Knowledge, patterns of care, and outcomes of care for generalists and specialists

Clinical Decision Support Requirements for Ventricular Tachycardia Diagnosis Within the Frameworks of Knowledge and Practice: Survey Study

BACKGROUND

Ventricular tachycardia (VT) diagnosis is challenging due to the similarity between VT and some forms of supraventricular tachycardia, complexity of clinical manifestations, heterogeneity of underlying diseases, and potential for life-threatening hemodynamic instability. Clinical decision support systems (CDSSs) have emerged as promising tools to augment the diagnostic capabilities of cardiologists. However, a requirements analysis is acknowledged to be vital for the success of a CDSS, especially for complex clinical tasks such as VT diagnosis.

OBJECTIVE

The aims of this study were to analyze the requirements for a VT diagnosis CDSS within the frameworks of knowledge and practice and to determine the clinical decision support (CDS) needs.

METHODS

Our multidisciplinary team first conducted semistructured interviews with seven cardiologists related to the clinical challenges of VT and expected decision support. A questionnaire was designed by the multidisciplinary team based on the results of interviews. The questionnaire was divided into four sections: demographic information, knowledge assessment, practice assessment, and CDS needs. The practice section consisted of two simulated cases for a total score of 10 marks. Online questionnaires were disseminated to registered cardiologists across China from December 2022 to February 2023. The scores for the practice section were summarized as continuous variables, using the mean, median, and range. The knowledge and CDS needs sections were assessed using a 4-point Likert scale without a neutral option. Kruskal-Wallis tests were performed to investigate the relationship between scores and practice years or specialty.

RESULTS

Of the 687 cardiologists who completed the questionnaire, 567 responses were eligible for further analysis. The results of the knowledge assessment showed that 383 cardiologists (68%) lacked knowledge in diagnostic evaluation. The overall average score of the practice assessment was 6.11 (SD 0.55); the etiological diagnosis section had the highest overall scores (mean 6.74, SD 1.75), whereas the diagnostic evaluation section had the lowest scores (mean 5.78, SD 1.19). A majority of cardiologists (344/567, 60.7%) reported the need for a CDSS. There was a significant difference in practice competency scores between general cardiologists and arrhythmia specialists (P=.02).

CONCLUSIONS

There was a notable deficiency in the knowledge and practice of VT among Chinese cardiologists. Specific knowledge and practice support requirements were identified, which provide a foundation for further development and optimization of a CDSS. Moreover, it is important to consider clinicians' specialization levels and years of practice for effective and personalized support.

Impact of socioeconomic factors on allergic diseases

Allergic and immunologic conditions, including asthma, food allergy, atopic dermatitis, and allergic rhinitis, are among the most common chronic conditions in children and adolescents that often last into adulthood. Although rare, inborn errors of immunity are life-altering and potentially fatal if unrecognized or untreated. Thus, allergic and immunologic conditions are both medical and public health issues that are profoundly affected by socioeconomic factors. Recently, studies have highlighted societal issues to evaluate factors at multiple levels that contribute to health inequities and the potential steps toward closing those gaps. Socioeconomic disparities can influence all aspects of care, including health care access and quality, diagnosis, management, education, and disease prevalence and outcomes. Ongoing research, engagement, and deliberate investment of resources by relevant stakeholders and advocacy approaches are needed to identify and address the impact of socioeconomics on health care disparities and outcomes among patients with allergic and immunologic diseases.

Shorter time to initiation of biologic therapy in the setting of a hidradenitis suppurativa specialty clinic

Hidradenitis suppurativa (HS) is a chronic condition with a significant psychological and physical burden but a paucity of effective treatments. Early intervention with adalimumab improves disease outcomes. Two previous studies in Denmark and Northern Ireland have identified a time of 8.2 and 2.9 years, respectively, from first HS systemic/dermatology consultation to commencing a biologic. We aimed to evaluate the time from disease onset and from first specialty HS clinic review to the initiation of biologic therapy. We retrospectively reviewed 34 patients on biologic treatment for HS. The mean diagnostic delay was 12.4 years. The mean time from disease onset to biologic initiation was 14.8 years. Prior to a biologic, patients received a median of 3.3 treatments from the specialty HS clinic. The median time to biologic from first presentation at the specialty HS clinic was 1 year. This is shorter than the therapeutic delay reported in dermatology clinics in Denmark and Northern Ireland, providing evidence on the importance of specialized HS treatment. However, to make an impact with specialized HS care and earlier biologic initiation, diagnostic delay needs to be reduced.

Oncologists' responsibility, comfort, and knowledge managing hyperglycemia in patients with cancer undergoing chemotherapy: a cross sectional study

PURPOSE

To assess oncologists' responsibility, comfort, and knowledge managing hyperglycemia in patients undergoing chemotherapy.

METHODS

In this cross-sectional study, a questionnaire collected oncologists' perceptions about professionals responsible for managing hyperglycemia during chemotherapy; comfort (score range 12-120); and knowledge (score range 0-16). Descriptive statistics were calculated including Student t-tests and one-way ANOVA for mean score differences. Multivariable linear regression identified predictors of comfort and knowledge scores.

RESULTS

Respondents (N = 229) were 67.7% men, 91.3% White and mean age 52.1 years. Oncologists perceived endocrinologists/diabetologists and primary care physicians as those responsible for managing hyperglycemia during chemotherapy, and most frequently referred to these clinicians. Reasons for referral included lack of time to manage hyperglycemia (62.4%), belief that patients would benefit from referral to an alternative provider clinician (54.1%), and not perceiving hyperglycemia management in their scope of practice (52.4%). The top-3 barriers to patient referral were long wait times for primary care (69.9%) and endocrinology (68.1%) visits, and patient's provider outside of the oncologist's institution (52.8%). The top-3 barriers to treating hyperglycemia were lack of knowledge about when to start insulin, how to adjust insulin, and what insulin type works best. Women (ß = 1.67, 95% CI: 0.16, 3.18) and oncologists in suburban areas (ß = 6.98, 95% CI: 2.53, 11.44) had higher comfort scores than their respective counterparts; oncologists working in practices with > 10 oncologists had lower comfort scores (ß = -2.75, 95% CI: -4.96, -0.53) than those in practices with ≤ 10. No significant predictors were identified for knowledge.

CONCLUSION

Oncologists expected endocrinology or primary care clinicians to manage hyperglycemia during chemotherapy, but long wait times were among the top barriers cited when referring patients. New models that provide prompt and coordinated care are needed.

Who should see the patient? on deviations from preferred patient-provider assignments in hospitals

In various organizations including hospitals, individuals are not forced to follow specific assignments, and thus, deviations from preferred task assignments are common. This is due to the conventional wisdom that professionals should be given the flexibility to deviate from preferred assignments as needed. It is unclear, however, whether and when this conventional wisdom is true. We use evidence on the assignments of generalist and specialists to patients in our partner hospital (a children's hospital), and generate insights into whether and when hospital administrators should disallow such flexibility. We do so by identifying 73 top medical diagnoses and using detailed patient-level electronic medical record (EMR) data of more than 4,700 hospitalizations. In parallel, we conduct a survey of medical experts and utilized it to identify the preferred provider type that should have been assigned to each patient. Using these two sources of data, we examine the consequence of deviations from preferred provider assignments on three sets of performance measures: operational efficiency (measured by length of stay), quality of care (measured by 30-day readmissions and adverse events), and cost (measured by total charges). We find that deviating from preferred assignments is beneficial for task types (patients' diagnosis in our setting) that are either (a) well-defined (improving operational efficiency and costs), or (b) require high contact (improving costs and adverse events, though at the expense of lower operational efficiency). For other task types (e.g., highly complex or resource-intensive tasks), we observe that deviations are either detrimental or yield no tangible benefits, and thus, hospitals should try to eliminate them (e.g., by developing and enforcing assignment guidelines). To understand the causal mechanism behind our results, we make use of mediation analysis and find that utilizing advanced imaging (e.g., MRIs, CT scans, or nuclear radiology) plays an important role in how deviations impact performance outcomes. Our findings also provide evidence for a "no free lunch" theorem: while for some task types, deviations are beneficial for certain performance outcomes, they can simultaneously degrade performance in terms of other dimensions. To provide clear recommendations for hospital administrators, we also consider counterfactual scenarios corresponding to imposing the preferred assignments fully or partially, and perform cost-effectiveness analyses. Our results indicate that enforcing the preferred assignments either for all tasks or only for resource-intensive tasks is cost-effective, with the latter being the superior policy. Finally, by comparing deviations during weekdays and weekends, early shifts and late shifts, and high congestion and low congestion periods, our results shed light on some environmental conditions under which deviations occur more in practice.

