Physician and Nurse Practitioner Attitudes on Generic Prescribing of Oral Contraceptive Pills and Antidepressants.

IMPORTANCE: As prescription drug costs rise, it is important to understand attitudes among primary care physicians and nurse practitioners (NPs) towards generic drugs. OBJECTIVE: We aimed to examine the generic skepticism index (GSI) among primary care clinicians, and their willingness to discuss and prescribe generic antidepressants (ADs) and generic oral contraceptives (OCPs). DESIGN: We used a factorial vignette design survey to test 4 factors: message source, message, brand preference, and drug class. Participants were randomized to different combinations of factors. SETTING: This was a cross-sectional study. PARTICIPANTS: Physicians registered with the American College of Physicians (ACP) and NPs registered with the American Association of Nurse Practitioners (AANP) participated in the study. MAIN MEASURES: The primary outcomes were generic skepticism as measured using the generic skepticism index (GSI), and clinician willingness to discuss and prescribe generics. RESULTS: Surveys were completed by 56% of physicians (n = 369/661) and 60% of NPs (n = 493/819). Compared with physicians, NPs were younger (p < 0.001), predominantly female (p < 0.001), and differed in the race (p < 0.001). According to the GSI, 16% (n = 138/862) were identified as generic skeptics (18.5% of NPs and 12.7% of physicians, p = 0.023). Generic skeptics had lower odds of willingness to discuss switching (OR 0.22, 95% CI (0.14-0.35), p < 0.001) or prescribe (OR 0.18, 95% CI (0.11-0.28), p < 0.001) generic OCPs. Participants had lower odds of willingness to prescribe generic drugs to patients with brand preference compared with brand-neutral patients (OR 0.64, 95% CI 0.50-0.82, p < 0.001). CONCLUSIONS AND RELEVANCE: Generic skepticism was associated with lower willingness to discuss or prescribe generic drugs. Clinicians reported lower willingness to discuss switching or prescribe generics for OCPs than for ADs. Patient brand preference hindered generic prescribing. Message source and message type were not significantly associated with outcomes.

Physicians' Perceptions of Proton Pump Inhibitor Risks and Recommendations to Discontinue: A National Survey.

OBJECTIVE: To provide contemporary estimates of internists' perceptions of adverse effects associated with proton pump inhibitors (PPIs) and self-reported clinical use. METHODS: We invited 799 internists, including specialists and postgraduate trainees, to complete an online survey. Topics included perceptions of PPI adverse effects (AEs) and effectiveness for upper gastrointestinal bleeding (UGIB) prevention, changes in prescribing, and management recommendations for patients using PPIs for gastroesophageal reflux disease or UGIB prevention. We used logistic regression to identify factors associated with appropriate PPI continuation in the scenario of a patient at high risk for UGIB. RESULTS: Among 437 respondents (55% response rate), 10% were trainees and 72% specialized in general medicine, 70% were somewhat/very concerned about PPI AEs, and 76% had somewhat/very much changed their prescribing. A majority believed PPIs increase the risk for 6 of 12 AEs queried. Fifty-two percent perceived PPIs to be somewhat/very effective for UGIB prevention. In a gastroesophageal reflux disease scenario in which PPI can be safely discontinued, 86% appropriately recommended PPI discontinuation. However, in a high-risk UGIB prevention scenario in which long-term PPI use is recommended, 79% inappropriately recommended discontinuation. In this latter scenario, perceived effectiveness for bleeding prevention was strongly associated with continuing PPI (odds ratio 7.68, P < 0.001 for moderately; odds ratio 17.3, P < 0.001 for very effective). Other covariates, including concern about PPI AEs, had no significant association. DISCUSSION: Most internists believe PPIs cause multiple AEs and recommend discontinuation even in patients at high risk for UGIB. Future interventions should focus on ensuring that PPIs are prescribed appropriately according to individual risks and benefits.

Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults.

BACKGROUND/OBJECTIVES: Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties. DESIGN: National cross-sectional survey. SETTING: Ambulatory. PARTICIPANTS: Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians. MEASUREMENTS: Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases. RESULTS: In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists). CONCLUSIONS: While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.

