Emergency Physician Opioid Prescribing and Risk of Long-term Use in the Veterans Health Administration: an Observational Analysis.

BACKGROUND: Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans. OBJECTIVE: To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans. DESIGN: Observational study using Veterans Health Administration (VA) encounter and prescription data. SETTING AND PARTICIPANTS: Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system ("opioid naïve"). MEASUREMENTS: We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses. RESULTS: We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004). CONCLUSIONS: ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.

[Use of the ICF in medical rehabilitation in Germany: claims and reality]. / Nutzung der ICF in der medizinischen Rehabilitation in Deutschland: Anspruch und Wirklichkeit.

BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) is being used in the medical rehabilitation practice in different ways. The World Health Organization (WHO) and many other stakeholders have formulated claims and expectations for its use. OBJECTIVES: A comparative presentation of the claims of various stakeholders for the use of the ICF with examples in current practice. MATERIALS AND METHODS: Database searches (PubMed, REHADAT, and Google Scholar) were conducted for studies concerning claims and the current use of the ICF in practice. RESULTS: There are different requirements regarding the use of the ICF. While lawmakers and social insurance agencies remain very cautious and vague, other stakeholders (research institutions, organizations, stakeholders, service providers) formulate higher expectations and call for greater use of the ICF. In practice, the ICF is used in the form of a bio-psycho-social model, a common language and many different adaptations. CONCLUSIONS: The different requirements for the use of ICF demonstrate the motivations and interests of the stakeholders. Signals must now be sent both by politics and by social insurance agencies that go far beyond non-binding declarations. Furthermore it is necessary to systematize and evaluate the many use adaptations that are primarily being used by service providers. Research is needed on the concrete use of ICF-based instruments and its intended and unintended effects.

A multidisciplinary approach to vascular surgery procedure coding improves coding accuracy, work relative value unit assignment, and reimbursement.

BACKGROUND: Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement. METHODS: This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy. RESULTS: During period 1, traditional coding resulted in a 4.4% (P = .004) loss in reimbursement and a 5.4% (P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding. CONCLUSIONS: Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement.

Rheumatologists and Ophthalmologists Differ in Treatment Decisions for Ocular Behçet Disease.

BACKGROUND: Ocular involvement in patients with Behçet disease represents a significant clinical morbidity in this disease, and the prevention of visual impairment is an important treatment goal. There are no randomized controlled trials for the treatment of ocular Behçet disease; however, clinicians must still make treatment decisions. OBJECTIVES: The goals of this study were to describe the treatment preferences of rheumatologists and ophthalmologists for the treatment of ocular Behçet disease and to identify factors that influence these decisions. METHODS: Eight hundred fifty-two rheumatologists and 934 ophthalmologists were surveyed via e-mail regarding their choice of therapy for a hypothetical patient with ocular Behçet disease. Respondents were asked to select first- and second-choice therapies and then reselect first and second choices assuming there would be no issues with cost or insurance prior authorization. RESULTS: One hundred thirty two physicians (7.4%) who were willing to recommend treatment completed the survey: 68 rheumatologists and 64 ophthalmologists. The most common first-choice therapy for both specialties was a biologic agent. Significantly more rheumatologists than ophthalmologists chose methotrexate (P < 0.025) and azathioprine (P < 0.005) as their first-choice therapy. After assuming there were no concerns with cost or prior authorization, rheumatologists were still more likely to choose azathioprine compared with ophthalmologists (P < 0.02), and ophthalmologists were more likely to choose local steroid implants (P < 0.02). Both rheumatologists and ophthalmologists increased their choice of an anti-tumor necrosis factor agent when cost and prior authorization issues were removed (P < 0.0001 and 0.008, respectively). CONCLUSIONS: Physician decision making is influenced by medical specialty and concerns regarding cost and prior authorization.

Doctors and Their Patients in the Seventeenth to Nineteenth Centuries.