Understanding and Balancing Generalist-Specialist Approaches in Dementia Research and Care Practice, Qualitative Research with 44 Dementia Professors in The Netherlands

Dementia is one of the leading causes of death and disability among citizens and a societal challenge because of aging worldwide. As dementia has physical, psychological, social, material, and economic impacts, both research and care practice require many disciplines to develop and implement diagnostics, medical and psychosocial interventions, and support, crossing all domains of housing, public services, care, and cure. Notwithstanding large research efforts, much knowledge about mechanisms, interventions, and needs' based care pathways is still lacking. To cope with these challenges in research and practice, this paper is the first to question how generalist and specialist orientations can be unfolded. In the Netherlands, all dementia professors (N = 44) at eight Dutch academic centers have been interviewed. Qualitative analyses revealed three subgroups of dementia professors, one with a generalist orientation, one adhering to specialist approaches, and a third group that pleas for mixed orientations, with some differences between research and care practice. Each group has arguments for its generalist/specialist vision, but the synthesis suggests a paradigm of personalized and integrated dementia care, aimed at the individual in his own living environment. Sustainable strategies to cope with dementia require (inter)national programs and strong collaboration to build multi- and interdisciplinarity within and between research and practice.

Knowledge about Prescribing Antibiotics as Prophylaxis in Patients with Open Globe Injury: A Survey in Iranian Ophthalmologists

Objective

This study aimed to evaluate the Iranian ophthalmologists' knowledge of prescribing prophylactic antibiotics to patients with open globe injury (OGI) in Iran.

Methods

In this cross-sectional study, we utilized a questionnaire to evaluate the ophthalmologists' knowledge about prescribing antibiotics as prophylaxis. This survey was conducted in Tehran and its suburbs. The questionnaire included demographic information as well as ophthalmologists' knowledge levels. Cronbach's alpha was used to determine its validity and reliability. The obtained data were analyzed using SPSS 24.0.

Results

Of 192 subjects, 111 (35 women, 76 men) were included. About 65 (58.6%) specialists and 45 (41.4%) subspecialists with different orientations completed the questionnaires. The total knowledge score was 13.04±2.96. The following are the results of ophthalmologists' responses to questions regarding the cornea/scleral injury (1.09±1.72), prophylactic antibiotics administration (2.79±1.11), the infectious agents in eye surgeries (3.21±1.49), diagnosis and treatment (2.84±0.944), and the effects of ocular antibiotics as well as their proper dosage (2.96±2.35). There was no significant relationship between some demographic information such as sex, working hours, workplace, and the number of studied articles (p>0.05). In addition, ophthalmologists with less work experience had significantly higher levels of knowledge than those with more work experience.

Conclusion

The findings indicated that the majority of ophthalmologists had a basic knowledge of prescribing prophylactic antibiotics in OGI.

Identification of patient-related, healthcare-related and knowledge-related factors associated with inadequate blood pressure control in outpatients: a cross-sectional study in Serbia

OBJECTIVES

To determine rate of blood pressure (BP) control and to analyse patient-related, medication-related and healthcare system-related factors associated with poor BP control in outpatients with hypertension (HT).

DESIGN

Cross-sectional study.

SETTING

Two study sites with different levels of healthcare (primary healthcare (PHC) and secondary level of healthcare (SHC)) in Vojvodina, Northern Serbia.

PARTICIPANTS

A total of 581 patients (response rate 96.8%) visiting their primary care physician between July 2019 and June 2020 filled out a pretested semistructured questionnaire and had a BP reading during their regular appointments.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data on demographics, medication, BP control (target systolic BP≤140 mm Hg and∕ or diastolic BP≤90 mm Hg) and knowledge on HT was collected. Based on the median of knowledge score, patients were classified as having poor, average and adequate knowledge.

RESULTS

Majority of the respondents (74.9%) had poorly controlled BP and had HT longer than 10 years. Larger number of patients at PHC site was managed with monotherapy while at the SHC majority received three or more antihypertensive drugs. Respondents from SHC showed a significantly lower knowledge score (9, 2-15) compared with the respondents from PHC (11, 4-15, p=0.001). The share of respondents with adequate knowledge on HT was significantly higher in the group with good BP control (26% and 9.2%, respectively). In a multivariate regression analysis, factors associated with poor BP control were knowledge (B=-1.091; p<0001), number of drugs (B=0536; p<0001) and complications (B=0898; p=0004).

CONCLUSIONS

Poor BP control is common in outpatients in Serbia, irrespective of the availability of different levels of healthcare. Patients with poor knowledge on HT, with complications of HT and those with multiple antihypertensive drugs, were at particular risk of poor BP control. Our study could serve as a basis for targeted interventions to improve HT management.

Pediatric Antibiotic Stewardship for Community-Acquired Pneumonia: A Pre-Post Intervention Study

We aimed to investigate the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescription in children with community-acquired pneumonia (CAP). Antibiotic purchasing data were collected for children aged 3 months to 18 years diagnosed with CAP from November 2016 to April 2017 (pre-intervention period) and from November 2017 to April 2018 (post-intervention period). The intervention was a 1-day seminar for primary care pediatricians on the diagnosis and treatment of CAP in children according to national guidelines. There was a substantial decrease in the use of azithromycin after the intervention. In younger children, there was a 42% decrease, alongside an increased use of amoxicillin (P < .001). In older children, there was a smaller, non-statistically significant decrease in the use of azithromycin (P = .45). Our data demonstrate that the implementation of an ASP was associated with a reduction in the use of broad-spectrum antibiotics and macrolides and increased guideline adherence for the safe treatment of CAP.

Newly Diagnosed Type 2 Diabetes Care between Family Physicians, Endocrinologists, and Other Internists in Taiwan: A Retrospective Population-Based Cohort Study

(1) Background: We aimed to determine whether physicians of different specialties perform differently in the monitoring, cost control, and prevention of acute outcomes in diabetes care. (2) Methods: Using data from the Health and Welfare Data Science Center, participants with newly diagnosed type 2 diabetes (n = 206,819) were classified into three cohorts based on their primary care physician during the first year of diagnosis: family medicine (FM), endocrinologist, and other internal medicine (IM). The three cohorts were matched in a pairwise manner (FM (n = 28,269) vs. IM (n = 28,269); FM (n = 23,407) vs. endocrinologist (n = 23,407); IM (n = 43,693) vs. endocrinologist (n = 43,693)) and evaluated for process indicators, expenditure on diabetes care, and incidence of acute complications (using subdistribution hazard ratio; sHR). (3) Results: Compared to the FM cohort, both the IM (sHR, 1.26; 95% CI, 1.08 to 1.47) and endocrinologist cohorts (sHR, 1.57; 95% CI, 1.38−1.78) had higher incidences of acute complications. The FM cohort incurred lower costs than the IM cohort (USD 487.41 vs. USD 507.67, p = 0.01) and expended less than half of the diabetes-related costs of the endocrinology cohort (USD 484.39 vs. USD 927.85, p < 0.001). (4) Conclusion: Family physicians may provide better care at a lower cost to newly diagnosed type 2 diabetes patients. Relatively higher costs incurred by other internists and endocrinologists in the process of diabetes care may be explained by the more frequent ordering of specialized tests.

From generalist to specialist: A qualitative study of the perceptions of infertility patients

Few studies explore in-depth accounts of women's and men's experiences with, and transitions between, obstetrician/gynaecologists (OB/GYNs) and reproductive endocrinologists during infertility diagnostic and treatment processes. This study examined this subject matter with data from qualitative, in-depth, semi-structured interviews. Between April 2007 and March 2008, the first author interviewed 20 women and eight men from a large midwestern metropolitan area in the USA who had used, or were in the process of using, any fertility treatment in the 5 years preceding the interview. Six couples and 16 individuals were interviewed, resulting in narratives of 22 distinct infertility journeys. The main complaints made by respondents about OB/GYNs were that they were insufficiently concerned with providing timely treatment and that they paid insufficient attention to male partners. Women felt that their concerns were taken more seriously by reproductive endocrinologists, but complained of insensitivity, depersonalization and misinformation, and were suspicious of a profit orientation.

Resource Use Among Diabetes Patients Who Mainly Visit Primary Care Physicians Versus Medical Specialists: a Retrospective Cohort Study

BACKGROUND

It is not uncommon for medical specialists to predominantly care for patients with certain chronic conditions rather than primary care physicians (PCPs), yet the resource implications from such patterns of care are not well understood.

