Slow-growing lesion on eyebrow.

It took a dermatoscopic examination followed by an e-consultation and shave biopsy to arrive at the diagnosis.

Responsibilities, Strategies, and Practice Factors in Clinical Cost Conversations: a US Physician Survey.

BACKGROUND: Physicians play a key role in mitigating and managing costs in healthcare which are rising. OBJECTIVE: Conduct a cross-sectional survey in 2017, comparing results to a 2012 survey to understand US physicians' evolving attitudes and strategies concerning healthcare costs. PARTICIPANTS: Random sample of 1200 US physicians from the AMA Masterfile. MEASURES: Physician views on responsibility for costs of care, enthusiasm for cost-saving strategies, cost-consciousness scale, and practice strategies on addressing cost. KEY RESULTS: Among 1200 physicians surveyed in 2017, 489 responded (41%). In 2017, slightly more physicians reported that physicians have a major responsibility for addressing healthcare costs (32% vs. 27%, p = 0.03). In 2017, more physicians attributed "major responsibility" for addressing healthcare costs to pharmaceutical companies (68% vs. 56%, p < 0.001) and hospital and health systems (63% vs. 56%%, p = 0.008) in contrast to 2012. Fewer respondents in 2017 attributed major responsibility for addressing costs to trial lawyers (53% vs. 59%, p = 0.007) and patients (42% vs. 52%, p < 0.0001) as compared to 2012. Physician enthusiasm for patient-focused cost-containment strategies like high deductible health plans and higher co-pays (62% vs. 42%, p < 0.0001 and 62% vs. 39%, p < 0.0001, not enthusiastic, respectively) declined. Physicians reported that when they discussed cost, it resulted in a change in disease management 56% of the time. Cost-consciousness within surveyed physicians had not changed meaningfully in 2017 since 2012 (31.7 vs. 31.2). Most physicians continued to agree that decision support tools showing costs would be helpful in their practice (> 70%). After adjusting for specialty, political affiliation, practice setting, age, and gender, only democratic/independent affiliation remained a significant predictor of cost-consciousness. CONCLUSIONS AND RELEVANCE: US physicians increasingly attribute responsibility for rising healthcare costs to organizations and express less enthusiasm for strategies that increase patient out-of-pocket cost. Interventions that focus on physician knowledge and communication strategies regarding cost of care may be helpful.

Examining the Utility of a Novel Neurologic Test in Patients With Obstructive Sleep Apnea: A Pilot Study.

Purpose: To test the association between participant King-Devick Test (KDT) times and obstructive sleep apnea (OSA) severity and evaluate for improvement after continuous positive airway pressure (CPAP) treatment. Methods: Study dates January 30 to July 31, 2018. Patients were referred for initial evaluation of sleep disordered breathing concerns. OSA severities were defined by Apnea Hypopnea Index (AHI) results, with ≥15 considered at least moderate OSA. The KDT is an objective physical measure of brain function. We estimated correlation between KDT time and AHI and compared mean KDT time between patients with and without moderate OSA. For the OSA subgroup, we evaluated for potential improvement in KDT after CPAP. Results: We enrolled 60 participants, of whom 35 (58.3%) had OSA with an AHI ≥15. Initial analyses noted no significant KDT time differences between patients based on OSA severity. However, after excluding 3 participants who had baseline neurologic illness, adjusted analyses demonstrated that mean KDT time was significantly prolonged for patients with moderate or greater OSA (AHI ≥15) as compared to those with mild or no sleep apnea (AHI <15); 63.4 seconds (95% CI 58.9-67.8) versus 55.7 seconds (95% CI 50.2-61.1), P = .03. CPAP-treated subjects demonstrated significantly improved KDT test times; 63.5 seconds mean pretreatment versus 55.6 posttreatment; -6.6 seconds mean difference, 95%CI (-12.0, -1.13), P = .02. Conclusion: Neurologic abnormalities in patients with OSA are potentially demonstrable utilizing this objective physical measure. Significant improvement is achieved in patients after CPAP treatment.

The benefits of a standardized approach to opioid prescribing.

This initiative increased patient acceptance of controlled substance agreements and random urine drug screening, and it led many patients to discontinue opioid therapy.

Impact of standardized templates and skin cancer learning modules for teledermatology consultations.