How can these finings be interpreted in conclusion? Analysis has revealed firstly that, depending on the chosen period, the socio-geographical situation and the profile of the individual doctor's practice, the clientele varied widely in terms of gender, age and social rank. The consultation behaviour of men and women changed noticeably. Findings overall suggest that up until t8o the gender distribution varied in the individual practices. There was a trend for women to be overrepresented in urban practices during the earlier period. But in general, from the mid-nineteenth century they predominated - in towns as well as in the country in allopathic as well as homeopathic practices. The absence of children, which was bemoaned by many physicians, did not apply to the practices under investigation. On the contrary: the percentage is consistently high while older patients remained underrepresented right up until the end of the period under investigation, even though their proportion increased in the individual practices during the course of the nineteenth century In each of the nineteenth century practices investigated - and increasingly among the lower and middle classes - the physicians' services were used by several members of the same family. We have found no evidence to support the thesis that up until the nineteenth century academic physicians were mainly consulted by aristocratic or wealthy bourgeois patients. The theory probably applies only to early modern urban doctors. In the practices examined here, from the middle of the eighteenth century, patients from all social strata went to consult physicians. The participation of members of the lower classes or from an artisanal, (proto) industrial or agricultural background clearly increased over time 'despite ubiquitous economic and cultural barriers. That the annual numbers of consultations per physician increased - despite the growing number of physicians available - suggests that for economically disadvantaged social groups also, the consultation of learned physicians became more common: in towns from the first half of the nineteenth century and in the country from the middle of the century. In addition, the individual findings reveal that, prior to the introduction of statutory health insurance for salaried persons, patients of more secure social standing consulted a physician considerably more frequently in the course of the year than lower class patients. While the patient structure clearly changed around 1800, the relationship between physician and patient continued without major changes from the seventeenth to the nineteenth century. The therapeutic encounter up until the end of the investigated period can be summarized as a negotiation process. Patients were discerning in their choice of healer and did not refrain from using rival services. They sought help for unpleasant symptoms such as indigestion, pain or fever, and only rarely in cases of emergency Therapy was decided on after an exchange between a critical and autonomous client and the medical specialist who was generally willing to compromise. While the patient structure clearly changed around 1800, the relationship between physician and patient continued without major changes from the seventeenth to the nineteenth century. The therapeutic encounter up until the end of the investigated period can be summarized as a negotiation process. Patients were discerning in their choice of healer and did not refrain from using rival services. they sought help for unpleasant symptoms such as indigestion, pain or fever, and only rarely in cases of emergency. Therapy was decided on after an exchange between critical and autonomous client and the medical specialist who was generally willing to compromise.

Classifying physician practice style: a new approach using administrative data in British Columbia.

BACKGROUND: Primary medical care is changing-more female providers, desire for better work-life balance, and increasing availability of walk-in clinics have altered service delivery. There is no uniform physician practice style, and understanding service availability and delivery requires analysis of family physicians' practice patterns, rather than just physician counts. METHODS: This paper offers a new approach for describing the practice habits of primary care physicians. We use administrative data to identify activities associated with acting as "most responsible" physicians. We used British Columbia's administrative health care data from 2007/2008 to 2011/2012 to derive information regarding physicians, patients, and service delivery. We developed 5 variables to describe practice style: referrals, oversight, screening, initial prescribing for long-term medications, and repeat visits. Cluster analysis revealed 3 distinct groups of physicians. RESULTS: Only 24% of the primary care physicians were assigned to the high-responsibility group, whereas 36% and 39% were in the low-responsibility and mixed-practice groups, respectively. All cluster variables follow a similar pattern, with the high-responsibility and low-responsibility physicians many multiples apart on the means and the mixed group falling in between. Several forms of sensitivity analysis confirmed the robustness of these results. CONCLUSIONS: Physician practice patterns influence the effective supply of primary care. The fact that more than one third of British Columbia physicians are identified as "low responsibility" has implications for the delivery of primary care, both in ensuring that people have access to regular care and in insuring high-quality and comprehensive care.

The value of Retrospective and Concurrent Think Aloud in formative usability testing of a physician data query tool.