OBJECTIVE

To assess resource use of diabetes patients who predominantly visit a PCP versus a medical specialist.

DESIGN

Retrospective cohort study of diabetes patients aging into the traditional Medicare program. Patients were attributed to a PCP or medical specialist annually based on a preponderance of ambulatory care visits and categorized according to whether attribution changed year to year. Propensity score weighting was used to balance baseline demographic characteristics, diabetes complications, and underlying health conditions between patients attributed to PCPs and to medical specialists. Spending and utilization were measured up to 3 patient-years.

SUBJECTS

A total of 141,558 patient-years.

MAIN MEASURES

Total visits, unique physicians, hospital admissions, emergency department visits, procedures, imaging, and tests.

KEY RESULTS

Each year, roughly 70% of patients maintained attribution to a PCP and 15% to a medical specialist relative to the previous year. After propensity weighting, patients continuously attributed to a PCP versus medical specialist from 1 year to the next had lower average total payer payments ($10,326 [SD $57,386] versus $14,971 [SD $74,112], P<0.0001) and lower total patient out-of-pocket payments ($1,707 [SD $6,020] versus $2,443 [SD $7,984], P<0.0001). Rates of hospitalization, emergency department visits, procedures, imaging, and tests were lower among patients attributed to PCPs as well.

CONCLUSIONS

Older adults with diabetes who receive more of their ambulatory care from a PCP instead of a medical specialist show evidence of lower resource use.

Headache neuroimaging: A survey of current practice, barriers, and facilitators to optimal use

OBJECTIVE

The objective of this study was to understand current practice, clinician understanding, attitudes, barriers, and facilitators to optimal headache neuroimaging practices.

BACKGROUND

Headaches are common in adults, and neuroimaging for these patients is common, costly, and increasing. Although guidelines recommend against routine headache neuroimaging in low-risk scenarios, guideline-discordant neuroimaging is still frequently performed.

METHODS

We administered a 60-item survey to headache clinicians at the Veterans Affairs health system to assess clinician understanding and attitudes on headache neuroimaging and to determine neuroimaging practice patterns for three scenarios describing hypothetical patients with headaches. Descriptive statistics were used to summarize responses, stratified by clinician type (physicians or advanced practice clinicians [APCs]) and specialty (neurology or primary care).

RESULTS

The survey was successfully completed by 431 of 1426 clinicians (30.2% response rate). Overall, 317 of 429 (73.9%) believed neuroimaging was overused for patients with headaches. However, clinicians would utilize neuroimaging a mean (SD) 30.9% (31.7) of the time in a low-risk scenario without red flags, and a mean 67.1% (31.9) of the time in the presence of minor red flags. Clinicians had stronger beliefs in the potential benefits (268/429, 62.5%) of neuroimaging compared to harms (181/429, 42.2%) and more clinicians were bothered by harms stemming from the omission of neuroimaging (377/426, 88.5%) compared to commission (329/424, 77.6%). Additionally, APCs utilized neuroimaging more frequently than physicians and were more receptive to potential interventions to improve neuroimaging utilization.

CONCLUSIONS

Although a majority of clinicians believed neuroimaging was overused for patients with headaches, many would utilize neuroimaging in low-risk scenarios with a small probability of changing management. Future studies are needed to define the role of currently used red flags given their importance in neuroimaging decisions. Importantly, APCs may be an ideal target for future optimization efforts.

Differences in Hospitalization Outcomes of Kidney Disease between Patients Who Received Care by Nephrologists and Non-Nephrologist Physicians: A Propensity-Score-Matched Study

The influence of physician specialty on the outcomes of kidney diseases (KDs) remains underexplored. We aimed to compare the complications and mortality of patients with admissions for KD who received care by nephrologists and non-nephrologist (NN) physicians. We used health insurance research data in Taiwan to conduct a propensity-score matched study that included 17,055 patients with admissions for KD who received care by nephrologists and 17,055 patients with admissions for KD who received care by NN physicians. Multivariable logistic regressions were conducted to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for 30-day mortality and major complications associated with physician specialty. Compared with NN physicians, care by nephrologists was associated with a reduced risk of 30-day mortality (OR 0.29, 95% CI 0.25–0.35), pneumonia (OR 0.82, 95% CI 0.76–0.89), acute myocardial infarction (OR 0.68, 95% CI 0.54–0.87), and intensive care unit stay (OR 0.78, 95% CI 0.73–0.84). The association between nephrologist care and reduced admission adverse events was significant in every age category, for both sexes and various subgroups. Patients with admissions for KD who received care by nephrologists had fewer adverse events than those who received care by NN physicians. We suggest that regular nephrologist consultations or referrals may improve medical care and clinical outcomes in this vulnerable population.

National Trends and Outcomes Associated With Presence and Type of Usual Clinician Among Older Adults With Multimorbidity

IMPORTANCE

Declining primary care visit rates and increasing specialist visit rates among older adults with multimorbidity raise questions about the presence, specialty, and outcomes associated with usual clinicians of care for these adults.

OBJECTIVE

To examine trends in the presence and specialty of usual clinicians and the association with preventive care receipt and spending.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used repeated cross-sectional analyses of Medicare Current Beneficiary Survey data from 2010, 2013, and 2016. Participants were community-dwelling Medicare Advantage and traditional Medicare members with at least 2 chronic conditions. Data were analyzed from March 1, 2020, to February 5, 2021.

MAIN OUTCOMES AND MEASURES

Trends and factors associated with self-reported usual clinician presence and specialty. Multivariable regression was used to examine associations between usual clinician presence and specialty with preventive care receipt and spending, controlling for respondent sociodemographic and clinical characteristics.

RESULTS

A total of 25 490 unweighted respondent-years were examined, representing 90 324 639 respondent-years across the United States. Overall, 58.4% of respondent-years belonged to women, and the mean (SD) age of respondents was 77.5 (7.5) years. From 2010 to 2016, those reporting usual clinicians dropped from 94.2% to 91.0% (P < .001). Across study years, respondents were more likely to report a usual clinician if they were women (adjusted marginal difference [AMD], 2.5 percentage points; 95% CI, 1.5-3.5 percentage points) or had higher income (≥$50 000 vs <$15 000: AMD, 2.2 percentage points; 95% CI, 1.1-3.4 percentage points) and less likely if they were Black beneficiaries (vs White: AMD, -2.8 percentage points; 95% CI, -4.3 to -1.3 percentage points) or had traditional Medicare (vs Medicare Advantage: AMD, -3.2 percentage points; 95% CI. -4.1 to -2.3 percentage points). Among 23 279 respondents with usual clinicians, those reporting specialists as their usual clinicians decreased from 5.3% to 4.1% (P < .001). Across the study period, respondents were more likely to report specialists as their usual clinicians if they had traditional Medicare (vs Medicare Advantage: AMD, 2.3 percentage points; 95% CI, 1.6 to 2.9 percentage points), were Black or non-White Hispanic (Black vs White: AMD, 1.5 percentage points; 95% CI, 0.2 to 2.8 percentage points; non-White Hispanic vs White: AMD, 3.8 percentage points; 95% CI, 1.9 to 5.7 percentage points), or lived in the Northeast (vs Midwest: AMD, 3.6 percentage points; 95% CI, 2.1 to 5.2 percentage points). Compared with those without usual clinicians, respondents with usual clinicians were more likely to receive all examined preventive services, such as cholesterol screening (AMD, 6.7 percentage points; 95% CI, 5.4 to 8.1 percentage points) and influenza vaccines (AMD, 11.6 percentage points; 95% CI, 9.2 to 14.0 percentage points). Among respondents with usual clinicians, those reporting specialist usual clinicians (vs primary care) were less likely to receive influenza vaccines (AMD, -5.6 percentage points; 95% CI, -9.2 to -2.1).

CONCLUSIONS AND RELEVANCE

In this study, older adults with multimorbidity were less likely to have a usual clinician over the study period, with potential implications for preventive care receipt. Our results suggest a key role for usual clinicians, especially primary care clinicians, in vaccination uptake for this population.

Understanding the factors that affect the appropriateness of rheumatology referrals

BACKGROUND

Reducing inappropriate referrals to specialists is a challenge for the healthcare system as it seeks to transition from volume to value-based healthcare. Given the projection of a severe shortage of rheumatologists in the near future, innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. Efforts to increase appropriate utilization through reductions in capacity may have the unintended consequence of reducing appropriate care as well. This highlights the challenges in increasing the appropriate use of high cost services as the health system transitions to value based care. The objective of this study was to analyze factors affecting appropriateness of rheumatology services.