BACKGROUND: Little research has been done in teledermatology to examine the effects of standardized templates and subject-specific learning modules. METHODS: We performed a prospective study examining the effects of standardized templates and standardized cutaneous oncology learning modules on teledermatology referrals at Mayo Clinic. This data was then compared to previous teledermatology referrals before standardized templates were adopted. RESULTS: A total of 42 teledermatology consultations were performed during the 4-month study period. The use of standardized templates resulted in an absolute reduction in face-to-face referrals. Teledermatology consultation increased the absolute diagnostic and management concordance by 26.2% (P = 0.02) and 33.3% (P < 0.01), respectively, and decreased the absolute diagnostic and management discordance by 19.1% (P = 0.03) and 31.0% (P < 0.01), respectively. The largest knowledge gaps were identified in cutaneous oncology. Educational intervention improved theoretical referral rates and confidence in diagnosis and management overall. CONCLUSION: The implementation of standardized intake templates reduces the rate of face-to-face referrals. Teledermatology improves primary care-based dermatological care and reduces theoretical referral rates.

Obstructive sleep apnea: A better Dx model for primary care.

This study identified a method that provides a truer assessment of disease probability than has been achieved with history and physical exam evaluation.

Spatiotemporal epidemiology of rabies at an interface between domestic dogs and wildlife in South Africa.

We characterized the spatiotemporal epidemiology of rabies from January 2009 through March 2014 across the interface between a wildlife reserve and communal livestock farming area in South Africa. Brain tissue from 344 animals of 28 different species were tested for lyssavirus antigen. Of these, 146 (42.4%) samples tested positive, of which 141 (96.6%) came from dogs. Brain samples of dogs were more likely to test positive for lyssavirus antigen if they were found and destroyed in the reserve, compared to samples originating from dogs outside the reserve (65.3% vs. 45.5%; odds ratio (OR) = 2.26, 95% confidence interval (CI) = 1.27-4.03), despite rabies surveillance outside the reserve being targeted to dogs that have a higher index of suspicion due to clinical or epidemiological evidence of infection. In the reserve, dogs were more likely to test positive for rabies if they were shot further from villages (OR = 1.42, 95% CI 1.18-1.71) and closer to water points (OR = 0.41, 95% CI 0.21-0.81). Our results provide a basis for refinement of existing surveillance and control programs to mitigate the threat of spillover of rabies to wildlife populations.

Cervicogenic Dizziness Successfully Treated With Upper Cervical Medial Branch Nerve Radiofrequency Ablation: A Case Report.

Cervicogenic dizziness is a sensation of disequilibrium caused by abnormal afferent activity from the neck. Its diagnosis and treatment are challenging. In a case of cervicogenic dizziness, we performed diagnostic upper cervical medial branch nerve blocks with near complete symptomatic relief for around 20 hours. Radiofrequency ablation of these nerves resulted in near complete relief for 7 months. Subsequent repeat ablations provided the same relief lasting for 6-10 months. This case suggests that upper cervical medial branch block can serve as a diagnostic test for cervicogenic dizziness, and radiofrequency ablation of these nerves might be an effective treatment.

Family Medicine Panel Size with Care Teams: Impact on Quality.

PURPOSE: The demand for comprehensive primary health care continues to expand. The development of team-based practice allows for improved capacity within a collective, collaborative environment. Our hypothesis was to determine the relationship between panel size and access, quality, patient satisfaction, and cost in a large family medicine group practice using a team-based care model. METHODS: Data were retrospectively collected from 36 family physicians and included total panel size of patients, percentage of time spent on patient care, cost of care, access metrics, diabetic quality metrics, patient satisfaction surveys, and patient care complexity scores. We used linear regression analysis to assess the relationship between adjusted physician panel size, panel complexity, and outcomes. RESULTS: The third available appointments (P < .01) and diabetic quality (P = .03) were negatively affected by increased panel size. Patient satisfaction, cost, and percentage fill rate were not affected by panel size. A physician-adjusted panel size larger than the current mean (2959 patients) was associated with a greater likelihood of poor-quality rankings (≤25th percentile) compared with those with a less than average panel size (odds ratio [OR], 7.61; 95% confidence interval [CI], 1.13-51.46). Increased panel size was associated with a longer time to the third available appointment (OR, 10.9; 95% CI, 1.36-87.26) compared with physicians with panel sizes smaller than the mean. CONCLUSIONS: We demonstrated a negative impact of larger panel size on diabetic quality results and available appointment access. Evaluation of a family medicine practice parameters while controlling for panel size and patient complexity may help determine the optimal panel size for a practice.

Simple Interventions Improve the Quality of a Missed Lab Appointment Process.

