Reduced Cognitive Burden and Increased Focus: A Mixed-methods Study Exploring How Implementing Scribes Impacted Physicians.

BACKGROUND: Understanding how medical scribes impact care delivery can inform decision-makers who must balance the cost of hiring scribes with their contribution to alleviating clinician burden. OBJECTIVE: The objective of this study was to understand how scribes impacted provider efficiency and satisfaction. DESIGN: This was mixed-methods study. PARTICIPANTS: Internal and family medicine clinicians were included. MEASURES: We administered structured surveys and conducted unstructured interviews with clinicians who adopted scribes. We collected average days to close charts and quantity of after-hours clinical work in the 6 months before and after implementation using electronic health record data. We conducted a difference in difference (DID) analysis using a multilevel Poisson regression. RESULTS: Three themes emerged from the interviews: (1) charting time is less after training; (2) clinicians wanted to continue working with scribes; and (3) scribes did not reduce the overall inbox burden. In the 6-month survey, 76% of clinicians endorsed that working with a scribe improved work satisfaction versus 50% at 1 month. After implementation, days to chart closure decreased [DID=0.38 fewer days; 95% confidence interval (CI): -0.61, -0.15] the average minutes worked after hours on clinic days decreased (DID=-11.5 min/d; 95% CI: -13.1, -9.9) as did minutes worked on nonclinical days (DID=-24.9 min/d; 95% CI: -28.1, -21.7). CONCLUSIONS: Working with scribes was associated with reduced time to close charts and reduced time using the electronic health record, markers of efficiency. Increased satisfaction accrued once scribes had experience.

A risk prediction model to allow personalized screening for cervical cancer.

IMPORTANCE: Cervical cancer screening guidelines are in evolution. Current guidelines do not differentiate recommendations based on individual patient risk. OBJECTIVE: To derive and validate a tool for predicting individualized probability of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) at a single time point, based on demographic factors and medical history. DESIGN: The study design consisted of an observational cohort with hierarchical generalized linear regression modeling. SETTING: The study was conducted in a setting of 33 primary care practices from 2004 to 2010. PARTICIPANTS: The participants of the study were women aged ≥ 30 years. MAIN OUTCOME AND MEASURES: CIN2+ was the main outcome on biopsy, and the following predictors were included: age, race, marital status, insurance type, smoking history, median income based on zip code, prior human papilloma virus (HPV) results. RESULTS: The final dataset included 99,319 women. Of these, 745 (0.75%) had CIN2+. The multivariable model had a C-statistic of 0.81. All factors but race were independently associated with CIN2+. The model categorized women as having below-average CIN2+ risk (0.15% predicted vs. 0.12% observed risk), average CIN2+ risk (0.42% predicted vs. 0.36% observed), and above-average CIN2+ risk (1.76% predicted vs. 1.85% observed). Before screening, women at below-average risk had a risk of CIN2+ well below that of women with ASCUS and HPV negative (0.12 vs. 0.20%). CONCLUSIONS AND RELEVANCE: A multivariable model using data from the electronic health record was able to stratify women across a 50-fold gradient of risk for CIN2+. After further validation, use of a similar model could enable more targeted cervical cancer screening.

Cost-Effectiveness of Primary HPV Testing, Cytology and Co-testing as Cervical Cancer Screening for Women Above Age 30 Years.

BACKGROUND: Cervical cancer screening guidelines for women aged ≥30 years allow for co-testing or primary cytology testing. Our objective was to determine the test characteristics and costs associated with Cytology, HPV and Co-testing screening strategies. MAIN METHODS: Retrospective cohort study of women undergoing cervical cancer screening with both cytology and HPV (Hybrid Capture 2) testing from 2004 to 2010 in an integrated health system. The electronic health record was used to identify women aged ≥30 years who had co-testing. Unsatisfactory or unavailable test results and incorrectly ordered tests were excluded. The main outcome was biopsy-proven cervical intraepithelial neoplasia grade 3 or higher (CIN3+). KEY RESULTS: The final cohort consisted of 99,549 women. Subjects were mostly white (78.4 %), married (70.7 %), never smokers (61.3 %) and with private insurance (86.1 %). Overall, 5121 (5.1 %) tested positive for HPV and 6115 (6.1 %) had cytology ≥ ASCUS; 1681 had both and underwent colposcopy and 310 (0.3 %) had CIN3+. Sensitivity for CIN3+ was 91.9 % for Primary Cytology, 99.4 % for Co-testing, and 94.8 % for Primary HPV; specificity was 97.3 % for Co-testing and Primary Cytology and 97.9 % for Primary HPV. Over a 3-year screening interval, Primary HPV detected more cases of CIN3+ and was less expensive than Primary Cytology. Co-testing detected 14 more cases of CIN3+ than Primary HPV, but required an additional 100,277 cytology tests and 566 colposcopies at an added cost of $2.38 million, or $170,096 per additional case detected. CONCLUSIONS: Primary HPV was more effective and less expensive than Primary Cytology. Primary HPV screening appears to represent a cost-effective alternative to Co-testing.

