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.

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.

Evaluating acutely injured patients for internal derangement of the knee.

Although historical findings have some value in diagnosing internal derangement of the knee, a thorough physical examination can often rule out fracture and ligamentous and meniscal injuries. The Ottawa Knee Rule can help physicians determine which patients require radiography. Positive physical examination tests and findings of acute effusion suggest internal derangement. An abnormal McMurray or Thessaly test strongly suggests meniscal injury, whereas a normal Thessaly test may rule out meniscal injury. Absence of evidence of joint effusion significantly decreases the probability of internal derangement. Magnetic resonance imaging should be reserved for ruling out internal derangement in patients with suggestive historical and physical examination findings.

Slow-growing lesion on eyebrow.

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

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.

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.

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.

Assessing adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection.

OBJECTIVE: To assess adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection (UTI) in a family medicine residency clinic setting. PATIENTS AND METHODS: We retrospectively reviewed the medical records of female patients seen in 2005 at the Mayo Clinic Family Medicine Center in Scottsdale, Ariz, who were identified by International Classification of Diseases, Ninth Revision code 599.0 (UTI). We assessed documentation rates, use of diagnostic studies, and antibiotic treatments. Antibiotic sensitivity patterns from outpatient urine culture and sensitivity analyses were determined. RESULTS: Of 228 patients, 68 (30%) had uncomplicated UTI. Our physicians recorded essential history and examination findings for most patients. Documentation of the risk of sexually transmitted disease differed between residents and attending physicians and was affected by patient age. Urine dipstick and urine culture and sensitivity analyses were ordered in 57 (84%) and 52 (76%) patients, respectively. Eighty percent of patients with positive results on urine dipstick analyses also had urine culture and sensitivity analyses. Sulfamethoxazole-trimethoprim (SMX-TMP) was used as initial therapy in 26 patients (38%). Sixty-one percent of SMX-TMP and ciprofloxacin prescriptions were appropriately provided for 3 days. Escherichia coil was sensitive to SMX-TMP in 33 (94%) of 35 cultures. Treatment was not changed in any patient with an uncomplicated UTI because of results of urine culture and sensitivity analyses. Antibiotic sensitivity patterns for outpatients were significantly different from those for inpatients. CONCLUSION: Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Urine culture and sensitivity analyses were performed frequently, even in patients who already had positive results on a urine dip-stick analysis. Although SMX-TMP is effective, it is underused. On the basis of these findings, we hope to provide interventions to increase SMX-TMP prescription, decrease use of urine culture and sensitivity analyses, and increase the frequency of 3-day antibiotic treatments at our institution.

Clinical inquiries. Should patients receive 23-valent pneumococcal vaccination more than once?

No patient-oriented evidence supports pneumococcal revaccination of any patient (high-risk or otherwise). Antibody levels may be augmented by revaccination; however, the clinical efficacy of revaccination, even among high-risk patients, is unknown. Revaccination is recommended by the Advisory Committee on Immunization Practices (ACIP) in certain circumstances (strength of recommendation [SOR]: C, expert opinion based on physiology/bench research). Revaccination once appears to be safe, especially if provided 5 years or more after primary vaccination (SOR: B, based upon consistent results of cohort studies and nonrandomized prospective trials).

How should patients with Barrett's esophagus be monitored?

Some patients who have been diagnosed with Barrett's esophagus will develop dysplasia and, in some cases, esophageal carcinoma (strength of recommendation [SOR]: A, based on consistent cohort studies). Endoscopic surveillance is recommended for all patients with Barrett's esophagus as it is superior to other methods for detecting esophageal cancer (SOR: B, based on systematic review). The degree of dysplasia noted on biopsy specimens correlates with the risk of esophageal carcinoma development and should guide the frequency of subsequent evaluations (SOR: B, based on consistent cohort studies). The optimal frequency of endoscopy has yet to be determined in any randomized trial. Recommendations from the 2002 American College of Gastroenterology (ACG) Practice Guideline provide guidance as to the frequency of endoscopy surveillance but were not based on an explicit systematic review of the literature (SOR: C, based on expert opinion).

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.

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.

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.