OBJECTIVE: To compare the performance of the Concurrent (CTA) and Retrospective (RTA) Think Aloud method and to assess their value in a formative usability evaluation of an Intensive Care Registry-physician data query tool designed to support ICU quality improvement processes. METHODS: Sixteen representative intensive care physicians participated in the usability evaluation study. Subjects were allocated to either the CTA or RTA method by a matched randomized design. Each subject performed six usability-testing tasks of varying complexity in the query tool in a real-working context. Methods were compared with regard to number and type of problems detected. Verbal protocols of CTA and RTA were analyzed in depth to assess differences in verbal output. Standardized measures were applied to assess thoroughness in usability problem detection weighted per problem severity level and method overall effectiveness in detecting usability problems with regard to the time subjects spent per method. RESULTS: The usability evaluation of the data query tool revealed a total of 43 unique usability problems that the intensive care physicians encountered. CTA detected unique usability problems with regard to graphics/symbols, navigation issues, error messages, and the organization of information on the query tool's screens. RTA detected unique issues concerning system match with subjects' language and applied terminology. The in-depth verbal protocol analysis of CTA provided information on intensive care physicians' query design strategies. Overall, CTA performed significantly better than RTA in detecting usability problems. CTA usability problem detection effectiveness was 0.80 vs. 0.62 (p<0.05) respectively, with an average difference of 42% less time spent per subject compared to RTA. In addition, CTA was more thorough in detecting usability problems of a moderate (0.85 vs. 0.7) and severe nature (0.71 vs. 0.57). CONCLUSION: In this study, the CTA is more effective in usability-problem detection and provided clarification of intensive care physician query design strategies to inform redesign of the query tool. However, CTA does not outperform RTA. The RTA additionally elucidated unique usability problems and new user requirements. Based on the results of this study, we recommend the use of CTA in formative usability evaluation studies of health information technology. However, we recommend further research on the application of RTA in usability studies with regard to user expertise and experience when focusing on user profile customized (re)design.

A taxonomy of primary health care practices: an avenue for informing management and policy implementation.

Health policy and practice managers often treat primary practices as being homogenous, despite evidence that these organisations vary along multiple dimensions. This treatment can be a barrier to the development of a strong health care system. Therefore, a more sophisticated taxonomy of organisations could inform management and policy to better cater to the diversity of practice contexts, needs and capabilities. The purpose of this study was to categorise primary practices using practice features and characteristics associated with the job satisfaction of GPs. The current study uses data from 3906 GPs from the 2008 wave of the MABEL survey. Seven configurations of primary health care practices emerged from multivariate cluster analyses. The configurations incorporate, yet move beyond, simplistic categorisations such as geographic location and highlight the complexity facing managers and health policy interventions. The multidimensional configurations in the taxonomy are a mechanism for informing health care management and policy. The process of deriving configurations can be applied in a variety of countries and contexts.

Characteristics of a patient population seeking medical advice for nasal symptoms in Bulgaria.

BACKGROUND: The proportion of patients visiting general practitioners (GPs), otorhinolaryngologists (ORLs), and allergologists (ALRGs) for nasal complaints is unknown but important in estimating the number of subjects with nasal symptoms bothersome enough to warrant physician consultations and assessing nasal pathological conditions' burden on a national health care system. OBJECTIVE: The Symptoms of Nasal Inconvenience Fact Finding (SNIFF) survey was developed to (1) assess incidence of physician visits attributable to nasal complaints; (2) characterize patients' nasal conditions; and (3) outline differences across physician categories. METHODS: The SNIFF survey was completed over 20 days by Bulgarian GPs, ORLs, and ALRGs whom patients consulted for nasal symptoms. Survey forms differentiated type and severity of patients' conditions according to Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines and ranked bothersome symptoms. Smell impairment, comorbidities, and prescription practices were documented. RESULTS: Sixty-nine physicians (30 GPs, 8 ORLs, 31 ALRGs) completed 1,685 surveys. The proportion of patients with nasal symptoms over the total patients seen was 15.7%: ALRGs, 18.0%; GPs, 14.6%; ORLs, 13.1%. Patients were classified as having intermittent (38.8%) or persistent (61.2%) rhinitis, with most having moderate/severe symptoms (94.4%). Congestion was the leading symptom in 59.1%. Smell was impaired in 69.8% of patients, asthma was present in 21.4%, and cough in 62.9%. ALRGs were more likely to diagnose and manage patients per ARIA guidelines than were ORLs or GPs. CONCLUSION: The SNIFF survey results demonstrate congestion's role as a leading symptom motivating patients to seek medical advice. SNIFF also uncovered differences in practices among different categories of health care providers.

