Adolescents' Awareness of and Attitudes Toward Expedited Partner Therapy Provided in the Emergency Department.

BACKGROUND: Adolescents and young adults account for half of the 20 million new cases of sexually transmitted infections each year. Expedited partner therapy (EPT) has been shown to decrease reinfection rates and is recommended by the Centers for Disease Control and Prevention. We aimed to (1) assess adolescents' awareness of EPT, (2) assess their likelihood of giving EPT received in the pediatric emergency department (PED) to their partner(s), and (3) identify factors associated with increased likelihood of giving EPT to their partner(s). METHODS: Adolescents and young adults aged 14 to 22 years seeking care in 2 PEDs participated in a survey. Main outcomes were EPT awareness and likelihood of giving EPT to his/her partner(s). Patients were dichotomized into likely and not likely to provide partner(s) with EPT based on answers to a 5-point Likert scale question. χ and t tests were used to analyze the data. RESULTS: Three hundred ninety-three participants were included. Only 11% (n = 42) were aware of EPT; however, 80% (n = 316) reported to be likely to give EPT received in the PED to his/her partner(s). Study site, being sexually active, and engaging in high-risk sexual behaviors were associated with an increased likelihood of giving EPT to their partner(s) (P < 0.05). CONCLUSIONS: Many adolescents are not aware of EPT; however, most were theoretically likely to give EPT received in the PED to his/her partner(s). With increasing rates of sexually transmitted infections and high utilization of the PED for adolescent reproductive health services, efforts to incorporate the use of EPT in PED workflows would be beneficial.

Insights from pharmacists and pharmacy technicians about expedited partner therapy.

Background Expedited partner therapy (EPT) is an effective method to treat sexually transmissible infections (STIs) and prevent re-infections. Pharmacy staff play a vital role in the success of EPT. This study aims to assess pharmacy staff knowledge of EPT and identify potential barriers to filling EPT prescriptions. METHODS: The study was a cross-sectional, Internet-based survey distributed to members of the Pharmacy Society of Wisconsin. Non-retired pharmacists and pharmacy technicians were eligible. EPT knowledge was dichotomised into 'yes' versus 'no/unknown'. Statistical analyses included the χ2 test and Student's two-sided t-test; using an α of 0.05. RESULTS: Ninety-four questionnaires were analysed: 74 pharmacists, 20 pharmacy technicians. Overall, 73 (78%) knew EPT is legal in Wisconsin, 86% of pharmacists versus 45% of pharmacy technicians, P < 0.01. The mean time from graduation/training was less for participants who knew EPT is legal versus those who did not (12.8 years vs 20.2 years, P < 0.01). Sixty-four (68%) participants worked in an outpatient setting, of which 12 (19%) knew of a formal workplace EPT policy. Thirty-two (40%) of the 81 participants who had heard of EPT thought nameless EPT prescriptions should not be legal, commonly citing patient safety concerns. CONCLUSIONS: This study demonstrated inconsistent knowledge of EPT between pharmacists and pharmacy technicians. Knowledge of workplace EPT policies and patient safety concerns were barriers to EPT. Addressing these knowledge and policy barriers will be vital to improve the utilisation of EPT.

Expedited Partner Therapy: Pharmacist Refusal of Legal Prescriptions.

BACKGROUND: Expedited partner therapy (EPT) is an effective strategy for partner management of sexually transmitted infections. Some states, including Wisconsin, allow EPT prescriptions to be filled without a patient name. This study determined the refusal rates of nameless EPT prescriptions in Milwaukee pharmacies. METHODS: In this cross-sectional study, 3 trained research assistants of different age, sex, and race posed as "patients" and visited 50 pharmacy locations from one pharmacy chain in Milwaukee County, WI, to fill nameless EPT prescriptions. A χ test was used to compare demographics of patients, pharmacists, and pharmacies. Multiple logistic regression was used to identify factors associated with prescription refusal. RESULTS: Twenty-nine (58%) of 50 nameless EPT prescriptions were refused. Univariate analysis showed that prescriptions were more likely to be refused if the pharmacy was in the suburbs (77%) compared with Milwaukee city (43%; P = 0.01), if the pharmacist was older than the patient (82%) compared with being younger (46%) or within the same age group (33%; P = 0.01 for both), and if the patient was white (78%) compared with nonwhite (47%; P = 0.03). Multivariable regression revealed significantly higher refusals for pharmacies located in the suburbs compared with the city (odds ratio, 5.3; 95% confidence interval, 1.4-20.3; P = 0.03) and in patients who were white compared with nonwhite (odds ratio: 4.8; 95% confidence interval, 1.2-19.8; P = 0.01). CONCLUSIONS: More than half of nameless EPT prescriptions were refused in Milwaukee county pharmacies, more frequently at suburban pharmacies and for white patients. Increased pharmacist education regarding EPT is essential to help combat the sexually transmitted infection crisis.

