Primary care physician attitudes and perceptions of the impact of FDA-proposed REMS policy on prescription of extended-release and long-acting opioids.

With increasing numbers of patients experiencing chronic pain, opioid therapy is becoming more common, leading to increases in concern about issues of abuse, diversion, and misuse. Further, the US Food and Drug Administration recently released a statement notifying sponsors and manufacturers of extended-release and long-acting opioids of the need to develop Risk Evaluation and Mitigation Strategies (REMS) programs in order to ensure that the benefits of this therapy choice outweigh the potential risks. There is little research on physician opinions concerning opioid-prescribing and education policies. To assess attitudes surrounding new opioid policies, a survey was designed and distributed to primary care physicians in October 2011. Data collected from 201 primary care physicians show that most are not familiar with the REMS requirements proposed by the Food and Drug Administration for extended-release and long-acting opioids; there is no consensus among primary care physicians on the impact of prescribing requirements on patient education and care; and increasing requirements for extended-release and long-acting opioid education may decrease opioid prescribing. Physician attitudes toward increased regulatory oversight of opioid therapy prescriptions should be taken into consideration by groups developing these interventions to ensure that they do not cause undue burden on already busy primary care physicians.

Understanding the factors that influence the adoption and meaningful use of social media by physicians to share medical information.

BACKGROUND: Within the medical community there is persistent debate as to whether the information available through social media is trustworthy and valid, and whether physicians are ready to adopt these technologies and ultimately embrace them as a format for professional development and lifelong learning. OBJECTIVE: To identify how physicians are using social media to share and exchange medical information with other physicians, and to identify the factors that influence physicians' use of social media as a component of their lifelong learning and continuing professional development. METHODS: We developed a survey instrument based on the Technology Acceptance Model, hypothesizing that technology usage is best predicted by a physician's attitudes toward the technology, perceptions about the technology's usefulness and ease of use, and individual factors such as personal innovativeness. The survey was distributed via email to a random sample of 1695 practicing oncologists and primary care physicians in the United States in March 2011. Responses from 485 physicians were analyzed (response rate 28.61%). RESULTS: Overall, 117 of 485 (24.1%) of respondents used social media daily or many times daily to scan or explore medical information, whereas 69 of 485 (14.2%) contributed new information via social media on a daily basis. On a weekly basis or more, 296 of 485 (61.0%) scanned and 223 of 485 (46.0%) contributed. In terms of attitudes toward the use of social media, 279 of 485 respondents (57.5%) perceived social media to be beneficial, engaging, and a good way to get current, high-quality information. In terms of usefulness, 281 of 485 (57.9%) of respondents stated that social media enabled them to care for patients more effectively, and 291 of 485 (60.0%) stated it improved the quality of patient care they delivered. The main factors influencing a physician's usage of social media to share medical knowledge with other physicians were perceived ease of use and usefulness. Respondents who had positive attitudes toward the use of social media were more likely to use social media and to share medical information with other physicians through social media. Neither age nor gender had a significant impact on adoption or usage of social media. CONCLUSIONS: Based on the results of this study, the use of social media applications may be seen as an efficient and effective method for physicians to keep up-to-date and to share newly acquired medical knowledge with other physicians within the medical community and to improve the quality of patient care. Future studies are needed to examine the impact of the meaningful use of social media on physicians' knowledge, attitudes, skills, and behaviors in practice.

Primary care physician attitudes and practice patterns in the management of obese adults: results from a national survey.

PURPOSE: Obesity remains a serious public health problem. The purpose of this study was to identify the current attitudes and practices of primary care physicians (PCPs) with respect to obesity. METHODS: A survey was systematically developed and administered electronically to PCPs, who received a small honorarium for their time. Results were analyzed to identify specific attitudes and practices and their associations with each other and with demographic and other variables. RESULTS: Physicians expressed little confidence in their ability to manage obesity. In general, however, they believed that obesity could be successfully managed. Lifestyle changes were perceived to be the most effective available method for patients to lose weight, and respondents were more likely to recommend this approach over pharmacotherapy or bariatric surgery. Respondents perceive the greatest barrier to managing obese patients to be a lack of patient motivation. Physicians were significantly more likely to initiate discussions with obese patients about their weight if they believed they had positive attitudes about and knowledge of weight management, and adequate resources to manage the problem. CONCLUSIONS: Physicians report a lack of confidence in managing obesity. Lack of patient motivation is perceived to be the greatest barrier. Physicians with greater knowledge, more positive attitudes toward obesity management, and access to more resources are more likely to provide weight management in primary care settings.