METHODS

This was a cross-sectional study of patients receiving Rheumatology services between November 2013 and October 2019. We used a proxy for "appropriateness": whether or not there was any follow-up care after the first appointment. Results from regression analysis and physicians' chart reviews were compared using an inter-rater reliability measure (kappa). Data was drawn from the EHR 2013-2019.

RESULTS

We found that inappropriate referrals increased 14.3% when a new rheumatologist was hired, which increased to 14.8% after wash-out period of 6 months; 15.7% after 12 months; 15.5% after 18 months and 16.7% after 18 months. Other factors influencing appropriateness of referrals included severity of disease, gender and insurance type, but not specialty of referring provider.

CONCLUSIONS

Given the projection of a severe shortage of rheumatologists in the near future, innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. Innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. These findings may apply to other specialties as well. This study is relevant for health care systems that are implementing value-based payment models aimed at reducing inappropriate care.

Enhancing clinical judgement in virtual care for complex chronic disease

The COVID-19 pandemic has transformed traditional in-person care into a new reality of virtual care for patients with complex chronic disease (CCD), but how has this transformation impacted clinical judgement? I argue that virtual specialist-patient interaction challenges clinical reasoning and clinical judgement (clinical reasoning combined with statistical reasoning). However, clinical reasoning can improve by recognising the abductive, deductive, and inductive methods that the clinician employs. Abductive reasoning leading to an inference to the best explanation or invention of an explanatory hypothesis is the default response to unfamiliar or confusing situations. Deductive reasoning supports a previously established goal, but deductive accuracy requires sound premises leading to a valid conclusion. Inductive reasoning uses efficient data sorting, data interpretation, and plan creation without a previously established goal, and allows assessing inferential accuracy over time. In all cases, communication remains the backbone of the clinical encounter. Virtual care for CCD challenges clinical judgement by reducing available information, so even experienced specialists who use induction might default to deduction or abduction. The visit might shorten, decreasing narrative competence and in-turn management quality. Clinical judgement in virtual encounters can be enhanced by allowing sufficient time, employing allied health staff, using an advance script, avoiding dogmatic commitment to either virtual or in-person encounters, special training in virtual care, and conscious awareness of abductive, deductive, and inductive reasoning processes. Clinical judgement in virtual encounters especially calls for Gestalt cognition to assess a situational pattern irreducible to its parts and independent of its particulars, so that efficient data interpretation and self-reflection are enabled. Gestalt cognition integrates abduction, deduction, and induction, appropriately divides the time and effort spent on each, and can compensate for reduced available information. Evaluating one's clinical judgement for those components especially vulnerable to compromise can help optimize the delivery of virtual care for patients with CCD.

Mismatch of corneal specialists' expectations and keratoconus knowledge in general ophthalmologists - a prospective observational study in Switzerland

BACKGROUND

To assess whether Swiss general ophthalmologists have the minimal keratoconus knowledge that corneal specialists would expect them to have.

METHODS

Corneal specialists defined "minimal keratoconus knowledge" (MKK) with respect to definition, risk factors, symptoms and possible treatment options of keratoconus. A telephone interview survey was conducted among one hundred ophthalmologists (mean age 51.9 years (SD 9.5), 60 % male) from the German-speaking part of Switzerland. For each participant, years of work experience, number of keratoconus patients seen per year and access to a topography device were obtained. We calculated the proportion of MKK and examined in multivariate analyses whether ophthalmologists with access to topography and with greater work experience performed better than other groups.

RESULTS

No single ophthalmologist had MKK. The mean MKK was 52.0 %, and the range was 28.6-81.0 %. Per 10 years of working in private practice, the MKK decreased by 8.1 % points (95 % CI: -14.2, -2.00; p = 0.01). Only 24 % of participants correctly recalled the definition of keratoconus, 9 % all risk factors, 5 % all symptoms and 20 % all treatment modalities. The MKK values were not associated with the number of keratoconus patients seen per year and the availability of topography to diagnose keratoconus.

CONCLUSIONS

There is a substantial mismatch between corneal specialist' expectations and general ophthalmologists' knowledge about keratoconus. The low recall of symptoms and risk factors may explain why ophthalmologists diagnose relatively few cases of keratoconus, resulting in inefficient care delivery and delayed intervention.

Uncontrolled Asthma: Unmet Needs in the Management of Patients

The recent scientific research has provided clinicians with the tools for substantially upgrading the standard of care in the field of bronchial asthma. Nevertheless, satisfactory asthma control still remains an unmet need worldwide. Identifying the major determinants of poor control in different asthma severity levels represents the first step towards the improvement of the overall patients' management. The present review aims to provide an overview of the main unmet needs in asthma control and of the potential tools for overcoming the issue. Implementing a personalized medicine approach is essential, not only in terms of pharmacological treatments, biologic drugs or sophisticated biomarkers. In fact, exploring the complex profile of each patient, from his inflammation phenotype to his preferences and expectations, may help in filling the gap between the big potential of currently available treatments and the overall unsatisfactory asthma control. Telemedicine and e-health technologies may provide a strategy to both optimize disease assessment on a regular basis and enhance patients' empowerment in managing their asthma. Increasing patients' awareness as well as the physicians' knowledge about asthma phenotypes and treatment options besides corticosteroid probably represent the key and more difficult goals of all the players involved in asthma management at every level.

The Path Analysis of Family Doctor's Gatekeeper Role in Shanghai, China: A Structural Equation Modeling (SEM) Approach

Studies globally have provided substantial evidence that PHC could conduct doctor-visiting behaviors, control medical expense, and improve population health. This study aimed to map how family doctor (FD) in Shanghai achieved gate-keeper goals including health management, medical expense control, and conducting ordered doctor-visiting behavior. A total of 2754 and 1995 valid questionnaires were collected in 2013 and 2016 respectively in Shanghai. The data were analyzed using structural equation modeling (SEM). Invariance analysis was also performed for 2 waves of data. We found that the coefficient of cognition on health management (β₅ = 0.26, P < .05) was larger than that of signing with FD (β₄ = 0.06, P < .05). SEM model also showed that first-contact at community health service center (CHSC) had a positive effect on health management (β₆ = 0.30, P < .05), and the latter also affected health management results positively (β₈ = 0.39, P < .05), suggesting that the path for FD was through first-contact and health management. Besides, the gate-keeper role of medical expense control was significant through the first-contact (β₁₀ = −0.12, P < .05) mediation rather than health management (β₉ = 0.03, P > .05). The model fit was acceptable (RMSEA = 0.033). A “cognition-behavior-outcomes (health and medical expense)” path of FD’s gate-keeper role was found. It is necessary to consolidate FD contracted services rather than reimbursement discount the latter of which is proved to be unsustainable.

High-Skilled vs. Low-Skilled Migrant Women: the Use of Competencies and Knowledge—Theoretical and Political Implications: an Example of the Elderly Care Sector in Poland

This paper presents the influx of migrants into the elderly care sector in Poland, which, until recently, has been perceived as a country that “exports” caregivers. It describes the results of 31 individual in-depth interviews conducted with immigrant women who take care of elderly in Poland. The purpose of the study was to determine the profile of an immigrant taking up work in the elderly care sector, including the specification of their education level and competencies. It was determined that 55% of the respondents have higher education, including over 20% with a degree in nursing or physiotherapeutic education. It was established that, when analysing migrants in the care sector, it seems necessary not to divide migrants based on their education level (high- vs. low-skilled), but rather to consider the education profile as a whole (general and special profile education). Women with specialised education differ from the other migrants in regard to their better labour market position (higher remuneration, legal employment) and the scope of skill usage. The comparison of high-skilled and low-skilled workers in the care sector is very useful from the perspective of policymakers due to the fact that there is an issue of over-qualification in Poland. The article contributes to the literature, especially research dealing with brain waste, as there is theoretical and empirical gap in research on the differences between high-skilled and low-skilled migrants working in elderly care.

Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study

Background

The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.

Objective

To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.

Methods

The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.

Results

In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.

Limitations

Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.

Conclusions

The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.

Future work

The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.

Study registration

This study is registered as Integrated Research Application System project ID 191393.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

Use of National Asthma Guidelines by Allergists and Pulmonologists: A National Survey

BACKGROUND

Little is known about specialist-specific variations in guideline agreement and adoption.

OBJECTIVE

To assess similarities and differences between allergists and pulmonologists in adherence to cornerstone components of the National Asthma Education and Prevention Program's Third Expert Panel Report.