Simple interventions resolve the problem of missed lab appointments. It is essential that patients complete ordered laboratory studies. This maintains clinical quality and, potentially, keeps patients safe from harm. In our academic family medicine practice, baseline data demonstrated patients completed 94.7% of labs as ordered (26850/28348 patients per year) while 1498 (5.3%) did not. Our baseline patient reminder process, a mail or portal based generic letter, resulted in only 449 (30%) of patients ultimately completing them (1049 [70%] did not). Our baseline system was 96.3 % reliable. This process did not allow for provider review or input, and was not personalized for patients. We designed a quality improvement project involving three PDSA (Plan, Do, Study, and Act) cycles of about two months each. Desk staff created weekly reports of unresolved lab orders. A message in the electronic medical record (EMR) solicited provider input. Providers could elect to cancel studies (if already completed, reordered, or no longer clinically indicated) or have the patient receive a personalized reminder, including provider name and associated diagnoses. This reminder was sent by patient portal secure messaging (if an account existed) or with a mailed letter. These interventions resulted in 98.8 % process reliability. The frequency of unresolved lab orders decreased from 70% at baseline to 25%. In the second PDSA cycle, we contacted patients by the portal only if there was evidence of an active account. Otherwise, they were contacted by telephone. Patients without a portal account continued to receive a letter by mail. These modified processes resulted in an overall reliability rate of 99.2%. The frequency of unresolved lab orders decreased to 17%. A final PDSA cycle utilized only telephone contact with patients with unresolved lab orders. Schedulers offered patients a choice of appointment dates if they spoke personally. Otherwise, they were left messages with a future lab appointment date two weeks later.Overall process reliability now increased to 100%. The frequency of unresolved lab orders decreased to 0%. Our interventions resulted in increased system reliability.Provider input was not perceived as burdensome. Desk staff work effort was not increased.Telephone patient contact resulted in more frequent lab order completion than other methods.

Validating the Diagnostic Accuracy of the Sleep Apnea Clinical Score for Use in Primary Care Populations.

OBJECTIVE: To provide external validation of the diagnostic accuracy of the Sleep Apnea Clinical Score (SACS) tool in a new setting and patient population. PATIENTS AND METHODS: We conducted a prospective cohort study. Potential participants were adult family medicine patients. We excluded patients with a SACS of 0, known obstructive sleep apnea (OSA), negative results of previous testing, or life-limiting conditions. After SACS determination, participants completed overnight oximetry, sleep medicine consultation, and polysomnography. Those interpreting tests were blind to the participant's SACS. We determined likelihood ratios (LRs) for OSA diagnosis and posttest probabilities (PTPs). We calculated OSA prevalence (pretest probability), sensitivity, specificity, and positive and negative predictive values. RESULTS: One hundred ninety-one of 312 participants (61%) completed all steps. The prevalence of OSA was similar to that found in the derivation cohort (40% vs 45%; P=.31). With OSA defined as Apnea Hypopnea Index greater than 10, a SACS greater than 15 was 40% sensitive and 90% specific, with a positive predictive value of 73% and a negative predictive value of 69%. A SACS greater than 15 in our cohort produced an LR of 4.03 (95% CI, 3.12-5.22) with 73% PTP for OSA as compared with an LR of 5.17 (95% CI, 2.54-10.51) with 78% PTP found in the derivation cohort. CONCLUSION: The present study provides external validation of the SACS tool. It reliably predicted OSA for patients in our family medicine practice. Broader implementation in primary care practice is recommended. Further study will examine SACS uptake by clinicians and the resulting impact on utilization and clinical efficiency in primary care practices.

Clinicians Report Difficulty Limiting Low-Value Services in Daily Practice.

Health care services that increase costs but fail to improve health are of low value. Limiting low-value services has potential to decrease health care expenditures by eliminating waste. We examined the opinions of Continuing Medical Education attendees about the "Choosing Wisely" campaign and decreasing use of potentially unnecessary services of low value. We compared our attendees' responses to those of participants who completed a survey a year earlier. Respondents acknowledged waste of resources as a common and serious problem and noted frequent opportunities to address low-value services with their patients. They also reported limited ability to successfully reduce unnecessary services in daily clinical care. Lack of familiarity with "Choosing Wisely" may be related.

Physician Cost Consciousness and Use of Low-Value Clinical Services.