Competencies for Those Who Coach Physicians: A Modified Delphi Study.

The rapidly evolving coaching profession has permeated the health care industry and is gaining ground as a viable solution for addressing physician burnout, turnover, and leadership crises that plague the industry. Although various coach credentialing bodies are established, the profession has no standardized competencies for physician coaching as a specialty practice area, creating a market of aspiring coaches with varying degrees of expertise. To address this gap, we employed a modified Delphi approach to arrive at expert consensus on competencies necessary for coaching physicians and physician leaders. Informed by the National Board of Medical Examiners' practice of rapid blueprinting, a group of 11 expert physician coaches generated an initial list of key thematic areas and specific competencies within them. The competency document was then distributed for agreement rating and comment to over 100 stakeholders involved in physician coaching. Our consensus threshold was defined at 70% agreement, and actual responses ranged from 80.5% to 95.6% agreement. Comments were discussed and addressed by 3 members of the original group, resulting in a final model of 129 specific competencies in the following areas: (1) physician-specific coaching, (2) understanding physician and health care context, culture, and career span, (3) coaching theory and science, (4) diversity, equity, inclusion, and other social dynamics, (5) well-being and burnout, and (6) physician leadership. This consensus on physician coaching competencies represents a critical step toward establishing standards that inform coach education, training, and certification programs, as well as guide the selection of coaches and evaluation of coaching in health care settings.

Update on nonhormonal approaches to menopausal management.

The risk-benefit evaluation for managing vasomotor symptoms and other menopause-related health issues should be tailored to each individual woman, taking into account her own assessment of the most bothersome symptom(s) and her personal weighting of risks versus quality of life. For most symptomatic menopausal women, hormone therapy (HT) remains the best treatment, but various nonhormonal options are available for treating menopausal symptoms and bone loss in women who are unable or unwilling to take HT. Low doses of local vaginal estrogen remain an option for treatment of vaginal atrophy in these women. This article reviews alternatives to systemic HT for treating menopausal symptoms and related health issues.

Repeat dual-energy X-ray absorptiometry (DXA) resulting from reminder letters for women with a baseline abnormal DXA.

The objective was to assess the effects of reminder letters on women returning for repeat bone density. We queried our clinical data repository to identify all women undergoing dual-energy X-ray absorptiometry (DXA) during the entire 2003 calendar year. Women with abnormal DXAs were entered into a database for reminder letters. The electronic medical record was then reviewed for the presence of the reminder letter and whether any repeat DXA scan was done. Approximately half of the women returned for repeat DXA of this group, approximately one-third were improved, one-third deteriorated, and the remaining were unchanged. We suggest a clinical benchmark of a minimum of 50% of women with abnormal bone density returning for repeat DXA on the same machine at a DXA imaging center should be a quality improvement goal. Further research into exploring why patients do not return for serial DXA and the impact of reminder letters on improving treatment outcomes should be conducted.

Osteoporosis Management.

The clinical update serves as a brief review of recently published, high-impact, and potentially practice changing journal articles summarized for our readers. Topics include menopause, sexual dysfunction, breast health, contraception, osteoporosis, and cardiovascular disease. In this clinical update, we selected recent publications relevant to osteoporosis management. We highlight articles on the safety of long-term use of denosumab and bisphosphonates, fracture risk after discontinuing menopausal hormone therapy, calcium intake and cardiovascular risk, as well as the value of repeat dual X-ray absorptiometry scanning to monitor those on osteoporosis treatment.

Secondary osteoporosis: are we recognizing it?

BACKGROUND: As a growing percentage of Americans will be reaching their elderly years in the next decade, the prevalence of osteoporosis and its effects will have an even greater impact on the healthcare system. Advancements in bone research and development of newer treatments have allowed for the establishment of more refined guidelines and a growing awareness of the need to prevent, screen, and diagnose osteoporosis. Thus, more women are now being screened with dual x-ray absorptiometry scans (DXA) than ever before. The importance of a true understanding of the test results obtained from such screening is paramount. In our institution, recommendations to consider a secondary evaluation are made by the DXA interpreters when the Z-score is low. Few, if any, studies have evaluated the rates of physician and patient adherence with specific recommendations provided on the bone density report. METHODS: To assess compliance with such recommendations provided in DXA interpretations, we investigated the number of ordering providers who actually pursued these advisements. RESULTS: We found that among providers ordering DXAs, primary care providers did not pursue recommendations to pursue a secondary workup as often as their subspecialty counterparts. We also found a significant amount of vitamin D deficiency/insufficiency and primary hyperparathyroidism in the population evaluated. CONCLUSIONS: Primary care providers should be further educated on treatable secondary causes of osteoporosis as opposed to an often reflexive response of prescribing a pharmacological antiresportive agent without other consideration.