METHODS

Self-reported guideline agreement, self-efficacy, and adherence were assessed in allergists (n = 134) and pulmonologists (n = 99) in the 2012 National Asthma Survey of Physicians. Multivariate models were used to assess if physician and practice characteristics explained bivariate associations between specialty and "almost always" adhering to recommendations (ie, ≥75% of the time).

RESULTS

Allergists and pulmonologists reported high guideline self-efficacy and moderate guideline agreement. Both groups "almost always" assessed asthma control (66.2%, standard error [SE] 4.3), assessed school/work asthma triggers (71.3%, SE, 3.9), and endorsed inhaled corticosteroids use (95.5%, SE 2.0). Repeated assessment of the inhaler technique, use of asthma action/treatment plans, and spirometry were lower (39.7%, SE 4.0; 30.6%, SE 3.6; 44.7%, SE 4.1, respectively). Compared with pulmonologists, more allergists almost always performed spirometry (56.6% vs 38.6%, P = .06), asked about nighttime awakening (91.9% vs 76.5%, P = .03) and emergency department visits (92.2% vs 76.5%, P = .03), assessed home triggers (70.5% vs 52.6%, P = .06), and performed allergy testing (61.8% vs 21.3%, P < .001). In multivariate analyses, practice-specific characteristics explained differences except for allergy testing.

CONCLUSIONS

Overall, allergists and pulmonologists adhere to the asthma guidelines with notable exceptions, including asthma action plan use and inhaler technique assessment. Recommendations with low implementation offer opportunities for further exploration and could serve as targets for increasing guideline uptake.

A Bayesian Account of Generalist and Specialist Formation Under the Active Inference Framework

This paper offers a formal account of policy learning, or habitual behavioral optimization, under the framework of Active Inference. In this setting, habit formation becomes an autodidactic, experience-dependent process, based upon what the agent sees itself doing. We focus on the effect of environmental volatility on habit formation by simulating artificial agents operating in a partially observable Markov decision process. Specifically, we used a "two-step" maze paradigm, in which the agent has to decide whether to go left or right to secure a reward. We observe that in volatile environments with numerous reward locations, the agents learn to adopt a generalist strategy, never forming a strong habitual behavior for any preferred maze direction. Conversely, in conservative or static environments, agents adopt a specialist strategy; forming strong preferences for policies that result in approach to a small number of previously-observed reward locations. The pros and cons of the two strategies are tested and discussed. In general, specialization offers greater benefits, but only when contingencies are conserved over time. We consider the implications of this formal (Active Inference) account of policy learning for understanding the relationship between specialization and habit formation.

Provision of primary care by specialist physicians: a systematic review

Patients with stable chronic diseases such as diabetes and hypertension can be safely managed at the primary care level. Yet many such patients continue to follow-up with specialists at a higher expense with no added benefit. We introduce a new term to describe this phenomenon: scope inversion, defined as the provision of primary care by specialist physicians. We aimed to quantify the extent of scope inversion by conducting a systematic review. MEDLINE and five other databases were searched using the keywords 'specialist AND (routine OR primary) AND provi*' as well as other variations. The search was limited to human research without restrictions on language or date of publication. The inclusion criterion was studies on rates of the provision of routine primary care by specialist physicians. Thirteen observational studies met the inclusion criteria. A wide range of primary care involvement was observed among specialists, from 2.6% to 65% of clinic visits. Among children, 41.3% of visits with specialists were routine follow-ups for conditions such as allergic rhinitis and seborrhoeic dermatitis which could be managed in primary care. Data quality was moderate to low across the studies due to limitations of source data and varying definitions of primary care. Specialist physicians provide primary care to patients in a substantial proportion of clinic visits. Scope inversion is wasteful as it diverts patients to more expensive care without improving outcomes. A systems approach is needed to mitigate scope inversion and its harmful effects on healthcare service delivery.

The problems of smaller, rural and remote hospitals: Separating facts from fiction

Smaller hospitals internationally are under threat. The narratives around the closure of smaller hospitals, regardless of size and location, are all constructed around three common problems - cost, quality and workforce. The literature is reviewed, demonstrating that there is little hard evidence to support the contention that hospital merger/closure solves these problems. The disbenefits of mergers and closures, including loss of resources, increased pressure on neighbouring organisations, shifting risk from the healthcare system to patients and their families, and the threat hospital closure represents to communities, are explored. Alternative structures, policies and funding mechanisms, based on the evidence, are urgently needed to support smaller hospitals in the UK and elsewhere.

Immunization Adherence in Children With Sickle Cell Disease: A Single-Institution Experience

OBJECTIVES

The Advisory Committee on Immunization Practices (ACIP) recommends additional immunizations for people with asplenia or functional asplenia, such as children with sickle cell disease. Adherence rate to the recommended immunization schedule for functional asplenia remains low for children with sickle cell disease. The purpose of this study was to assess the immunization adherence for this population at a single institution in Kentucky and to evaluate the use of the Kentucky Immunization Registry (KYIR) by providers.

METHODS

A single-center retrospective chart review was conducted for 107 children with sickle cell disease ages 2 through 18 years. Immunization histories were obtained from the hospital EMRs, the sickle cell clinic EMR, the KYIR, and by requesting records from primary care physicians. Each patient was documented as either missing or having complete records in the KYIR.

RESULTS

The complete adherence rate to the ACIP-recommended immunization schedule for children with functional asplenia was 6% (6 of 107). Nearly all children were compliant with the Haemophilus influenzae type B vaccination, whereas the adherence rate for the meningococcal and pneumococcal vaccines ranged from 25% to 77%. The lowest immunization rate was observed in children eligible for the meningococcal B vaccine (25%). Only 3 patients had a complete immunization history documented in the KYIR.

CONCLUSIONS

Adherence to the ACIP-recommended immunization schedule for functionally asplenic patients is poor among children with sickle cell disease included in this study. Quality improvement measures should focus on increasing immunization adherence and improving documentation of immunization records in the KYIR for this patient population.

Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study

BACKGROUND

Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines.

OBJECTIVE

We examined system and clinician factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA.

DESIGN

Qualitative study using a positive deviance approach to understand practice variation in high- and low-testosterone prescribing sites.

PARTICIPANTS

Twenty-two interview participants included primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high- and 3 low-testosterone prescribing sites.

APPROACH

Semi-structured phone interviews were conducted, transcribed, and coded using a priori theoretical constructs and emergent themes. Case studies were developed for each site and a cross-case matrix was created to evaluate variation across high- and low-prescribing sites.

KEY RESULTS

We identified four system-level domains related to variation in testosterone prescribing: organizational structures and processes specific to testosterone prescribing, availability of local guidance on testosterone prescribing, well-defined dissemination process for local testosterone polices, and engagement in best practices related to testosterone prescribing. Two clinician-level domains were also identified, specifically, structured initial testosterone prescribing process and specified follow-up testosterone prescribing process. High- and low-testosterone prescribing sites systematically varied in the four system-level domains, while the clinician-level domains looked similar across all sites. The third high-prescribing site was unusual in that it exhibited the four domains similar to the 3 low-prescribing sites at the time of our visit. This site had greatly reduced its prescribing of testosterone in the interim.

CONCLUSIONS

Findings suggest that local organizational factors play an important role in influencing prescribing. Sites have the potential to transform their utilization patterns by providing access to specialty care expertise, an electronic health record-based system to facilitate guideline-concordant prescribing, well-defined dissemination processes for information, guidance from multiple sources, and clarity regarding best practices for prescribing.

Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance access to specialist care: a scoping review

INTRODUCTION

Electronic consultation (eConsult)-provider-to-provider electronic asynchronous exchanges of patient health information at a distance-is emerging as a potential tool to improve the interface between primary care providers and specialists. Despite growing evidence that eConsult has clinical benefits, it is not widely adopted. We investigated factors influencing the adoption and implementation of eConsult services.

METHODS

We applied established methods to guide the review, and the recently published Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews to report our findings. We searched five electronic databases and the grey literature for relevant studies. Two reviewers independently screened titles and full texts to identify studies that reported barriers to and/or facilitators of eConsult (asynchronous (store-and-forward) use of telemedicine to exchange patient health information between two providers (primary and secondary) at a distance using secure infrastructure). We extracted data on study characteristics and key barriers and facilitators were analysed thematically and classified using the Quadruple Aim framework taxonomy. No date or language restrictions were applied.

RESULTS

Among the 2579 publications retrieved, 130 studies met eligibility for the review. We identified and summarised key barriers to and facilitators of eConsult adoption and implementation across four domains: provider, patient, healthcare system and cost. Key barriers were increased workload for providers, privacy concerns and insufficient reimbursement for providers. Main facilitators were remote residence location, timely responses from specialists, utilisation of referral coordinators, addressing medicolegal concerns and incentives for providers to use eConsult.