Patients' views on changes in doctor-patient communication between 1982 and 2001: a mixed-methods study.

BACKGROUND: Doctor-patient communication has been influenced over time by factors such as the rise of evidence-based medicine and a growing emphasis on patient-centred care. Despite disputes in the literature on the tension between evidence-based medicine and patient-centered medicine, patients' views on what constitutes high quality of doctor-patient communication are seldom an explicit topic for research. The aim of this study is to examine whether analogue patients (lay people judging videotaped consultations) perceive shifts in the quality of doctor-patient communication over a twenty-year period. METHODS: Analogue patients (N = 108) assessed 189 videotaped general practice consultations from two periods (1982-1984 and 2000-2001). They provided ratings on three dimensions (scale 1-10) and gave written feedback. With a mixed-methods research design, we examined these assessments quantitatively (in relation to observed communication coded with RIAS) and qualitatively. RESULTS: 1) The quantitative analyses showed that biomedical communication and rapport building were positively associated with the quality assessments of videotaped consultations from the first period, but not from the second. Psychosocial communication and personal remarks were related to positive quality assessments of both periods; 2) the qualitative analyses showed that in both periods, participants provided the same balance between positive and negative comments. Listening, giving support, and showing respect were considered equally important in both periods. We identified shifts in the participants' observations on how GPs explained things to the patient, the division of roles and responsibilities, and the emphasis on problem-focused communication (first period) versus solution-focused communication (last period). CONCLUSION: Analogue patients recognize shifts in the quality of doctor-patient communication from two different periods, including a shift from problem-focused communication to solution-focused communication, and they value an egalitarian doctor-patient relationship. The two research methods were complementary; based on the quantitative analyses we found shifts in communication, which we confirmed and specified in our qualitative analyses.

The revision of the Korean classifications of health interventions based on the proposed ICHI semantic model and lessons learned.

The Korean Medical Association and the Health Information Review Agency have decided to re-engineer the different Korean coding systems of health interventions based on a proposed ontology framework defined in 2010 for the prospective International Classification of Health Interventions (ICHI). The authors present the interim report of the project focused on this model: 5,338 procedures of the Korean version of ICD9-CM 5,150 procedures covered by Korean health insurance and 6,619 uncovered procedure labels were processed with the participation of 8 coders and 310 medical doctors. As of 28th January 61.8% of data was processed. The ontology framework model itself was not enough to represent all the labels when the preliminary data from obstetrics and gynecology was explored. However, when modified with 7 notations, it was possible to assign each label of ICD 9 CM Volume 3 and 30 % to 57 % of specific Korean interventions to the semantic model.

Characteristics and practice patterns of advanced practice registered nurses caring for older adults: A survey of Gerontological Advanced Practice Nurses Association members.

BACKGROUND: Advanced practice registered nurses (APRNs) play a pivotal role in meeting the increasing needs of elder care given the aging population. A good understanding of the characteristics of gerontological APRNs is important for future workforce planning. PURPOSE: To understand the demographic, employment, and practice characteristics of APRNs who provide elder care. METHODS: A 34-item survey was distributed to 2,500 current members of the Gerontological Advanced Practice Nurses Association. Three hundred and sixty-four members provided demographic information and employment and practice patterns. To examine the sample representativeness, the survey sample was compared with a sample drawn from the National Sample Survey of Nurse Practitioners 2012. Descriptive statistics were used for analysis. RESULTS: Most respondents were older than 55 years, held a master's degree, were certified as a Gerontology APRN, worked in a long-term/elder care setting as an APRN, earned a salary ranging from $105,001 to $125,000, and practiced in urban or suburban areas. Most respondents worked full time, provided care for people who were 55 to 75 years old, and prescribed under a collaborative agreement. IMPLICATIONS FOR PRACTICE: The study results suggested that gerontological APRNs have the experience and competence to meet the increasing needs of elder care, practice in a variety of settings, including in rural areas, and spend much time with patients. Future efforts are needed to support APRN practice, such as improving their autonomy and independence.

