Physician attitudes toward the use of fecal microbiota transplantation for the treatment of recurrent Clostridium difficile infection.

BACKGROUND: Fecal microbiota transplantation (FMT) is a safe and effective, yet infrequently used therapy for recurrent Clostridium difficile infection (CDI). OBJECTIVE: To characterize barriers to FMT adoption by surveying physicians about their experiences and attitudes toward the use of FMT. METHODS: An electronic survey was distributed to physicians to assess their experience with CDI and attitudes toward FMT. RESULTS: A total of 139 surveys were sent and 135 were completed, yielding a response rate of 97%. Twenty-five (20%) physicians had treated a patient with FMT, 10 (8%) offered to treat with FMT, nine (7%) referred a patient to receive FMT, and 83 (65%) had neither offered nor referred a patient for FMT. Physicians who had experience with FMT (performed, offered or referred) were more likely to be male, an infectious diseases specialist, >40 years of age, fellowship trained and practicing in an urban setting. The most common reasons for not offering or referring a patient for FMT were: not having 'the right clinical situation' (33%); the belief that patients would find it too unappealing (24%); and institutional or logistical barriers (23%). Only 8% of physicians predicted that the majority of patients would opt for FMT if given the option. Physicians predicted that patients would find all aspects of the FMT process more unappealing than they would as providers. CONCLUSIONS: Physicians have limited experience with FMT despite having treated patients with multiple recurrent CDIs. There is a clear discordance between physician beliefs about FMT and patient willingness to accept FMT as a treatment for recurrent CDI.

Patient attitudes toward the use of fecal microbiota transplantation in the treatment of recurrent Clostridium difficile infection.

BACKGROUND: Fecal microbiota transplantation (FMT), a safe, effective alternative therapy for recurrent Clostridium difficile infection (CDI), is infrequently used, in part because of an assumption that patients are unwilling to consider FMT because of its unappealing nature. METHODS: Through a structured survey, including hypothetical case scenarios, we assessed patient perceptions of the aesthetics of FMT and their willingness to consider it as a treatment option, when presented with scenarios involving recurrent CDI. RESULTS: Four hundred surveys were distributed; 192 (48%) were returned complete. Seventy percent of respondents were female; 59% were >49 years of age. When provided efficacy data only, 162 respondents (85%) chose to receive FMT, and 29 (15%) chose antibiotics alone. When aware of the fecal nature of FMT, 16 respondents changed their choice from FMT to antibiotics alone, but there was no significant change in the total number choosing FMT (154 [81%]; P = .15). More respondents chose FMT if offered as a pill (90%; P = .002) or if their physician recommended it (94%; P < .001). Respondents rated all aspects of FMT at least "somewhat unappealing," selecting "the need to handle stool" and "receiving FMT by nasogastric tube" as most unappealing. Women rated all aspects of FMT more unappealing; older respondents rated all aspects less unappealing. Most respondents preferred to receive FMT in the hospital (48%) or physician's office (39%); 77% were willing to pay out-of-pocket for FMT. CONCLUSIONS: Patients recognize the inherently unappealing nature of FMT, but they are nonetheless open to considering it as a treatment alternative for recurrent CDI, especially when recommended by a physician.

A business case for shared medical appointments in dermatology: improving access and the bottom line.

OBJECTIVES: To evaluate the economic viability of shared medical appointments (SMAs) in dermatology. Secondary objectives include a comparison of the hourly adjusted census levels generated by SMAs compared with regular clinic appointments (RCAs), as well as a comparison between the economic viability of dermatology SMAs and SMAs in other fields of medicine. DESIGN: Cost-benefit analysis. SETTING: Outpatient clinics within an academic medical center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. PATIENTS: No patient-identifying information was obtained or reported. The SMA census data included 301 SMAs (11 different programs and 5 separate departments), representing 2045 appointments over 16 months. Comparisons between patient groups were based on data from the SMA census and mean provider census (MPC) for RCAs, matched on reason for appointment. MAIN OUTCOME MEASURES: Hourly adjusted census levels and profit differences (charges less costs) between SMAs and MPC for RCAs. RESULTS: All individual and departmental SMAs generated significantly higher mean census levels and profits per hour than the respective non-SMA MPC of the health care provider leading the SMA (individual, P < .05; departmental, P < .001). All dermatology SMAs generated significantly greater differences in hourly adjusted census levels and profit in comparisons between SMAs and MPC for RCAs than the respective measures in all other departments (P < .001). CONCLUSION: Taken together, the results of this study provide strong evidence to support a business case for SMAs in dermatology as a means of simultaneously improving access, productivity, and the bottom line.