitive decline between the groups.

Discussion

Providing cognitive information to physicians resulted in higher rates of physician-initiated interventions for patients with CI.

Knowledge, attitudes, and practice patterns among healthcare providers in the prevention of recurrent kidney stones in Northern Ontario

INTRODUCTON

Kidney stone recurrence is common. Preventive measures can lead to improved quality of life and costs savings to the individual and healthcare system. Guidelines to prevent recurrent kidney stones are published by various urological societies. Adherence to guidelines amongst healthcare professionals in general is poor, while adherence to preventive management guidelines regarding stone disease is unknown. To understand this issue, we conducted an online study to assess the knowledge, attitudes, and practice patterns of healthcare practitioners in Northern Ontario.

METHODS

We used the database of healthcare providers affiliated with the Northern Ontario School of Medicine, in Sudbury (East Campus) and Thunder Bay (West Campus), Ontario. We designed the survey based on current best practice guidelines for the management of recurrent kidney stones. Questions covered 3 domains: knowledge, attitudes, and practice patterns. Demographic data were also collected. The survey was distributed electronically to all participants.

RESULTS

A total of 68 healthcare providers completed the survey. Of these, most were primary care physicians (72%). To keep uniformity, we analyzed the data of this homogenous group. A total of 70% of the respondents were aware of the current guidelines; however, only 43% applied their knowledge in clinical practice. Most participants lacked confidence while answering most items in the attitude domain.

CONCLUSIONS

Most primary care physician respondents were aware of the appropriate preventive measures for recurrent kidney stones; however, they do not appear to apply this knowledge effectively in clinical practice. A low response rate is a limitation of our study. Further studies involving a larger sample size may lead to information sharing and collaborative care among healthcare providers.

Evaluation of the effect of decision support on the efficiency of primary care providers in the outpatient practice

Background: Clinical decision support (CDS) for primary care has been shown to improve delivery of preventive services. However, there is little evidence for efficiency of physicians due to CDS assistance. In this article, we report a pilot study for measuring the impact of CDS on the time spent by physicians for deciding on preventive services and chronic disease management. Methods: We randomly selected 30 patients from a primary care practice, and assigned them to 10 physicians. The physicians were requested to perform chart review to decide on preventive services and chronic disease management for the assigned patients. The patients assignment was done in a randomized crossover design, such that each patient received 2 sets of recommendations—one from a physician with CDS assistance and the other from a different physician without CDS assistance. We compared the physician recommendations made using CDS assistance, with the recommendations made without CDS assistance. Results: The physicians required an average of 1 minute 44 seconds, when they were they had access to the decision support system and 5 minutes when they were unassisted. Hence the CDS assistance resulted in an estimated saving of 3 minutes 16 seconds (65%) of the physicians’ time, which was statistically significant (P < .0001). There was no statistically significant difference in the number of recommendations. Conclusion: Our findings suggest that CDS assistance significantly reduced the time spent by physicians for deciding on preventive services and chronic disease management. The result needs to be confirmed by performing similar studies at other institutions.

A taxonomy of primary health care practices: an avenue for informing management and policy implementation

Health policy and practice managers often treat primary practices as being homogenous, despite evidence that these organisations vary along multiple dimensions. This treatment can be a barrier to the development of a strong health care system. Therefore, a more sophisticated taxonomy of organisations could inform management and policy to better cater to the diversity of practice contexts, needs and capabilities. The purpose of this study was to categorise primary practices using practice features and characteristics associated with the job satisfaction of GPs. The current study uses data from 3906 GPs from the 2008 wave of the MABEL survey. Seven configurations of primary health care practices emerged from multivariate cluster analyses. The configurations incorporate, yet move beyond, simplistic categorisations such as geographic location and highlight the complexity facing managers and health policy interventions. The multidimensional configurations in the taxonomy are a mechanism for informing health care management and policy. The process of deriving configurations can be applied in a variety of countries and contexts.

Impact of an educational intervention designed to reduce unnecessary recall during screening mammography

RATIONALE AND OBJECTIVES

The aim of this study was to describe the impact of a tailored Web-based educational program designed to reduce excessive screening mammography recall.