Development and testing of a module to promote generic oral contraceptive prescribing among nurse practitioners.

Although generic oral contraceptives (OCPs) can improve adherence and reduce health care expenditures, use of generic OCPs remains low, and the factors that affect generic prescribing are not well understood. We aimed to understand the barriers and facilitators of generic OCP prescribing and potential solutions to increase generic OCP prescribing, as well as pilot an educational module to address clinician misconceptions about generic OCPs. We developed focus group scripts using the 4D model of appreciative inquiry. A total of four focus groups occurred, two at the American Association of Nurse Practitioners (AANP) national conference and two at the American College of Physicians (ACP) Internal Medicine meeting. Focus group transcripts were analyzed using a constant comparative method with no a priori hypothesis to generate emerging and reoccurring themes. Findings from these focus groups were used to develop an educational module promoting generic OCP prescribing. Participants were recruited from the AANP Network for Research and the ACP Research Panel. This study demonstrates that health system factors, workflow factors, clinician factors, and patient factors were the main barriers to and facilitators of generic OCP prescribing. Nurse practitioners were responsive to an educational module and reported increased willingness to discuss and prescribe generic OCPs after completing the module. Interventions to increase generic OCP prescribing must address clinician and patient factors within the context of workflow and larger health system factors.

Use of Filters for Residency Application Review: Results From the Internal Medicine In-Training Examination Program Director Survey.

BACKGROUND: The increase in applications to residency programs, known as "application inflation," creates challenges for program directors (PDs). Prior studies have shown that internal medicine (IM) PDs utilize criteria, such as United States Medical Licensing Examination (USMLE) Step examination performance, when reviewing applications. However, little is known about how early these filters are utilized in the application review cycle. OBJECTIVE: This study sought to assess the frequency and types of filters utilized by IM PDs during initial residency application screening and prior to more in-depth application review. METHODS: A web-based request for the 2016 Internal Medicine In-Training Examination (IM-ITE) PD Survey was sent to IM PDs. Responses from this survey were analyzed, excluding non-US programs. RESULTS: With a 50% response rate (214 of 424), IM PDs responded that the most commonly used data points to filter applicants prior to in-depth application review were the USMLE Step 2 Clinical Knowledge score (32%, 67 of 208), USMLE Step 1 score (24%, 50 of 208), and medical school attended (12%, 25 of 208). Over half of US IM PD respondents (55%, 114 of 208) indicated that they list qualifying interview criteria on their program website, and 31% of respondents (50 of 160) indicated that more than half of their applicant pool does not meet the program's specified interview criteria. CONCLUSIONS: Results from the 2016 IM-ITE PD Survey indicate many IM PDs use filters for initial application screening, and that these filters, when available to applicants, do not affect many applicants' decisions to apply.

Cascades of Care After Incidental Findings in a US National Survey of Physicians.

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. Design, Setting, and Participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. Main Outcomes and Measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. Conclusions and Relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Development and testing of a web module to IMPROVE generic prescribing of oral contraceptives among primary care physicians.