Attitudes toward management of decreased sexual desire in premenopausal women: a national survey of nurse practitioners and physician assistants.

Recent studies have determined that low sexual desire affects between one quarter to one third of adult premenopausal women, leading to distress. The prevalence of distress from low desire may suggest management gaps in the clinicians managing these patients, as recent studies have shown a reluctance to discuss sexual concerns. A survey based on the Theory of Planned Behavior, a predictive model linking attitudes and behavior, was designed to determine what factors influenced behavioral intent and behavior of nurse practitioners and physician assistants when managing decreased sexual desire and sexual concerns in premenopausal women. A path analysis found that attitudes and subjective norms were associated with behavioral intent in both groups and explained roughly one third of the intent to initiate a discussion about sexual health. In general, nurse practitioners and physician assistants had positive attitudes toward managing sexual concerns in female patients but were still at times reluctant to initiate sexual health discussions. This study shows that increased education is needed on female sexual dysfunction in the allied health professional community, as well as techniques for communicating with patients about their sexual concerns.

Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians.

PURPOSE: Even with the dissemination of several clinical guidelines, chronic obstructive pulmonary disease (COPD) remains underdiagnosed and mismanaged by many primary care physicians (PCPs). The objective of this study was to elucidate barriers to consistent implementation of COPD guidelines. PATIENTS AND METHODS: A cross-sectional study implemented in July 2008 was designed to assess attitudes and barriers to COPD guideline usage. RESULTS: Five hundred US PCPs (309 family medicine physicians, 191 internists) were included in the analysis. Overall, 23.6% of the surveyed PCPs reported adherence to spirometry guidelines over 90% of the time; 25.8% reported adherence to guidelines related to long-acting bronchodilator (LABD) use in COPD patients. In general, physicians were only somewhat familiar with COPD guidelines, and internal medicine physicians were significantly more familiar than family physicians (P < 0.05). In a multivariate model controlling for demographics and barriers to guideline adherence, we found significant associations with two tested guideline components. Adherence to spirometry guidelines was associated with agreement with guidelines, confidence in interpreting data, ambivalence to outcome expectancy, and ability to incorporate spirometry into patient flow. Adherence to LABD therapy guidelines was associated with agreement with guidelines and confidence in gauging pharmacologic response. CONCLUSIONS: Adherence to guideline recommendations of spirometry use was predicted by agreement with the recommendations, self-efficacy, perceived outcome expectancy if recommendations were adhered to, and resource availability. Adherence to recommendations of LABD use was predicted by agreement with guideline recommendations and self-efficacy. Increasing guideline familiarity alone may have limited patient outcomes, as other barriers, such as low confidence and outcome expectancy, are more likely to impact guideline adherence.

Effectiveness of INROADS into pain management, a nursing educational intervention.

Nurses play a critical role in managing a patient's pain, from initial evaluation to ongoing patient education. However, little information exists on current gaps in nurses' knowledge and their pain-related decision making. To this end, an educational intervention-the INROADS initiative-was designed to improve the knowledge of nurses involved in patient management as well as to guide them toward practices that are consistent with currently available evidence. The results from an evaluation of this intervention show that nurses participating in the INROADS program were 52% more likely to make evidence-based care choices for their patients, compared with a control group of demographically similar nurses. The effect of this program may reinforce it as a model for the design of future interventions for pain management.

Communication gaps between physicians and patients with postherpetic neuralgia: results from a national study on practice patterns.