Genetics and Genomics in Clinical Practice: The Views of Wisconsin Physicians.

INTRODUCTION: Decreasing costs and increased availability of genetic testing and genome sequencing mean many physicians will consider using these services over the next few years. Despite this promising future, some argue the present roadmap for translating genetics and genomics into routine clinical practice is unclear. OBJECTIVE: We conducted a pilot study to explore Wisconsin physicians' views, practices and educational desires regarding genetic and genomic testing. METHODS: Our study consists of an Internet survey (n=155) conducted in August and September 2015 and follow-up phone interviews with a portion of survey participants. Physicians of all specialties were invited to participate. Variables measured include physicians' general knowledge and experience regarding genetic and genomic testing, attitudes and perceptions toward these tests, testing intentions, and educational desires. Sociodemographic variables included gender, age, and medical specialty. RESULTS: In our exploratory survey of Wisconsin physicians, adult primary care providers (PCPs) lagged behind other providers in terms of familiarity and experience with genetic and genomic testing. PCPs in our sample were less likely than other physicians to feel their training in genetics and genomics is adequate. Physicians younger than 50 were more likely than older colleagues to feel their training is adequate. CONCLUSIONS: Our exploratory study suggests a gap in physician education and understanding regarding genomic testing, which is fast becoming part of personalized medical care. Future studies with larger samples should examine ways for physicians to close this gap, with special focus on the needs of PCPs.

The composition of intern work while on call.

BACKGROUND: The work of house staff is being increasingly scrutinized as duty hours continue to be restricted. OBJECTIVE: To describe the distribution of work performed by internal medicine interns while on call. DESIGN: Prospective time motion study on general internal medicine wards at a VA hospital affiliated with a tertiary care medical center and internal medicine residency program. PARTICIPANTS: Internal medicine interns. MAIN MEASURES: Trained observers followed interns during a "call" day. The observers continuously recorded the tasks performed by interns, using customized task analysis software. We measured the amount of time spent on each task. We calculated means and standard deviations for the amount of time spent on six categories of tasks: clinical computer work (e.g., writing orders and notes), non-patient communication, direct patient care (work done at the bedside), downtime, transit and teaching/learning. We also calculated means and standard deviations for time spent on specific tasks within each category. We compared the amount of time spent on the top three categories using analysis of variance. KEY RESULTS: The largest proportion of intern time was spent in clinical computer work (40 %). Thirty percent of time was spent on non-patient communication. Only 12 % of intern time was spent at the bedside. Downtime activities, transit and teaching/learning accounted for 11 %, 5 % and 2 % of intern time, respectively. CONCLUSION: Our results suggest that during on call periods, relatively small amounts of time are spent on direct patient care and teaching/learning activities. As intern duty hours continue to decrease, attention should be directed towards preserving time with patients and increasing time in education.

Correlation of salivary and nasal lavage pepsin with MII-pH testing.

OBJECTIVES: Laryngopharyngeal reflux (LPR) is a common upper airway disease. Salivary pepsin is a proposed marker for LPR; however, the optimal time for collection of specimens for pepsin detection and pepsin's presence in the oral and nasal secretions relative to concurrent multichannel intraluminal impedance-pH (MII-pH) monitoring are unknown. STUDY DESIGN: Prospective case-control study with an experimental design. METHODS: Patients undergoing MII-pH testing for evaluation of LPR and asymptomatic control subjects were selected. Nasal lavage and saliva samples were collected in the clinic prior to MII-pH probe placement. Additional saliva samples were obtained an hour after each meal and upon waking the following morning. Nasal lavage and salivary pepsin were measured by ELISA. RESULTS: Twenty-six patients undergoing MII-pH testing and 13 reflux-free control patients were enrolled. Salivary pepsin was detected in 11 of 26 patients with suspected LPR and 0 of 13 controls. Pepsin was most frequently detected in the specimen provided upon waking at an average concentration of 186.9 ng/mL. A significant correlation was observed between salivary pepsin in waking samples to MII-pH measurements, including reflux bolus duration, and proximal and distal recumbent reflux episodes (P < 0.05). A significant correlation was also observed between salivary pepsin upon waking or sinus lavage and reflux symptom index (P < 0.05). CONCLUSION: Pepsin in salivary and nasal lavage samples demonstrated an association with MII-pH-documented LPR. Pepsin detection was most frequent in morning samples, supporting use of morning salivary pepsin levels as a potential noninvasive technique for LPR diagnosis. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:961-966, 2020.

Changes in written sign-out composition across hospitalization.