WHAT IS KNOWN AND OBJECTIVE: The use of generic oral contraceptives (OCPs) can improve adherence and reduce healthcare costs, yet scepticism of generic drugs remains a barrier to generic OCP discussion and prescription. An educational web module was developed to reduce generic scepticism related to OCPs, improve knowledge of generic drugs and increase physician willingness to discuss and prescribe generic OCPs. METHODS: A needs assessment was completed using in-person focus groups at American College of Physicians (ACP) Annual Meeting and a survey targeting baseline generic scepticism. Insights gained were used to build an educational web module detailing barriers and benefits of generic OCP prescription. The module was disseminated via email to an ACP research panel who completed our baseline survey. Post-module evaluation measured learner reaction, knowledge and intention to change behaviour along with generic scepticism. RESULTS AND DISCUSSION: The module had a response rate of 56% (n = 208/369). Individuals defined as generic sceptics at baseline were significantly less likely to complete our module compared to non-sceptics (responders 9.6% vs non-responders 16.8%, P = 0.04). The majority (85%, n = 17/20) of baseline sceptics were converted to non-sceptics (P < 0.01) following completion of the module. Compared to non-sceptics, post-module generic sceptics reported less willingness to discuss (sceptic 33.3% vs non-sceptic 71.5%, P < 0.01), but not less willingness to prescribe generic OCPs (sceptic 53.3% vs non-sceptic 67.9%, P = 0.25). Non-white physicians and international medical graduates (IMG) were more likely to be generic sceptics at baseline (non-white 86.9% vs white 69.9%, P = 0.01, IMG 13.0% vs USMG 5.0% vs unknown 18.2%, P = 0.03) but were also more likely to report intention to prescribe generic OCPs as a result of the module (non-white 78.7% vs white 57.3%, P < 0.01, IMG 76.1% vs USMG 50.3% vs unknown 77.3%, P = 0.03). WHAT IS NEW AND CONCLUSION: A brief educational web module can be used to promote prescribing of generic OCPs and reduce generic scepticism.

U.S. Internists' Perspectives on Discussing Cost of Care With Patients: Structured Interviews and a Survey.

Background: Rising out-of-pocket costs are creating a need for cost conversations between patients and physicians. Objective: To understand the factors that influence physicians to discuss and consider cost during a patient encounter. Design: Mixed-methods study using semistructured interviews and a survey. Setting: United States. Participants: 20 internal medicine physicians were interviewed; 621 internal medicine physician members of the American College of Physicians completed the survey. Measurements: Interviews were analyzed by using thematic analysis, and surveys were analyzed by using descriptive statistics. Results: From the interviews, 4 themes were identified: Physicians are 1) aware that patients are struggling to afford medical care; 2) relying on clues from patients that hint at their cost sensitivity; 3) relying on experience to anticipate potentially high-cost treatments; and 4) aware that patients are making financial trade-offs to afford their care. Three quarters (n = 466) of survey respondents stated that they consider out-of-pocket costs when making most clinical decisions. For 31% (n = 191) of participants, there were times in the past year that they wanted to discuss out-of-pocket prescription drug costs with patients but did not. The most influential factors for ordering a test are the desire to be as thorough as possible (71% [n = 422]) and insurance coverage for the test (68% [n = 422]). Limitation: Findings are self-reported, the sample is limited to a single specialty, the survey response rate was low, information on the patient population was limited, and the survey instrument is not validated. Conclusion: Physicians are attuned to the burden of health care costs and are willing to consider alternative options based on a patient's cost sensitivity. Primary Funding Source: Robert Wood Johnson Foundation.

Physician Perspectives In Year 1 Of MACRA And Its Merit-Based Payment System: A National Survey.

We surveyed a national sample of internal medicine physicians in March-May 2017 to explore their beliefs about the newly implemented Merit-based Incentive Payment System (MIPS). Respondents believed that their efforts in the four focus areas identified in the survey would ultimately improve the value of care. When informed that those areas represented the four MIPS domains, the majority remained positive about the likely impact on value. However, expectations varied by physicians' characteristics and sense of control over the desired outcomes, and many respondents believed that unintended consequences could occur. Moreover, respondents generally reported low familiarity with the policy and disagreed with program guidelines for weighting domains in the composite score. These findings indicate the need to educate physicians about MIPS and suggest potentially fruitful approaches. Moving forward, policy makers should monitor for unintended consequences and explore ways to better align program guidelines with physicians' perspectives.

Relationship Between Institutional Investment in High-Value Care (HVC) Performance Improvement and Internal Medicine Residents' Perceptions of HVC Training.