MATERIALS AND METHODS

Radiologists enrolled in one of four mammography registries in the United States were invited to take part and were randomly assigned to receive the intervention or to serve as controls. The controls were offered the intervention at the end of the study, and data collection included an assessment of their clinical practice as well. The intervention provided each radiologist with individual audit data for his or her sensitivity, specificity, recall rate, positive predictive value, and cancer detection rate compared to national benchmarks and peer comparisons for the same measures; profiled breast cancer risk in each radiologist's respective patient populations to illustrate how low breast cancer risk is in population-based settings; and evaluated the possible impact of medical malpractice concerns on recall rates. Participants' recall rates from actual practice were evaluated for three time periods: the 9 months before the intervention was delivered to the intervention group (baseline period), the 9 months between the intervention and control groups (T1), and the 9 months after completion of the intervention by the controls (T2). Logistic regression models examining the probability that a mammogram was recalled included indication of intervention versus control and time period (baseline, T1, and T2). Interactions between the groups and time period were also included to determine if the association between time period and the probability of a positive result differed across groups.

RESULTS

Thirty-one radiologists who completed the continuing medical education intervention were included in the adjusted model comparing radiologists in the intervention group (n = 22) to radiologists who completed the intervention in the control group (n = 9). At T1, the intervention group had 12% higher odds of positive mammographic results compared to the controls, after controlling for baseline (odds ratio, 1.12; 95% confidence interval, 1.00-1.27; P = .0569). At T2, a similar association was found, but it was not statistically significant (odds ratio, 1.10; 95% confidence interval, 0.96 to 1.25). No associations were found among radiologists in the control group when comparing those who completed the continuing medical education intervention (n = 9) to those who did not (n = 10). In addition, no associations were found between time period and recall rate among radiologists who set realistic goals.

CONCLUSIONS

This study resulted in a null effect, which may indicate that a single 1-hour intervention is not adequate to change excessive recall among radiologists who undertook the intervention being tested.

Does Receiving Clinical Preventive Services Vary across Different Types of Primary Healthcare Organizations? Evidence from a Population-Based Survey

OBJECTIVE

To measure the association between primary healthcare (PHC) organizational types and patient coverage for clinical preventive services (CPS).

METHOD

Study conducted in Quebec (2005), including a population-based survey of patients' experience of care (N=4,417) and a survey of PHC clinics.

OUTCOME MEASURES

Patient-reported CPS delivery rates and CPS coverage scores. Multiple logistic regressions used to assess factors associated with higher probability of receiving CPS.

RESULTS

CPS delivery rates were higher among patients with a regular source of PHC. Higher CPS score was associated with having a public (OR 1.79; 95% CI 1.35-2.37) or mixed (OR 1.22; 95% CI 1.01-1.48) type of organization as source of PHC compared to a private one, and having had a high number of visits to the regular source of PHC in the past two years (≤6: OR 1.83; 95% CI 1.41-2.38) compared to a single visit.

CONCLUSION

Public and mixed PHC organizations seem to perform better. CPS delivery is strongly associated with having a regular source of care.

A systematic approach to practice assessment and quality improvement intervention tailoring

BACKGROUND

The ways in which tailored interventions foster sustained improvement in the quality of health care delivery across different practice settings are not well understood. Using the empirically developed Practice Change Model (PCM), we identify and describe assessment and tailoring activities with potential to enhance the fit between proposed interventions and practice settings.

METHODS

We obtained quantitative and qualitative data from 2 quality improvement trials conducted in diverse primary care practices in northeast Ohio. A multidisciplinary team used a PCM-based template to identify features of practice assessment and tailoring associated with practices' willingness and ability to change.

RESULTS

Our results suggest that intervention tailoring requires assessment of key stakeholders' motivations, external influences, resources and opportunities for change, and the interactions between these factors. Using this information, intervention tailoring then includes seeking and working with key stakeholders, building assets, providing options, keeping change processes flexible, offering feedback, providing exposure to scientific evidence, facilitating group processes, involving new partners, brainstorming, using stories/play acting/humor, assuming a consultant role, reframing, moving meetings off-site, and stepping back or pausing.

CONCLUSIONS

A model-driven approach guiding practice assessment enables tailored responses to the unique and emerging conditions that distinguish health care practices and influence implementation of quality management interventions.