BACKGROUND: Inaccurate or incomplete information in the written portion of the patient handoff, or sign-out, may be associated with adverse events in hospitalized patients. Little is known about what information providers actually include in written sign-out documents and how sign-outs change over time. OBJECTIVES: (1) Provide a descriptive analysis of initial and subsequent hospital day-written sign-out content, and (2) evaluate the relationship between team workload and sign-out composition. DESIGN: Retrospective review of sign-out documents from a larger observational study of general medicine patients admitted to housestaff and hospitalist teams at 3 hospitals. MAIN MEASURES: The presence of 13 components of a high-quality sign-out. We performed descriptive analyses and compared initial and subsequent day sign-outs for content. KEY RESULTS: We reviewed 200 patient hospitalizations (200 initial handoffs, 580 subsequent day handoffs). Initial sign-out entries contained a mean of 7.54 (standard deviation: 2.27) key sign-out components. Subsequent day sign-outs contained a higher percentage of certain key elements but had more vague language. The number of elements present in the sign-out was reduced as patient census increased (r = -0.295, P < 0.01). CONCLUSIONS: Sign-out composition changes over time, and is associated with workload. Future interventions to improve quality should take these factors into consideration.

Multisite Study to Examine the Amount of Inpatient Physician Continuity Experienced by Hospitalized Patients.

BACKGROUND: Continuity for inpatient medicine has been widely discussed, but methods for measuring it have been lacking. OBJECTIVE: To measure the continuity of care experienced by hospitalized patients and to identify predictors of continuity. METHODS: This was a multisite prospective cohort study and retrospective chart review that took place at 3 hospitals: an academic tertiary care center, a Veterans Affairs medical center, and a community teaching hospital. Subjects were general medicine patients and internal medicine residents. We measured continuity of care using 3 metrics: (1) the percentage of hospital time covered by the primary intern; (2) the amount of time between admission and the first handoff of care; and (3) admission-discharge continuity. We conducted univariate analyses to identify patient and hospital factors that may be associated with each type of continuity of care. RESULTS: Our sample included 869 patients with a mean age of 62.6 years (SD = 17.2) and 34% female patients. The mean percentage of hospital time covered by the primary intern was 39.2% (SD = 16.3%). The mean time between admission and the first handoff of care was 13.3 hours (SD = 7.1). Forty percent of patients experienced admission-discharge continuity. In univariate and multivariable modeling, the site was significantly associated with each type of continuity. CONCLUSIONS: The amount of continuity varied greatly and was influenced by the site and other factors. No site maximized every aspect of continuity. Programs and institutions should decide which aspects of continuity are most important locally and design schedules accordingly.

Does providing care for uninsured patients decrease emergency room visits and hospitalizations?

BACKGROUND: Access to primary care could reduce use of more costly health care by uninsured individuals through prevention and early treatment. We analyzed data from a program providing free primary care to test this hypothesis. METHODS: We compared emergency room (ER) visits and hospitalizations among uninsured, low-income adults who received immediate versus delayed access to a program providing free primary care, including labs, X-rays, and specialty consultation. We used surveys to identify ER visits and hospitalizations during the 12 months preceding and following program enrollment or wait list entry. RESULTS: Hospitalizations decreased from the year before entry to the year following entry in participants with immediate and delayed (6.0% vs 8.8% decrease) access. ER use also decreased in both groups (11.2% vs 15.4%). CONCLUSIONS: Free primary care services and specialty consultation did not reduce use of more costly health care services during its first year. More prolonged availability of primary care might have greater impact.

Self-reported subjective workload of on-call interns.

BACKGROUND: Workload has traditionally been measured by using surrogates, such as number of patients admitted or census, but these may not fully represent the complex concept of workload. OBJECTIVE: We measured self-reported subjective workload of interns and explored the relationship between subjective workload and possible predictors of it. METHODS: Trained research assistants observed internal medicine interns on call on a general medicine service. Approximately once an hour, the research assistants recorded the self-reported subjective workload of the interns by using Borg's Self-Perceived Exertion Scale, a 6 to 20 scale, and also recorded their own perceptions of the intern's workload. Research assistants continuously recorded the tasks performed by the interns. Interns were surveyed before and after the observation to obtain demographic and census data. RESULTS: Our sample included 25 interns, with a mean age of 28.6 years (SD, 2.4 years). Mean self-reported subjective workload was 12.0 (SD, 2.4). Mean self-reported subjective workload was significantly correlated with intern age (r  =  0.49, P < .05), but not with team or intern census, number of admissions, or number of patients cross-covered. Self-reported subjective workload in the period after sign-out was significantly higher than in the period before and during sign-out (P < .001). CONCLUSIONS: Self-reported subjective workload was not associated with traditional measures of workload. However, receiving sign-out and assuming the care of cross-coverage patients may be related to higher subjective workload in interns. Given the patient safety implications of workload, it is important that the medical education community have tools to evaluate workload and identify contributors to it.