PURPOSE: To measure the association between institutional investment in high-value care (HVC) performance improvement and resident HVC experiences. METHOD: The authors analyzed data from two 2014 surveys assessing institutions' investments in HVC performance improvement as reported by program directors (PDs) and residents' perceptions of the frequency of HVC teaching, participation in HVC-focused quality improvement (QI), and views on HVC topics. The authors measured the association between institutional investment and resident-reported experiences using logistic regression, controlling for program and resident characteristics. RESULTS: The sample included 214 programs and 9,854 residents (59.3% of 361 programs, 55.2% of 17,851 residents surveyed). Most PDs (158/209; 75.6%) reported some support. Residents were more likely to report HVC discussions with faculty at least a few times weekly if they trained in programs that offered HVC-focused faculty development (odds ratio [OR] = 1.19; 95% confidence interval [CI] 1.04-1.37; P = .01), that supported such faculty development (OR = 1.21; 95% CI 1.04-1.41; P = .02), or that provided physician cost-of-care performance data (OR = 1.19; 95% CI 1.03-1.39; P = .02). Residents were more likely to report participation in HVC QI if they trained in programs with a formal HVC curriculum (OR = 1.83; 95% CI 1.48-2.27; P < .001) or with HVC-focused faculty development (OR = 1.46; 95% CI 1.15-1.85; P = .002). CONCLUSIONS: Institutional investment in HVC-related faculty development and physician feedback on costs of care may increase the frequency of HVC teaching and resident participation in HVC-related QI.

Internists' Perceptions of Proton Pump Inhibitor Adverse Effects and Impact on Prescribing Practices: Results of a Nationwide Survey.

BACKGROUND: Observational studies have linked proton pump inhibitors (PPIs) with serious adverse effects. The study aimed to evaluate internists' perceptions of PPI harms and effects on prescribing. METHODS: This was an online survey of a representative sample of the American College of Physicians in 2013. We queried familiarity with and concern about PPI adverse effects (1 - 7 Likert-type scales, anchored by "not at all" and "extremely"). We also asked how frequently (often, sometimes, rarely, or never) participants used any of three "de-escalation" strategies to stop or reduce PPIs because of concern about adverse effects: reducing patients' PPI dose, switching to H2 blocker, or discontinuing PPI. We used multivariable logistic regression to evaluate associations between sometimes/often using any PPI de-escalation strategy and gender, time in practice, familiarity, and concern. RESULTS: The response rate was 53% (487/914). Seventy percent were male, median time in practice was 11 - 15 years, and most practiced general medicine (58%). Ninety-nine percent reported at least some familiarity with reported adverse effects (mean 4.9, standard deviation (SD) 1.0), and 98% reported at least some concern (mean 4.6, SD 1.3). Sixty-three percent reported sometimes/often reducing the PPI dose, 52% switching to H2 blocker, and 44% discontinuing PPI. In multivariable analysis, familiarity with adverse effects (OR 1.66 (1.31 - 2.10) for 1-point increase, P < 0.001) and concern (OR 2.14 (1.76 - 2.61) for 1-point increase, P < 0.001) were independently associated with de-escalation. Gender and time in practice had no effects. CONCLUSION: Almost all internists report awareness and concern about PPI adverse effects, and most are de-escalating PPIs as a result. Research on which approach is most effective for which patients is critically important.

Penalizing Physicians for Low-Value Care in Hospital Medicine: A Randomized Survey.

Low-value services-those for which there is little to no benefit, little benefit relative to cost, or outsized potential harm compared with benefit-persist widely despite professional consensus, guidelines, and national campaigns to reduce them. As policy makers consider financially penalizing physicians to deter low-value services, physician support for such penalties remains unknown. We conducted a randomized survey experiment among physicians to evaluate how the framing of harms from low-value care-in terms of those to patients, healthcare institutions, or society-influenced physician support of financial penalties for low-value care services. Policy support rate was 39.6% overall and highest when the harms of low-value care were framed as costs to society (48.4%). Compared with respondents receiving the "patient harm" version, those receiving the "societal harm" version (adjusted odds ratio [OR] 2.83; 95% confidence interval [CI], 1.20-6.69), but not the "institutional harm" framing (adjusted OR 1.53; 95% CI, 0.66-3.53), were more likely to report policy support. Our results suggest that emphasizing the impact of these harms may increase acceptability of financial penalties among physicians and contribute to the larger effort to decrease low-value care in hospital settings.

When Reducing Low-Value Care in Hospital Medicine Saves Money, Who Benefits ?