CONCLUSION

There are multiple barriers to and facilitators of eConsult adoption across the domains of Quadruple Aim framework. Our findings will inform the development of practice tools to support the wider adoption and scalability of eConsult implementation.

Implementation of Value-based Medicine (VBM) to Patients With Chronic Hepatitis C (HCV) Infection

INTRODUCTION

With the significant clinical and economic burden of chronic HCV, effective treatment must be provided efficiently and appropriately. VBM is predicated upon improving health outcomes (clinical and quality) while optimizing the cost of delivering these outcomes. This review explores the concepts of VBM and how it can be used as a strategy for HCV eradication, using the United States as a case example. Once treated with interferon-based regimens, patients with HCV experienced low cure rates, very poor health-related quality of life (HRQoL), decreased work productivity and significant costs. In this context, the old treatment of HCV produced little value to the patient and the society. However, the development of new antiviral regimens for HCV which are free of interferon, has greatly improved treatment success rates as documented with very high cure rates and by improving patient-reported outcomes (PROs), including HRQoL. However, the short-term economic investment to deliver this curative treatment to all HCV-infected patients can be sizeable. In contrast, if one takes the long-term view from the societal perspective, these new treatment regimens can lead to savings by reducing the costs of long-term complications of HCV infection.

CONCLUSIONS

All of the necessary tools are now available to implement strategies to eradicate HCV. The new all oral direct acting antivirals brings value to the patients and the society because it leads to improvements of clinically important outcomes. Furthermore, the costs associated with these treatment regimens can be recovered by preventing the future economic burden of HCV-complications.

Seven years of telemedicine in Médecins Sans Frontières demonstrate that offering direct specialist expertise in the frontline brings clinical and educational value

Background

Médecins Sans Frontières (MSF), a medical humanitarian organization, began using store-and-forward telemedicine in 2010. The aim of the present study was to describe the experience of developing a telemedicine service in low-resource settings.

Methods

We studied the MSF telemedicine service during the period from 1st July 2010 until 30th June 2017. There were three consecutive phases in the development of the service, which we compared. We also examined the results of a quality assurance program which began in 2013.

Results

During the study period, a total of 5646 telemedicine cases were submitted. The workload increased steadily, and the median referral rate rose from 2 to 18 cases per week. The number of hospitals submitting cases and the number of cases per hospital also increased, as did the case complexity. Despite the increased workload, the allocation time reduced from 0.9 to 0.2 hours, and the median time to answer a case decreased from 20 to 5 hours. The quality assurance scores were stable. User feedback was generally positive and more than 90% of referrers who provided a progress report about their case stated that it had been sent to an appropriate specialist, that the response was sufficiently quick and that the teleconsultation provided an educational benefit. Referrers noted a positive impact of the system on patient outcome in 39% of cases.

Conclusions

The quality of the telemedicine service was maintained despite rising caseloads. The study showed that offering direct specialist expertise in low-resource settings improved the management of patients and provided additional educational value to the field physicians, thus bringing further benefits to other patients.

Actionable Analysis: Toward a Jurisdictional Evaluation of Primary Care Access in the Community Context

Primary care is the foundation of health care systems and has potential to alleviate inequities in population health. We examined multiple measures of adult primary care access, health status, and socioeconomic position at the New York City Council District level—a unit of analysis both relevant to and actionable by local policymakers. The results showed significant associations between measures of primary care access and health status after adjustment for socioeconomic factors. We found that an increase of 1 provider per 10 000 people was associated with a 1% decrease in diabetes rates and a 5% decrease in rates of adults without an influenza immunization. Furthermore, higher rates of primary care providers in high-poverty districts accepted Medicaid and had Patient-Centered Medical Home recognition, increasing constituent accessibility. Our findings highlight the significant contribution of primary care access to community health; policies and resource allocation must prioritize primary care facility siting and provider recruitment in low-access areas.

Trainers' and trainees' expectations of entrustable professional activities (EPAs) in a primary care training programme

Introducing Entrustable Professional Activities (EPAs) into primary care postgraduate medical education (PGME) programmes may be challenging, due to the general nature of primary care medicine, but trainers and trainees both stand to benefit from their use. We investigated the expectations of trainers and trainees in a primary care PGME programme regarding the use of EPAs. We held two focus group discussions with trainers and four with trainees from the Dutch General Practice training programme, to explore their views on the use of EPAs in their training programme. Focus group discussions were audio-recorded and transcribed verbatim. The transcripts were analysed using conventional content analysis. Trainers and trainees felt that the large number of EPAs in the training programme, and the general way they are formulated, made them unsuitable for use in formal assessments. However, they felt that EPAs can be a useful aid to trainee learning. EPAs may help trainers to give trainees specific feedback on their performance. While the use of the classic EPA method in primary care PGME programmes may be challenging, EPAs in such programmes might be more suitable as design and learning tools than as a tool for formal assessment.

A comparison of one-year treatment utilization for shoulder osteoarthritis patients initiating care with non-orthopaedic physicians and orthopaedic specialists

Background

In this paper we investigate patients seeking care for a new diagnosis of shoulder osteoarthritis (OA) and the association between a patient’s initial physician specialty choice and one-year surgical and conservative treatment utilization.

Methods

Using retrospective data from a single large regional healthcare system, we identified 572 individuals with a new diagnosis of shoulder OA and identified the specialty of the physician which was listed as the performing physician on the index shoulder visit. We assessed treatment utilization in the year following the index shoulder visit for patients initiating care with a non-orthopaedic physician (NOP) or an orthopaedic specialist (OS). Descriptive statistics were calculated for each group and subsequent one-year surgical and conservative treatment utilization was compared between groups.

Results

Of the 572 patients included in the study, 474 (83%) received care from an OS on the date of their index shoulder visit, while 98 (17%) received care from a NOP. There were no differences in baseline patient age, gender, BMI or pain scores between groups. OS patients reported longer symptom duration and a higher rate of comorbid shoulder diagnoses. Patients initiating care with an OS on average received their first treatment much faster than patients initiating care with NOP (16.3 days [95% CI, 12.8, 19.7] vs. 32.3 days [95% CI, 21.0, 43.6], Z = 4.9, p < 0.01). Additionally, patients initiating care with an OS had higher odds of receiving surgery (OR = 2.65, 95% CI: 1.42, 4.95) in the year following their index shoulder visit.

Conclusions

Patients initiating care with an OS received treatment much faster and were treated with more invasive services over the year following their index shoulder visit. Future work should compare patient-reported outcomes across patient groups to assess whether more expensive and invasive treatments yield better outcomes for patients with shoulder OA.

Referral Patterns for Dual-Energy Computed Tomography in Diagnosis and Management of Gout: Ten-Year Experience at a Canadian Institution

PURPOSE

To analyze the utilization, indications, and outcomes of dual-energy computed tomography (DECT) gout imaging in clinical practice.

METHODS

This retrospective study was ethics approved. Radiology reports of DECT gout scans between 2007 and 2016 were analyzed for trends of utilization, referral pattern, indication, and diagnosis.

RESULTS

DECT gout referrals increased substantially (2007: 37; 2008: 72; 2016: 385; total: 1877). The largest number of referrals were from rheumatology (1160), emergency medicine (283), and family medicine (177). Most referrals (92%) were requested to aid an initial diagnosis of gout. Other reasons included estimating the disease burden (6%) or monitoring disease progression and effectiveness of treatment (2%). Rheumatology accounted for most referrals for the latter two reasons (81% and 97%). Imaging findings of urate presence were similar in referrals from rheumatology (62%), family medicine (62%), and other medical specialties (62%). The urate positive rates were slightly lower in referrals from emergency medicine (47%) and surgical specialties (41%). The most common differential diagnoses by referring specialties were calcium pyrophosphate dihydrate crystal deposition disease (CPPD) and other inflammatory or erosive arthritides (rheumatology, family medicine), CPPD and infections (other medical specialties), infections and fractures (emergency medicine), neoplasm and infections (surgical specialties).

CONCLUSIONS

The increasing utilization of DECT for gout imaging validates its clinical value. Varying clinical presentation could explain differences of urate positive rates among specialties. Our results support a multispecialty collaborative approach to the diagnosis and management of gout, with direct access to DECT gout imaging provided to various physician specialties.