PURPOSE: Choosing WiselyTM engaged medical specialties, creating "top 5 lists" of low-value services. We describe primary care physicians' (PCPs') self-reported use of these services and perceived barriers to guideline adherence. We quantify physician cost consciousness and determine associations with use. METHODS: PCP attendees of a continuing medical education conference completed a survey. For each Family Medicine Choosing Wisely behavior, participants reported clinical adherence. Likert scale items assessed perceived barriers. Low-value service frequency was the dependent variable. A validated Cost Consciousness Scale created the predictor variable. We hypothesized that participants with greater cost consciousness would report less frequent use of low-value services. RESULTS: Of 199 PCP attendees, 143 (72%) participated. Papanicolaou test after hysterectomy was performed least (0.2 mean services performed/10 patients). Provider knowledge of sinusitis treatment guidelines was greatest but provided most frequently (3.9 mean services performed/10 patients). Practice related barriers were perceived most frequently for adhering to sinusitis treatment guidelines. Attitudinal barriers were greatest for avoiding osteoporosis screening in low risk patients. Greater cost consciousness was associated with less use of low-value services (P = .03), greater knowledge of guidelines (P = .001), and fewer perceived attitudinal and practice behavior-related barriers (P < .001 for each). Greater knowledge of guidelines was not associated with less use of low-value services (P = .58). Familiarity with Choosing Wisely was associated with both greater cost consciousness (P = .004) and less use of low-value services (P = .03). CONCLUSIONS: Greater PCP cost consciousness was associated with less use of low-value services. Interventions to decrease perceived barriers and increase cost consciousness, perhaps by increasing awareness of Choosing Wisely, may translate into improved performance.

Directors Recognize Difficulties in Providing Medical Care to Residents But Few Implement Policies to Address Them.

BACKGROUND AND OBJECTIVES: Residents find it difficult to access medical care. Some seek care within their own program. Our objectives were to (1) determine whether family medicine program directors see their own resident physicians as patients, (2) describe whether they perceive the residency culture as actively encouraging of this practice, and (3) assess perceptions about reasons to encourage or discourage this. METHODS: We used a paper-based self-administered survey November 2013--January 2014. A stratified random sample of family medicine residencies based on administrative type was used. Participants were directors of sampled programs. The main outcome measure was provision of medical care to resident physicians. RESULTS: A total of 137/250 directors (55%) responded. Thirty (22%) reported seeing residents as patients in their family medicine clinic while 107 did not (78%). Some directors who do see resident patients expressed discomfort in doing so (24%). Participants reported that other faculty physicians were significantly more likely to see residents (56%). Eighty-eight percent (114/129) agreed that "Having a doctor-patient relationship with a resident makes a supervisory relationship more difficult." Significant differences in attitudes were noted between directors who do and do not provide resident medical care. Few directors (10 %) agreed that their residency culture actively encouraged residents to establish doctor-patient relationships with faculty physicians. Only 16 (12%) had created written policies. CONCLUSIONS: It is uncommon for directors to see residents as patients, but most who do feel comfortable with it. Other faculty physicians provide care more frequently. Directors acknowledge potential difficulties with this practice, but few have addressed these issues by creating specific policies.

Use of FRAX as a determinant for risk-based osteoporosis screening may decrease unnecessary testing while improving the odds of identifying treatment candidates.

PURPOSE: We have assessed the hypothetical impact of guideline-concordant osteoporosis screening on baseline behaviors utilizing two different guidelines and determined the relative ability of each to identify osteoporosis treatment candidates. METHODS: We conducted secondary analyses from the Fracture Risk Perception Study, which enrolled patients aged 50 to 75 years to complete questionnaires about their bone health. We determined our baseline screening rates and detection of treatment candidates and then assessed the hypothetical impact of adherence to U.S. Preventive Services Task Force (USPSTF) and National Osteoporosis Foundation (NOF) criteria, particularly for women aged 50 to 64. RESULTS: Of 144 women aged 50 to 64 years screened, 14 (9.7%) were treatment candidates. Screening based on identification of one or more risks (NOF) would lead to testing of 102 of the 144 patients (71%) to identify 12 of 14 treatment candidates (86%). Applying USPSTF criteria (9.3% FRAX threshold) would test 45 of the same 144 women (31%) to identify 11 of 14 treatment candidates (79%). NOF risk-based criteria would result in a moderate absolute screening rate reduction (16%, p = .0011; 95% CI, 7%-25%), but only marginal improvement in identifying treatment candidates (odds ratio, 2.67; 95% CI, 0.57-12.47). Applying the more selective USPSTF criteria greatly reduced unnecessary testing (56% absolute screening rate reduction; p < .0001; 95% CI, 47%-64%) while further improving the odds of identifying treatment candidates (odds ratio, 10.35; 95% CI, 2.72-39.35). CONCLUSIONS: When contemplating screening younger patients, systematic calculation of FRAX and ordering only when the 9.3% fracture risk threshold is reached may decrease unnecessary screening for many women while still identifying appropriate osteoporosis treatment candidates.