BACKGROUND: The purpose of this study was to identify differences in perceptions of care regarding postherpetic neuralgia, including communication patterns between patients and physicians and levels of satisfaction with therapies and care. METHODS: A survey was developed for physicians (neurologists, internists, and family physicians) and patients with postherpetic neuralgia in order to determine their perspectives on its management. RESULTS: A total of 142 eligible patient respondents were included in the study, and responses were compared with those of 150 primary care physicians and 76 neurologist respondents. Few patients and physicians indicated satisfaction with the currently available treatments for postherpetic neuralgia. While nearly all physicians responded that they discuss the cause of postherpetic neuralgia with a patient, one in four patients indicated that their physician did not discuss the cause. Similarly, one in four patients were not aware of the duration of postherpetic neuralgia, the treatment side effects, or what to expect from treatment. Patients may be less likely to discuss treatment side effects and quality of life issues than physicians perceive. CONCLUSION: Physicians and patients have similar perceptions regarding treatment options for postherpetic neuralgia; however, certain gaps in communication were evident, which may be attributable to physician knowledge and communication skills with patients. Strategies to improve issues of expected outcomes and side effects of treatment may be useful to physicians.

Management of female sexual problems: perceived barriers, practice patterns, and confidence among primary care physicians and gynecologists.

INTRODUCTION: Although approximately 40% of women report female sexual problems--and particularly sexual desire disorders, there are numerous practical, professional, and personal barriers to their diagnosis and management by treating clinicians. AIM: To identify practice patterns, perceptions, and barriers to the diagnosis and management of female sexual problems among U.S. practicing primary care physicians (PCPs) and obstetrician/gynecologists (OB/GYNs). METHODS: A random sample of practicing U.S. PCPs and OB/GYNs were sent a case-vignette survey by e-mail and fax. Response to the survey was considered consent. A regression model was analyzed to assess predictors of confidence. MAIN OUTCOME MEASURE: Frequency and variability in diagnostic tests ordered and treatment recommendations provided for a patient with diminished sexual desire. Percent of physicians who reported they were confident in treating hypoactive sexual desire disorder (HSDD) and percent who reported significant barriers to initiating a dialogue about sexual health with female patients. RESULTS: A total of 505 responses were analyzed (8.8% response rate). Of respondents, 21% of OB/GYNs and 38% of PCPs stated they were not at all confident in treating HSDD. The majority of physicians would order a thyroid panel (PCP = 63%, OB/GYN = 53%) to assess a patient's diminished desire and recommended counseling and stress management to treat a patient with sexual complaints (PCP = 48%, OB/GYN = 54%). Regression results identified time constraints, the perceived lack of effective therapies, perceptions regarding patient-physician gender discordance, years in practice, number of patients seen per week, and perceptions regarding continuing medical education and practice experience as significant and independent predictors of confidence in treating HSDD patients.

Practice patterns and guideline adherence of medical oncologists in managing patients with early breast cancer.

BACKGROUND: Studies of adherence to breast cancer guidelines have often focused on primary therapies, but concordance with other guideline recommendations has not been examined as extensively. This study assesses the knowledge and practice patterns of medical oncologists in the United States to inform education and quality improvement initiatives that can improve breast cancer care. METHODS: A survey containing case vignettes and related questions was developed to examine oncologists' clinical decision-making in evaluating and treating women with early breast cancer. The instrument was distributed to a random sample of 742 oncologists in the United States and yielded 205 responses (27.6% response rate). Responses from 184 practicing medical oncologists were analyzed relative to the 2007 NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. RESULTS: Most oncologists made guideline-consistent choices in clarifying indeterminate human epidermal growth factor 2 (HER2) status (85%), initial treatment for early breast cancer (95%), and postsurgical management of locally advanced breast cancer (82%). Guideline-discordant choices were seen in the lack of clip placement before neoadjuvant chemotherapy (36%), unnecessary use of PET scanning for initial assessment (34%), inappropriate assessment of menopausal status (33%), inappropriate use of tumor markers (22%), and use of chest imaging (16%) during posttherapeutic surveillance. CONCLUSIONS: Oncologists often make guideline-consistent choices, but discordant clinical decisions may occur in important aspects of care for early breast cancer. Broadening the diffusion and adoption of guideline recommendations is an important mechanism for addressing these gaps and may substantially improve the quality of breast cancer care.

Improving the physician-patient cardiovascular risk dialogue to improve statin adherence.