One emerging policy solution for deterring low-value care is to financially penalize physicians who prescribe it. However, physicians' willingness to support such policies may depend on whether they perceive that benefits accrue to patients or to insurers and hospitals. We surveyed physicians practicing hospital medicine to evaluate the association between policy support and physician beliefs about who benefits from the money saved through reducing low-value services in hospital medicine. Overall, physicians believed that more of any money saved would go to profits and leadership salaries for insurance companies and hospitals and/or health systems rather than to patients. These beliefs were associated with policy support: 66% of those supporting physician penalties were more likely to believe that benefits accrue to patients or physicians, compared to 39% of those not supporting policies (P < .001). Our findings are consistent with a sense of healthcare justice, in which physicians are less likely to support penalties imposed on themselves if the resulting benefits accrue to corporate or organizational interests. Effective physician penalties will likely need to address the belief that insurers and provider organizations stand to gain more than patients when low-value care services are reduced.

Who is Responsible for What Happens Before, During, and After Colonoscopy? Results of a National Survey of Primary Care Physicians.

BACKGROUND AND AIMS: Primary care providers (PCPs) play a critical role in colon cancer screening by initiating referrals to gastroenterologists for colonoscopy, but little is known about their role in pre-colonoscopy bowel preparation selection and pre-colonoscopy follow-up care. This study aimed to better understand coordination of care between PCPs and gastroenterologists as well as the current availability of "open-access" screening colonoscopy. METHODS: A multiple-choice survey was developed to assess PCPs' experiences with open-access colonoscopy, their involvement in the pre-colonoscopy process, and follow-up after colonoscopy. The survey was distributed electronically to a nationally representative sample of PCPs, via the American College of Physicians (ACP) Research Center's Internal Medicine Insider Research Panel. RESULTS: Of 442 PCPs invited to participate, 210 responded (response rate, 210/442, 48%), and 29 were ineligible (spent <25% of their time on clinical care or placed no referrals to colonoscopy), yielding 181 completed surveys. A total of 39% reported that open access was "rarely" or "never" available in their practice setting. The majority reported that pre-colonoscopy care was coordinated by gastroenterologists rather than PCPs. For example, 93% reported that gastroenterologists were responsible for bowel preparation selection in their practice setting. Post-colonoscopy, 54% of PCPs reported that they were responsible for ordering subsequent colonoscopies. CONCLUSIONS: PCPs frequently coordinate follow-up care postprocedure but play a relatively minor role in the pre-colonoscopy bowel preparation process. Open access availability for screening colonoscopy remains limited in this national sample of PCPs.

Primary care physicians are under-testing for celiac disease in patients with iron deficiency anemia: Results of a national survey.

BACKGROUND: Iron deficiency anemia (IDA) is a common extra-intestinal manifestation of celiac disease (CD). Little is known about the frequency with which primary care physicians (PCPs) test for CD in patients with IDA. We aimed to describe how PCPs approach testing for CD in asymptomatic patients with IDA. METHODS: We electronically distributed a survey to PCPs who are members of the American College of Physicians. Respondents were asked whether they would test for CD (serologic testing, refer for esophagogastroduodenoscopy [EGD], or refer to GI) in hypothetical patients with new IDA, including: (1) a young Caucasian man, (2) a premenopausal Caucasian woman, (3) an elderly Caucasian man, and (4) a young African American man. These scenarios were chosen to assess for differences in testing for CD based on age, gender, and race. Multivariable logistic regression was used to identify independent predictors of testing. RESULTS: Testing for CD varied significantly according to patient characteristics, with young Caucasian men being the most frequently tested (61% of respondents reporting they would perform serologic testing in this subgroup (p<0.001)). Contrary to guideline recommendations, 80% of respondents reported they would definitely or probably start a patient with positive serologies for CD on a gluten free diet prior to confirmatory upper endoscopy. CONCLUSIONS: PCPs are under-testing for CD in patients with IDA, regardless of age, gender, race, or post-menopausal status. The majority of PCPs surveyed reported they do not strictly adhere to established guidelines regarding a confirmatory duodenal biopsy in a patient with positive serology for CD.