Physician experiences with sodium-glucose cotransporter (SGLT2) inhibitors, a new class of medications in type 2 diabetes, and adverse effects

Aim

The primary aim of our study is to identify physicians who have witnessed a complication attributed to sodium-glucose cotransporter (SGLT2) inhibitors. The secondary aim is to determine the type, severity, and setting of the event (inpatient versus outpatient).

Background

Diabetes is an increasing public health burden with 9.9% of Canadians expected to be diagnosed with it in 2020. A prominent change with respect to treatment options since the publication of the revised Diabetes Canada guidelines in May 2016 concerned the SGLT2 inhibitors. Their favorable clinical profile has increased interest among clinicians, but there is still reason for caution. Because these drugs are new, the balance of benefits versus risks is not well understood.

Methods

We conducted a cross-sectional survey of all in-practice physicians (excluding pediatricians). Data were collected through an online survey.

Findings

Our survey identified 154 physicians who have identified one or more adverse drug reactions (ADRs) related to SGLT2 inhibitor use. A total of 173 ADRs were identified. In total, 20.6% of family physician respondents had witnessed one or more ADRs. The most common complication is mycotic infection (82 cases) with 47% identified as a low level of severity and occurring mostly in the outpatient setting. The second most common complication is diabetic ketoacidosis (43 cases) with 67% identified as a high level of severity and occurring mostly in the inpatient setting. Other identified complications include hyperkalemia (6 cases), renal insufficiency (15 cases), and even amputation (2 cases). Our survey is the first to document real-world complications from SGLT2 inhibitors. In the outpatient setting, mycotic infections are most common and most often benign. In the inpatient setting, diabetic ketoacidosis is the most common and is severe. This is an important take-home message for family physicians to tailor their practice and vigilance according to the practice setting.

Association between physician characteristics and the use of 21-gene recurrence score genomic testing among Medicare beneficiaries with early-stage breast cancer, 2008-2011

PURPOSE

We sought to determine whether physician-level characteristics were associated with 21-gene recurrence score (RS) genomic testing to evaluate recurrence risk and benefit of adjuvant chemotherapy in patients with estrogen receptor-positive, node-negative breast cancer.

METHODS

Retrospective cohort study of a nationally representative sample of Medicare beneficiaries using Surveillance, Epidemiology, and End Results program-Medicare data linked with the American Medical Association physician master file. The main outcome was receipt of genomic testing within 1 year of diagnosis as a function of physician-level factors.

RESULTS

A total of 24,463 patients met the study criteria; they received care from 3172 surgeons and 2475 medical oncologists. Of 4124 tests ordered, 70% were ordered by a medical oncologist and 16% by a surgeon. In multivariable regression models, multiple variables were associated with receipt of testing, including having a medical oncologist (odds ratio [OR] 2.77; 95% CI 2.00-3.82), a surgeon specializing in surgical oncology (OR 1.20; 95% CI 1.09-1.31), and a female medical oncologist (OR 1.10; 95% CI 1.02-1.20). Having a medical oncologist with 5 or more years in practice was associated with lower odds of testing (OR 0.83; 95% CI 0.76-0.92). Surgical procedures performed at academic centers were associated with higher odds of testing (OR 1.11; 95% CI 1.02-1.20).

CONCLUSIONS

Although most RS testing was ordered by medical oncologists, physicians in other specialties ordered roughly one-third of the tests. Physician characteristics, including gender and time in practice, were associated with receiving testing, creating opportunities for targeting interventions to help patients receive optimal care.

Variation in the Echocardiographic Surveillance of Primary Mitral Regurgitation

BACKGROUND

Clinical outcomes after surgical treatment of mitral regurgitation are worse if intervention occurs after deterioration of left ventricular size and function. Transthoracic echocardiographic (TTE) surveillance of patients with mitral regurgitation is indicated to avoid adverse ventricular remodeling. Overly frequent TTEs can impair patient access and reduce value in care delivery. This balance between timely surveillance and overutilization of TTE in valvular disease provides a model to study variation in the delivery of healthcare services. We investigated patient and provider factors contributing to variation in TTE utilization and hypothesized that variation was attributable to provider practice even after adjustment for patient characteristics.

METHODS AND RESULTS

We obtained records of all TTEs from 2001 to 2016 completed at a large echocardiography laboratory. The outcome variable was time interval between TTEs. We constructed a mixed-effects linear regression model with the individual physician as the random effect in the model and used intraclass correlation coefficient to assess the proportion of outcome variation because of provider practice. Our study cohort was 55 773 TTEs corresponding to 37 843 intervals ordered by 635 providers. The mean interval between TTEs was 12.4 months, 17.0 months, 18.3 months, and 17.4 months for severe, moderate, mild, and trace mitral regurgitation, respectively, with 20% of providers deemed overutilizers of TTEs and 25% underutilizers.

CONCLUSIONS

We conclude that there is substantial variation in follow-up intervals for TTE assessment of mitral regurgitation, despite risk-adjustment for patient variables, likely because of provider factors.

Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics

BACKGROUND/OBJECTIVE

Previous studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia.

METHODS

We assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated.

RESULTS

We analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90).

CONCLUSIONS

For pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse.

Outcomes in Older Adults with Multimorbidity Associated with Predominant Provider of Care Specialty

OBJECTIVES

To determine whether receiving the predominance of ambulatory visits from a primary care provider compared to a specialty provider is associated with better outcomes in older adults with multi morbidity.

DESIGN

Observational study using propensity score matching.

SETTING

Medicare fee-for-service, 2011-12.

PARTICIPANTS

Beneficiaries aged 65 and older with multimorbidity.

MEASUREMENTS

The independent variable was an indicator for having a specialty (versus primary care) as the predominant provider of care (PPC). Main outcomes were 1-year mortality, hospitalization, standardized expenditures, and ambulatory visit patterns.

RESULTS

Two-thirds of 3,934,942 beneficiaries with multimorbidity had a primary care provider as their PPC. Individuals with a specialty PPC had more hospitalizations (40.3 more per 1,000) and higher spending ($1,781 more per beneficiary) than those with a primary care PPC, but there was little difference in mortality (0.2% higher) or preventable hospitalizations. Spending differences were largest for professional fees ($769 higher per beneficiary), inpatient stays ($572 higher per beneficiary), and outpatient facilities ($510 higher per beneficiary) (all P < .001). In addition, people with a specialist PPC had lower continuity of care and saw more providers.

CONCLUSIONS

Older adults with multimorbidity with a specialist as their main ambulatory care provider had higher spending and lower continuity of care than those whose PPC was in primary care but similar clinical outcomes.

Improved Outcomes Following Hepatocellular Carcinoma (HCC) Diagnosis in Patients Screened for HCC in a Large Academic Liver Center versus Patients Identified in the Community

Background and Aims: Hepatocellular carcinoma (HCC) is the sixth most commonly occurring cancer worldwide. Knowledge and adherence to HCC surveillance guidelines has been associated with earlier detection. We sought to evaluate characteristics and outcomes following HCC diagnosis in patients screened for HCC in a large academic liver center versus patients diagnosed and referred from the community. Methods: We reviewed the records of patients diagnosed with HCC in the liver center of an academic institution from January 1999 till December 2013. Patients were classified into two groups: patients followed in our hepatology clinic and patients with HCC recently referred to our center. Univariate analysis was performed using chi-squared test and multivariate analysis was performed using SPSS 22.0. Results: The records of 410 patients were reviewed, and included 77.3% of patients referred from the community and 22.7% of patients followed in our clinic. In the clinic group, 75.6% were identified with one nodule at initial diagnosis, compared to 65.6% in the referral group. Patients in the referral group were more likely to present with tumors ≥5 cm at diagnosis, with 28.7% compared to 5.4% in the clinic group (p < 0.0001). Patients referred from the community were also less likely to undergo transplant, with 32.2% as compared to 48.4% of the clinic group (p < 0.004). Conclusion: Patients with chronic liver disease managed in an academic liver center present in the early stage of HCC diagnosis and are more likely to meet the Milan criteria and undergo transplant. Early referral to a specialized transplant center, if feasible, where a multidisciplinary approach is utilized might be essential in the management of chronic liver disease.

The Challenges of Measuring, Improving, and Reporting Quality in Primary Care

We propose a new set of priorities for quality management in primary care, acknowledging that payers and regulators likely will continue to insist on reporting numerical quality metrics. Primary care practices have been described as complex adaptive systems. Traditional quality improvement processes applied to linear mechanical systems, such as isolated single-disease care, are inappropriate for nonlinear, complex adaptive systems, such as primary care, because of differences in care processes, outcome goals, and the validity of summative quality scorecards. Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.