Differences in surgical resection rate and risk of malignancy in thyroid cytopathology practice between Western and Asian countries: A systematic review and meta-analysis.

There is increasing evidence showing that clinicians employ different management strategies in their use of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC). In this meta-analysis, we investigated the differences in diagnosis frequency, resection rate (RR), and risk of malignancy (ROM) between Western (ie, American and European) and Asian cytopathology practices. We searched PubMed and Web of Science from January 2010 to January 2019. Proportion and 95% CIs were calculated using a random-effect model. We used independent sample t tests to compare frequencies, RR, and ROM between Western and Asian practices. We analyzed a total of 38 studies with 145,066 fine-needle aspirations. Compared with Asian practice, Western series had a significantly lower ROM in most of TBSRTC categories, whereas the RR was not statistically different. Focusing on indeterminate nodules, the RR in Western series was significantly higher (51.3% vs 37.6%; P = .048), whereas the ROM was significantly lower (25.4% vs 41.9%; P = .002) compared with those in Asian series. The addition of Asian cohorts increased ROM for most of diagnostic categories compared with the original TBSRTC. In conclusion, this study demonstrates a difference in Western and Asian thyroid cytology practice, especially regarding the indeterminate categories. Lower RR and higher ROM suggest that Asian clinicians adopt a more conservative approach, whereas immediate diagnostic surgery is favored in Western practice for indeterminate nodules. The addition of Asian series into a meta-analysis of TBSRTC altered ROM for several categories, which should be considered in future revisions of TBSRTC.

A Proposed Revision of the International Classification of Diseases, 11th Revision, Chapter 26.

In 2019, the World Health Assembly approved the International Classification of Diseases, 11th Revision (ICD-11), which included a traditional medicine chapter. This means that traditional medicine (TM) is incorporated into the mainstream medicine of the world. For TM to contribute to human health, the role of ICD-11, chapter 26 (ICD-11-26), is important. Since the ICD-11-26 is "a union set of harmonized traditional medicine conditions of the Chinese, Japanese, and Korean classifications," it is advisable to supplement the essential patterns while maintaining the already adopted patterns. The ICD-11-26 was originated from the World Health Organization International Standard Terminologies on Traditional Medicine in the Western Pacific Region (WHO-IST), and the WHO-IST is the world's most authoritative TM standard terminology system with an emphasis on traditional and conventional expression. In addition, it includes patterns that are widely used in TM clinical practice and have representative prescriptions at the same time. Therefore, future revisions of ICD-11-26 should make WHO-IST the main reference. Based on this spirit, this proposed revision is a modification of ICD-11-26's structure, order, and expression (English translation) with more essential patterns.

Joint injection practice variations in pediatric rheumatology - a global survey and call for action.

BACKGROUND: Intraarticular injections (IAI) were first reported in adult rheumatology in the 1950s and subsequently gained acceptance as a safe and efficacious treatment in Juvenile idiopathic arthritis (JIA). IAIs are now widely performed and recommended as the initial or only treatment of oligoarticular JIA and ancillary treatment of actively inflamed joints in other varieties of JIA. However, the performance of the procedure is currently not guided by standardized recommendations, and several practice variations are observed. METHODS: This worldwide survey of pediatric rheumatologists (with 48.5% response from Pediatric Rheumatology International Trials Organization [PRINTO and Pediatric Rheumatology Collaborative Study Group [PRCSG] members) captures the differences in pre-procedural, procedural and post-procedural protocols and practices observed across the globe and asks the necessity of developing consensus in this area of Pediatric Rheumatology. RESULTS: This worldwide survey of Pediatric Rheumatologists had a response rate of just under 50% and the views of about 42% who routinely performed the procedure. It captured the differences in IAI protocols and practices observed across the globe. Significant variations in practice were noted in use of Local anesthesia, choice, and dose of therapeutic agent for the intraarticular injection and use of ultrasound to guide injections. While some practice variations may be explained by institutional protocols in different parts of the world, the clinical implications of these are largely unknown and beg the need for further studies. CONCLUSIONS: Given these practice variations, the authors recommend further studies to explore the cost and clinical implications and subsequently work towards developing consensus plans to ensure uniformity in this widely used procedure in Pediatric Rheumatology.