BACKGROUND: The purpose of this study was to evaluate the effectiveness of a patient education program developed to facilitate statin adherence. METHODS: A controlled trial was designed to test the effectiveness of a multifaceted patient education program to facilitate statin adherence. The program included a brief, in-office physician counseling kit followed by patient mailings. The primary end point was adherence to filling statin prescriptions during a 120-day period. Patients new to statins enrolled and completed a survey. Data from a national pharmacy claims database were used to track adherence. RESULTS: Patients new to statin therapy exposed to a patient counseling and education program achieved a 12.4 higher average number of statin prescription fill days and were 10% more likely to fill prescriptions for at least 120 days (p = .01). CONCLUSION: Brief in-office counseling on cardiovascular risk followed by patient education mailings can be effective in increasing adherence. Physicians found a one-minute counseling tool and pocket guidelines useful in counseling patients.

Men's sexual health: evaluating the effectiveness of print- and PDA-based CME.

INTRODUCTION: Personal digital assistant (PDA)-based continuing medical education (CME) activities have become widely available. AIMS: To evaluate the effectiveness of print- and PDA-based CME materials in erectile dysfunction (ED). METHODS: CME materials describing links between ED and comorbid medical conditions, effects of certain lifestyle modifications on ED, and treatment of ED with phosphodiesterase 5 (PDE5) inhibitors were distributed as a print supplement and as electronic modules, viewed with PDAs. We evaluated how effectively these materials improved evidence-based clinical choices, using survey questions about case vignettes and comparing responses of CME participants (N = 85) and matched nonparticipants (N = 94). MAIN OUTCOME MEASURES: Effect size, measuring the difference in evidence-based clinical scores between participants and nonparticipants. RESULTS: CME certificates were awarded to 3,557 participants (459 print, 3,098 PDA). Among survey respondents, significantly more CME participants recognized that ED was associated with greater risk for myocardial infarction (61% participants; 34% nonparticipants; P

Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events.

BACKGROUND: Adherence to clinical practice guidelines for management of cardiovascular disease (CVD) is suboptimal. The purposes of this study were to identify practice patterns and barriers among U.S. general internists and family physicians in regard to cardiovascular risk management, and examine the association between physician characteristics and cardiovascular risk management. METHODS: A case vignette survey focused on cardiovascular disease risk management was distributed to a random sample of 12,000 U.S. family physicians and general internists between November and December 2006. RESULTS: Responses from a total of 888 practicing primary care physicians who see 60 patients per week were used for analysis. In an asymptomatic patient at low risk for cardiovascular event, 28% of family physicians and 37% of general internists made guideline-based preventive choices for no antiplatelet therapy (p < .01). In a patient at high risk for cardiovascular event, 59% of family physicians and 56% of general internists identified the guideline-based goal for serum fasting LDL level (< 100 mg/dl). Guideline adherence was inversely related to years in practice and volume of patients seen. Cost of medications (87.7%), adherence to medications (74.1%), adequate time for counseling (55.7%), patient education tools (47.1%), knowledge and skills to recommend dietary changes (47.8%) and facilitate patient adherence (52.0%) were cited as significant barriers to CVD risk management. CONCLUSION: Despite the benefits demonstrated for managing cardiovascular risks, gaps remain in primary care practitioners' management of risks according to guideline recommendations. Innovative educational approaches that address barriers may facilitate the implementation of guideline-based recommendations in CVD risk management.

Market effects on electronic health record adoption by physicians.

BACKGROUND: Despite the advantages of electronic health record (EHR) systems, the adoption of these systems has been slow among community-based physicians. Current studies have examined organizational and personal barriers to adoption; however, the influence of market characteristics has not been studied. PURPOSE: The purpose of this study was to measure the effects of market characteristics on EHR adoption by physicians. METHODOLOGY: Generalized hierarchal linear modeling was used to analyze EHR survey data from Florida which were combined with data from the Area Resource File and the Florida Office of Insurance Regulation. The main outcome variable was self-reported use of EHR by physicians. FINDINGS: A total of 2,926 physicians from practice sizes of 20 or less were included in the sample. Twenty-one percent (n = 613) indicated that they personally and routinely use an EHR system in their practice. Physicians located in counties with higher physician concentration were found to be more likely to adopt EHRs. For every one-unit increase in nonfederal physicians per 10,000 in the county, there was a 2.0% increase in likelihood of EHR adoption by physicians (odds ratio = 1.02, confidence interval = 1.00-1.03). Health maintenance organization penetration rate and poverty level were not found to be significantly related to EHR adoption. However, practice size, years in practice, Medicare payer mix, and measures of technology readiness were found to independently influence physician adoption. PRACTICE IMPLICATIONS: Market factors play an important role in the diffusion of EHRs in small medical practices. Policy makers interested in furthering the adoption of EHRs must consider strategies that would enhance the confidence of users as well as provide financial support in areas with the highest concentration of small medical practices and Medicare beneficiaries. Health care leaders should be cognizant of the market forces that enable or constrain the adoption of EHR among their practices and those of their competitors.