Access to Subspecialty Care And Survival Among Patients With Liver Disease

OBJECTIVES

Access to subspecialty care may be difficult for patients with liver disease, but it is unknown whether access influences outcomes among this population. Our objectives were to determine rates and predictors of access to ambulatory gastrointestinal (GI) subspecialty care for patients with liver disease and to determine whether access to subspecialty GI care is associated with better survival.

METHODS

We studied 28,861 patients within the Veterans Administration VISN 11 Liver Disease cohort who had an ICD-9-CM diagnosis code for liver disease from 1 January 2000 through 30 May 2011. Access was defined as a completed outpatient clinic visit with a gastroenterologist or hepatologist at any time after diagnosis. Multivariable logistic regression was used to determine predictors of access to a GI subspecialist. Survival curves were compared between those who did and those who did not see a specialist, with propensity score adjustment to account for other covariates that may affect access.

RESULTS

Overall, 10,710 patients (37%) had a completed GI visit. On multivariable regression, older patients (odds ratio (OR) 0.98, P<0.001), those with more comorbidities (OR 0.98, P=0.01), and those living farther from a tertiary-care center (OR 0.998/mi, P<0.001) were less likely to be seen in clinic. Patients who were more likely to be seen included those who had hepatitis C (OR 1.5, P<0.001) or cirrhosis (OR 3.5, P<0.001) diagnoses prior to their initial visit. Patients with an ambulatory GI visit at any time after diagnosis were less likely to die at 5 years when compared with propensity-score-matched controls (hazard ratio 0.81, P<0.001).

CONCLUSIONS

Access to ambulatory GI care was associated with improved 5-year survival for patients with liver disease. Innovative care coordination techniques may prove beneficial in extending access to care to liver disease patients.

A participatory model of the paradox of primary care

PURPOSE

The paradox of primary care is the observation that primary care is associated with apparently low levels of evidence-based care for individual diseases, but systems based on primary care have healthier populations, use fewer resources, and have less health inequality. The purpose of this article is to explore, from a complex systems perspective, mechanisms that might account for the effects of primary care beyond disease-specific care.

METHODS

In an 8-session, participatory group model-building process, patient, caregiver, and primary care clinician community stakeholders worked with academic investigators to develop and refine an agent-based computer simulation model to test hypotheses about mechanisms by which features of primary care could affect health and health equity.

RESULTS

In the resulting model, patients are at risk for acute illness, acute life-changing illness, chronic illness, and mental illness. Patients have changeable health behaviors and care-seeking tendencies that relate to their living in advantaged or disadvantaged neighborhoods. There are 2 types of care available to patients: primary and specialty. Primary care in the model is less effective than specialty care in treating single diseases, but it has the ability to treat multiple diseases at once. Primary care also can provide disease prevention visits, help patients improve their health behaviors, refer to specialty care, and develop relationships with patients that cause them to lower their threshold for seeking care. In a model run with primary care features turned off, primary care patients have poorer health. In a model run with all primary care features turned on, their conjoint effect leads to better population health for patients who seek primary care, with the primary care effect being particularly pronounced for patients who are disadvantaged and patients with multiple chronic conditions. Primary care leads to more total health care visits that are due to more disease prevention visits, but there are reduced illness visits among people in disadvantaged neighborhoods. Supplemental appendices provide a working version of the model and worksheets that allow readers to run their own experiments that vary model parameters.

CONCLUSION

This simulation model provides insights into possible mechanisms for the paradox of primary care and shows how participatory group model building can be used to evaluate hypotheses about the behavior of such complex systems as primary health care and population health.

Bronchodilators use in patients with COPD

BACKGROUND

Bronchodilators are commonly used as maintenance and rescue therapy in patients with COPD. We aimed to examine the prescribing patterns of bronchodilators in clinical practice.

METHODS

We identified patients with COPD who initiated oral or inhaled bronchodilators between 2001 and 2010 from the Taiwan National Health Insurance Research Database. We followed the patients for 1 year. For bronchodilator prescriptions, we classified the treatments based on medication classes and regimens (oral bronchodilators alone, oral and inhaled bronchodilators in combination, or inhaled bronchodilators alone). For inhaled bronchodilator prescriptions, we further classified the treatments as short-acting bronchodilators alone, short-acting and long-acting bronchodilators in combination, and long-acting bronchodilators alone. We evaluated the prescribing patterns and the change with time, in different physician specialists, and in different hospital accreditation levels.

RESULTS

Among a cohort of 4,387 study-eligible patients, we identified 21,235 bronchodilator prescriptions for the analysis. The majority of prescriptions were oral xanthines or beta-2 agonists (62.63% and 47.54%, respectively) rather than prescriptions for inhaled bronchodilators (less than 10%). Nearly 80% of prescriptions were oral bronchodilator alone regimens. Use of oral bronchodilators declined with time and varied with health care providers, which were most commonly prescribed by non-chest specialists and in primary care clinics. Despite limited use of inhaled bronchodilators, it was noted that short-acting bronchodilators alone regimens accounted for 60% of the inhaled bronchodilator prescriptions.

CONCLUSION

Excessive use of oral and short-acting bronchodilators is noted in general practice. Further research and education programs are warranted to decrease inadequate oral bronchodilators and optimize inhaled treatments in the management of patients with COPD.

The effect of clinical decision support for advanced inpatient imaging

PURPOSE

To examine the effect of integrating point-of-care clinical decision support (CDS) using the ACR Appropriateness Criteria (AC) into an inpatient computerized provider order entry (CPOE) system for advanced imaging requests.

METHODS

Over 12 months, inpatient CPOE requests for nuclear medicine, CT, and MRI were processed by CDS to generate an AC score using provider-selected data from pull-down menus. During the second 6-month period, AC scores were displayed to ordering providers, and acknowledgement was required to finalize a request. Request AC scores and percentages of requests not scored by CDS were compared among primary care providers (PCPs) and specialists, and by years in practice of the responsible physician of record.

RESULTS

CDS prospectively generated a score for 26.0% and 30.3% of baseline and intervention requests, respectively. The average AC score increased slightly for all requests (7.2 ± 1.6 versus 7.4 ± 1.5; P < .001), for PCPs (6.9 ± 1.9 versus 7.4 ± 1.6; P < .001), and minimally for specialists (7.3 ± 1.6 versus 7.4 ± 1.5; P < .001). The percentage of requests lacking sufficient structured clinical information to generate an AC score decreased for all requests (73.1% versus 68.9%; P < .001), for PCPs (78.0% versus 71.7%; P < .001), and for specialists (72.9% versus 69.1%; P < .001).

CONCLUSIONS

Integrating CDS into inpatient CPOE slightly increased the overall AC score of advanced imaging requests as well as the provision of sufficient structured data to automatically generate AC scores. Both effects were more pronounced in PCPs compared with specialists.

Factors associated with ordering laboratory monitoring of high-risk medications

BACKGROUND

Knowledge about factors associated with provider ordering of appropriate testing is limited.

OBJECTIVE

To determine physician factors associated with ordering recommended laboratory monitoring tests for high-risk medications.

METHODS

Retrospective cohort study of patients prescribed a high-risk medication requiring laboratory monitoring in a large multispecialty group practice between 1 January 2008 and 31 December 2008. Analyses are based on administrative claims and electronic medical records. The outcome is a physician order for each recommended laboratory test for each prescribed medication. Key predictor variables are physician characteristics, including age, gender, specialty training, years since completing training, and prescribing volume. Additional variables are patient characteristics such as age, gender, comorbidity burden, whether the medication requiring monitoring is new or chronic, and drug-test characteristics such as inclusion in black box warnings. We used multivariable logistic regression, accounting for clustering of drugs within patients and patients within providers.

RESULTS

Physician orders for laboratory testing varied across drug-test pairs and ranged from 9% (Primidone-Phenobarbital level) to 97% (Azathioprine-CBC), with half of the drug-test pairs in the 85-91% ordered range. Test ordering was associated with higher provider prescribing volume for study drugs and specialist status (primary care providers were less likely to order tests than specialists). Patients with higher comorbidity burden and older patients were more likely to have appropriate tests ordered. Drug-test combinations with black box warnings were more likely to have tests ordered.

CONCLUSIONS

Interventions to improve laboratory monitoring should focus on areas with the greatest potential for improvement: providers with lower frequencies of prescribing medications with monitoring recommendations and those prescribing these medications for healthier and younger patients; patients with less interaction with the health care system are at particular risk of not having tests ordered. Black box warnings were associated with higher ordering rates and may be a tool to increase appropriate test ordering.