Overcoming Barriers to Prescribing Buprenorphine for the Treatment of Opioid Use Disorder: Recommendations from Rural Physicians.

PURPOSE: The United States is in the midst of a severe opioid use disorder epidemic. Buprenorphine is an effective office-based treatment that can be prescribed by physicians, nurse practitioners, and physician assistants with a Drug Enforcement Administration (DEA) waiver. However, many providers report barriers that keep them from either getting a DEA waiver or fully using it. The study team interviewed rural physicians successfully prescribing buprenorphine to identify strategies for overcoming commonly cited barriers for providing this service. METHODS: Interview candidates were randomly selected from a list of rurally located physicians with a DEA waiver to prescribe buprenorphine who reported treating high numbers of patients on a 2016 survey. Forty-three rural physicians, who were prescribing buprenorphine to a high number of patients, were interviewed about how they overcame prescribing barriers previously identified in that survey. FINDINGS: Interviewed physicians reported numerous ways to overcome common barriers to providing buprenorphine treatment in rural areas. Key recommendations included ways to (1) get started and maintain medication-assisted treatment, (2) minimize DEA intrusion and medication diversion, and (3) address the lack of mental health providers and stigma surrounding opioid use disorder (OUD). Overall, physicians found providing this service to be very rewarding. CONCLUSIONS: Despite known barriers, rural physicians around the country have been successful in adding buprenorphine treatment to their practices. Nonprescribing providers can learn from the strategies used by successful prescribers to add this service.

Management of dry eye disease to optimize cataract surgery outcomes: Two tables for a daily clinical practice.

The increase in life expectancy has resulted in a greater number of patients presenting for cataract surgery as well as an increasing prevalence of dry eye disease (DED) symptoms or signs noted in these patients. Low grade and/or non-symptomatic DED is common and can be exacerbated after surgery. DED can induce errors in IOL power calculation. DED can impair the visual prognosis and patient comfort after cataract surgery, leading to dissatisfaction of both the patient and the surgeon. Hence, preoperative evaluation for DED for all cataract candidates is crucial to mitigate these risks. To optimize clinical efficiency during the screening examination, we propose a strategy of three levels of DED screening, according to a patient's risk of DED given his or her history. We also propose a summary of the main clinical points before, during and after cataract surgery in eyes with DED.

The feasibility and value of new measures showing patterns of quality for patients with 3 chronic conditions.

The aim of this study was to create new measures of quality that combine individual service measures. Using an all-or-none approach, we identify 5 levels of care reflecting the extent to which optimal patterns of service were obtained by patients with asthma, diabetes, and heart failure. We also assess the feasibility of these levels-of-care measures and their potential value in quality improvement efforts. The study was designed to analyze claims data to reflect patterns of services used in a single metropolitan market of about 1 million residents in the northeastern United States. More than 80,000 patients insured over 4 years (1994-1997) had claims with 1 or more of 3 chronic conditions. The analysis showed that the measures discriminated effectively among groups of patients with the 3 chronic conditions and highlighted areas to target quality improvement efforts. Although the numbers vary by year, for two of the diagnoses, most patients were in the lowest categories (59%-75%), and for the third, 40% were in these categories. Few were in the highest category. Most patients were in the same category from one year to the next. The levels-of-care approach to quality measurement can help caregivers and policy makers find methods for avoiding unnecessary utilization and expenditures while raising--not lowering--the probability that utilization patterns will conform to condition-specific recommended care.