Fracture risk perception study: patient self-perceptions of bone health often disagree with calculated fracture risk.

BACKGROUND: We sought to evaluate the concordance between self-assessed perceptions of fracture risk and actual risk calculated by World Health Organization's 10-year Fracture Risk Assessment Tool (FRAX). METHODS: We collected demographic data, lifestyle information, osteoporosis knowledge, bone density test results, and treatment history from patients aged 50 to 75 years. Subjects rated their perceptions of 10-year risk of sustaining fracture as low (0%-9%), intermediate (10%-19%), or high (≥20%). This rating was compared with risk calculated by FRAX. FINDINGS: Among 426 patients, the greatest agreement regarding fracture risk was noted for those in the low-risk FRAX group: 81% perceived themselves as having low risk. The most risk disagreement was in the high-risk FRAX group: Only 18% perceived their risk as high. Perceived risk was intermediate for 59% and low for 24%. Of patients at intermediate calculated risk by FRAX, 48% agreed with this with self-perceived risk. Overall, risk agreement was associated with bone density results, with higher T scores predictive of agreement. Underestimation was associated with being female and older. Patients with prescription treatment exposure frequently had risk disagreement and perceived their risk as lower than their calculated FRAX scores might indicate. Patients taking calcium and vitamin D similarly perceived lower risk than calculated by FRAX. CONCLUSIONS: Patients at intermediate and high calculated fracture risk frequently had self-perceptions of lower risk. Patients taking prescription osteoporosis medication and calcium and vitamin D treatment perceived less risk than calculated. Whether correcting misperceptions about personal susceptibility to fracture might result in behavioral changes will be determined.

Utilising the epidemiologic triad in analysing quality improvement data: antibiotic use for respiratory infections as a case example.

BACKGROUND: Quality improvement investigators working in field settings, who typically are not trained in epidemiological methods, may not consider all three elements of the epidemiologic triad (person, place and time) when planning their projects. AIM: To demonstrate how the epidemiological triad can guide analysis for quality assessment. Predictors of antibiotic use in primary care were analysed to illustrate the approach. METHODS: This study was a secondary analysis of data previously collected from medical records and a provider survey. A convenience sample of 467 family medicine patients treated in two clinic sites for acute respiratory tract infections was analysed by locating quality variation in person, place and time. Independent variables included patient age, date of clinic visit, and clinic site. The outcome measure was antibiotic prescription (yes or no). RESULTS: Antibiotics were prescribed for 69.2% of patients in the sample. Age group was not related to antibiotic prescribing. Prescription was related to time (P = 0.0344) and clinic site (P = 0.0001) in univariate tests. However, only site was independently related to antibiotic prescription (odds ratio = 0.47, confidence interval = 0.30 to 0.73, P = 0.0008). CONCLUSION: The epidemiological triad assisted in guiding further post hoc analysis of predictors of antibiotic prescriptions. Further investigations of this quality indicator can be directed at exploring site differences and testing interventions. Studies of other quality indicators in primary care can employ the triad to guide the analysis.

Addressing antibiotic use for acute respiratory tract infections in an academic family medicine practice.

The objective of this study was to educate health care providers and patients to reduce overall antibiotic prescription rates for patients with acute respiratory tract infection (ARTI). An interdisciplinary quality improvement team used the Define, Measure, Analyze, Improve, and Control quality improvement process to change patient expectations and provider antibiotic prescribing patterns. Providers received personal and group academic detailing about baseline behaviors, copies of treatment guidelines, and educational materials to use with patients. Get Smart About Antibiotics Week materials educated patients about appropriate antibiotic use. Providers collected demographic and clinical information about a case series of patients with ARTIs and their subsequent provision of antibiotics. In total, 241 patients with ARTIs were accrued. The antibiotic prescribing rate for patients aged 18 years and older was significantly reduced from 69% at baseline to 56% after interventions (95% confidence interval = 49.1%-63.4%; P<.001). Providers' prescribing behaviors significantly improved after multiple quality improvement interventions.