A standardized approach to assessing physician expectations and perceptions of continuing medical education.

INTRODUCTION: Rapidly expanding science and mandates for maintaining credentials place increasing demands on continuing medical education (CME) activities to provide information that is current and relevant to patient care. Quality may be seen as the perceived level of service measured against consumer expectations. Standard tools have not been developed to determine how well CME activities meet consumer expectations. METHODS: A widely used approach for evaluating perceptions of service quality in other fields, SERVQUAL, was adapted for CME by eliciting perspectives from physician consumers of CME and CME providers through nominal group techniques. These perspectives were used to develop a CMEQUAL evaluation survey instrument. Feasibility testing was conducted. Data were analyzed and items were tested for internal consistency. RESULTS: CME participants were individuals willing to complete items related to expectations before participation and perceptions after participation in a CME activity. Of the CME activity participants who provided CMEQUAL rating data for the study, 43% rated their overall perceptions of the CME activity below their overall expectations. CME activities most clearly met participant expectations in providing fair and balanced evidence-based content. Areas of lower priority for participants included opportunities for self-assessment, solving cases, and interactive learning. Two areas highly valued by participants but not adequately addressed by CME activities were (1) translating trial data to patient seen in practice and (2) addressing barriers to optimal patient management. DISCUSSION: Developing standards for evaluating physician perceptions of the quality of CME activities may assist CME providers in improving the effectiveness of CME activities in meeting physician learning needs.

Effective media communication of disasters: pressing problems and recommendations.

BACKGROUND: Public health officials and journalists play a crucial role in disseminating information regarding natural disasters, terrorism and other human-initiated disasters. However, research suggests that journalists are unprepared to cover terrorism and many types of natural disasters, in part because of lack sufficient expertise in science and medicine and training. The objective of this research was to identify solutions to problems facing journalists and public health public information officer (PIOs) of communicating with the public during natural and human-initiated disasters. METHODS: To assist in identifying the most pressing problems regarding media response to health-related risks such as terrorism and large-scale natural disasters, 26 expert advisors were convened, including leaders representing journalists and public information officers, state health officials, experts in terrorism and emergency preparedness, and experts in health, risk, and science communication. The advisory group participated in pre-arranged interviews and were asked to identify and review bioterrorism educational resources provided to journalist. All advisory group members were then invited to attend a day long meeting January 29, 2004 to review the findings and reach consensus. RESULTS: The most pressing problems were found to be a lack of coordination between PIO's and journalists, lack of resources for appropriately evaluating information and disseminating it efficiently, and a difference in perception of PIO's and journalist towards each others role during emergency situations. The advisory board developed a list of 15 recommendations that may enhance communication plans between PIO's, journalist and the public. The solutions were meant to be feasible in terms of costs and practical in terms of the professional and organizational realities in which journalists and PIO's work. CONCLUSION: It is clear that PIO's and journalists play crucial roles in shaping public response to terrorism and other disasters. The findings from this formative research suggest that perspectives and organizational processes often limit effective communication between these groups; though practical solutions such as participation of journalists in drills, scenario exercises, sharing of informational resources, and raising awareness at professional trade meetings may enhance the timely dissemination of accurate and appropriate information.

Hospital strategic preparedness planning: the new imperative.

Strategic preparedness planning is an important new imperative for many hospitals. Strategic preparedness planning goes beyond traditional product/market strategic planning by focusing on disaster prevention, containment, and response roles. Hospitals, because of their unique mission, size, complexity, the types of materials they handle, and the types of patients they encounter, are especially vulnerable to natural and human-initiated disasters. In addition, when disasters occur, hospitals must develop well-conceived first responder (receiver) strategies. This paper argues the case for strategic preparedness planning for hospitals and proposes a process for this relatively new and much needed type of planning.