Treatment options for menopausal hot flashes.

Although alternatives exist, hormone therapy remains the most effective treatment for menopausal symptoms such as hot flashes, and it is the only treatment approved by the US Food and Drug Administration (FDA) for this indication. The FDA recommends using the lowest effective dose of hormones. New low-dose preparations and new dosage forms of hormone therapy are available.

Cervical cancer screening: what's new and what's coming?

In their 2012 guidelines for cervical cancer screening, several organizations call for less-frequent but more-effective screening that incorporates testing for human papillomavirus (HPV). We review these recommendations and the possible future direction of screening.

Human papillomavirus vaccine: safe, effective, underused.

Vaccination against human papillomavirus (HPV) is safe and effective. It is recommended for females age 9 to 26 and for males age 11 to 26, yet vaccination rates are low. We review the host immune response, the data behind the recommendations for HPV vaccination, and the challenges of implementing the vaccination program.

Teaching while learning while practicing: reframing faculty development for the patient-centered medical home.

Soaring costs of health care, patients living longer with chronic illnesses, and continued attrition of interest in primary care contribute to the urgency of developing an improved model of health care delivery. Out of this need, the concept of the team-based, patient-centered medical home (PCMH) has developed. Amidst implementation in academic settings, clinical teachers face complex challenges not previously encountered: teaching while simultaneously learning about the PCMH model, redesigning clinical delivery systems while simultaneously delivering care within them, and working more closely in expanded interprofessional teams.To address these challenges, the authors reviewed three existing faculty development models and recommended four important adaptations for preparing clinical teachers for their roles as system change agents and facilitators of learning in these new settings. First, many faculty find themselves in the awkward position of teaching concepts they have yet to master themselves. Professional development programs must recognize that, at least initially, health professions learners and faculty will be learning system redesign content and skills together while practicing in the evolving workplace. Second, all care delivery team members influence learning in the workplace. Thus, the definition of faculty must expand to include nurses, pharmacists, social workers, medical assistants, patients, and others. These team members will need to accept their roles as educators. Third, learning to deliver health care in teams will require support of both interprofessional collaboration and intraprofessional identity development. Fourth, learning to manage change and uncertainty should be part of the core content of any faculty development program within the PCMH.

Cervical cancer screening: Less testing, smarter testing.

In its 2009 recommendations for cervical cancer screening, the American College of Obstetricians and Gynecologists (ACOG) calls for less-frequent but smarter screening that integrates testing for human papillomavirus (HPV) infection with the Papanicolaou (Pap) test. We review the recommendations from this and other organizations and how and why they are evolving.

Profile of teriparatide in the management of postmenopausal osteoporosis.

One out of every 2 women within postmenopause are at risk of fracture due to osteoporosis. Fortunately, a growing arsenal of therapies is becoming available to treat this disease and prevent fracture. A new class of anabolic agents has emerged within the last decade that brought with it a new concept in osteoporosis therapy: building new stronger bone rather than simply inhibiting bone turnover. Evidence is accumulating to understand how to best utilize these new agents, and which patients benefit most. This article will review the effectiveness, risks, timing and clinical uses of teriparatide in postmenopausal osteoporosis.

An observational study on the adherence to treatment guidelines of osteopenia.

BACKGROUND: Osteopenia/low bone mineral density (BMD) can lead to osteoporosis and is far more prevalent than osteoporosis. The National Osteoporosis Foundation (NOF) has recommendations for prevention and treatment of low BMD; however, the condition remains underrecognized and undertreated. We assessed practice patterns between physician knowledge of low BMD and prescribing of additional pharmacological therapies as defined by the NOF guidelines. METHODS: This is a retrospective, observational chart review of electronic medical records of 99 postmenopausal women aged > or =60 years with T-scores between -1.0 and -2.5 on baseline BMD done in 2003 at the Cleveland Clinic Women's Health Center. Counseling, advisement of weightbearing exercise, recommendation of calcium and vitamin D supplementation, and adequate pharmacological therapy in the form of bisphosphonates, hormone therapy, or selective estrogen receptor modulators (SERMs) were assessed. The management of bone specialists credentialed both by the International Society of Clinical Densitometry and the North American Menopause Society and non-bone specialists was also compared. RESULTS: Bone specialists were more likely than non-bone specialists to offer counseling in the form of letters, phone encounters, and follow-up office visits and recommend weightbearing exercises. Most physicians recommended calcium and vitamin D supplementation regardless of specialty. There is no significant difference in the prescribing of pharmacological agents vs. conservative measures for osteopenic postmenopausal women by non-bone specialists vs. bone specialists as defined by the NOF guidelines, such that non-bone specialists did not treat these women any less aggressively than did bone specialists. CONCLUSIONS: Osteopenia is adequately managed in our institution regardless of physician group. However, non-bone specialists should consider more direct counseling about bone health and consider advisement of weightbearing exercise.