Evaluation of an online bioterrorism continuing medical education course.

INTRODUCTION: Much of the international community has an increased awareness of potential biologic, chemical, and nuclear threats and the need for physicians to rapidly acquire new knowledge and skills in order to protect the public's health. The present study evaluated the educational effectiveness of an online bioterrorism continuing medical education (CME) activity designed to address clinical issues involving suspected bioterrorism and reporting procedures in the United States. METHODS: This was a retrospective survey of physicians who had completed an online CME activity on bioterrorism compared with a nonparticipant group who had completed at least 1 unrelated online CME course from the same medical school Web site and were matched on similar characteristics. An online survey instrument was developed to assess clinical and systems knowledge and confidence in recognition of illnesses associated with a potential bioterrorism attack. A power calculation indicated that a sample size of 100 (50 in each group) would achieve 90% power to detect a 10% to 15% difference in test scores between the two groups. RESULTS: Compared with nonparticipant physicians, participants correctly diagnosed anthrax (p = .01) and viral exanthem (p = .01), but not smallpox, more frequently than nonparticipants. Participants knew more frequently than nonparticipants who to contact regarding a potential bioterrorism event (p = .03) Participants were more confident than nonparticipants about finding information to guide diagnoses of patients with biologic exposure (p = .01), chemical exposure (p = .02), and radiation exposure (p = .04). DISCUSSION: An online bioterrorism course shows promise as an educational intervention in preparing physicians to better diagnose emerging rare infections, including those that may be associated with a bioterrorist event, in increasing confidence in diagnosing these infections, and in reporting of such infections for practicing physicians.

Chlamydia screening of at-risk young women in managed health care: characteristics of top-performing primary care offices.

OBJECTIVES: Despite effective approaches for managing chlamydial infection, asymptomatic disease remains highly prevalent. We linked administrative data with physician data from the American Medical Association physician survey to identify characteristics of primary care offices associated with best chlamydia screening practices. STUDY: Criteria from the National Committee for Quality Assurance provided chlamydia screening rates. We defined top-performing offices as those with rates in the top decile among 978 primary care offices from 26 states. RESULTS: Offices screened an average of 16.2% of at-risk, young women, but top-performing offices screened 42.2%. Top-performing offices on average had more black physicians (12.5%, 5.1%, P = 0.001) and were more often located in zip code areas with median income less than $30,000 (22.6%, 5.5%, P = 0.001). CONCLUSIONS: Although chlamydia screening rates are alarmingly low overall, there is substantial variation across offices. Understanding predictors of better office performance may lead to effective interventions to promote screening.

Using email reminders to engage physicians in an Internet-based CME intervention.

BACKGROUND: Engaging practicing physicians in educational strategies that reinforce guideline adoption and improve the quality of healthcare may be difficult. Push technologies such as email offer new opportunities to engage physicians in online educational reinforcing strategies. The objectives are to investigate 1) the effectiveness of email announcements in engaging recruited community-based primary care physicians in an online guideline reinforcement strategy designed to promote Chlamydia screening, 2) the characteristics of physicians who respond to email announcements, as well as 3) how quickly and when they respond to email announcements. METHODS: Over a 45-week period, 445 recruited physicians received up to 33 email contacts announcing and reminding them of an online women's health guideline reinforcing CME activity. Participation was defined as physician log-on at least once to the website. Data were analyzed to determine participation, to compare characteristics of participants with recruited physicians who did not participate, and to determine at what point and when participants logged on. RESULTS: Of 445 recruited physicians with accurate email addresses, 47.2% logged on and completed at least one module. There were no significant differences by age, race, or specialty between participants and non-participants. Female physicians, US medical graduates and MDs had higher participation rates than male physicians, international medical graduates and DOs. Physicians with higher baseline screening rates were significantly more likely to log on to the course. The first 10 emails were the most effective in engaging community-based physicians to complete the intervention. Physicians were more likely to log on in the afternoon and evening and on Monday or Thursday. CONCLUSIONS: Email course reminders may enhance recruitment of physicians to interventions designed to reinforce guideline adoption; physicians' response to email reminders may vary by gender, degree, and country of medical training. Repetition of email communications contributes to physician online participation.