Search

Background: Patients with atrial fibrillation (AF) must decide between warfarin and direct oral anticoagulants (DOACs), a decision involving important tradeoffs. Our objective was to understand whether physicians engage patients in informed decision making for anticoagulants., Design: We performed an analysis of recorded conversations between physicians and anticoagulation-naïve patients in the Verilogue Point-of-Practice database. We assessed the presence of 7 elements of informed decision making, as well as a discussion of financial costs., Results: Of 37 encounters with 21 physicians, 92% resulted in a DOAC prescription and 8% resulted in a warfarin prescription. Seventy percent met criteria for discussion of pros and cons, 70% for discussion of the alternatives, 43% presented the decision, 30% included an assessment of patient understanding, 22% included an explanation of the patient's role in decision making, 22% included an assessment of patient preferences, and 19% included a discussion of uncertainty. Two encounters (5%) included all 7 elements and 9 (24%) included none. Physicians discussed treatment costs with patients in 43% of encounters., Limitations: We assessed informed decision making in a single encounter. Physicians and patients may have had other discussions that were not captured in our data., Conclusions: Physicians often presented the alternatives but did not generally engage patients in informed decision making. The high rate of DOAC prescriptions is likely the result of physician preferences, as patient preferences were rarely assessed., Implications: Strategies to support physicians in engaging patients in informed decision making for anticoagulation are needed., Highlights: While physicians discussed the alternatives and presented pros and cons with patients, they rarely assessed patient preferences, explained the patient's role in decision making, or addressed uncertainty.The cost of treatment with DOACs versus warfarin was discussed by physicians in less than half of encounters, limiting patients' ability to make informed decisions for anticoagulation.Only 2 encounters (5%) fulfilled all 7 elements of informed decision making.

Aims: Acamprosate, naltrexone and disulfiram are underprescribed for alcohol use disorder (AUD) with marked variability among primary care providers (PCPs). We aimed to identify differences between high and low prescribers of medications for AUD (MAUD) with regard to knowledge, experiences, prioritization and attitudes., Methods: We surveyed PCPs from a large healthcare system with at least 20 patients with AUD. Prescribing rates were obtained from the electronic health record (EHR). Survey responses were scored from strongly disagree (1) to strongly agree (5). Multiple imputation was used to generate attitude scores for 7 missing subjects. PCPs were divided into groups by the median prescribing rate and attitude. Comparisons were made using Wilcoxon rank-sum and regression., Results: Of the 182 eligible PCPs, 68 (37.4%) completed the survey. Most indicated willingness to attend an educational course (57.4%). Compared with low prescribers, high prescribers viewed the effectiveness of medications more favorably (short term 4.0 vs 3.7, P = 0.02; long term 3.5 vs 3.2, P = 0.04) and were more likely to view prescribing as part of their job (3.9 vs 3.4, P = 0.04). PCPs with positive attitudes (72.4%, CI 60.9-83.8%) had a prescribing rate of 5.0% (CI 3.5-6.5%) compared to 1.9% (CI 0.5-3.4%) among those with negative attitudes (P = 0.028). When stratified by attitude, belief in effectiveness was associated with higher prescribing among PCPs with positive attitudes but not those with negative attitudes., Conclusions: PCPs indicated an interest in learning to prescribe MAUD. However, education alone may not be effective unless physicians have positive attitudes towards patients with AUD., (© The Author(s) 2022. Medical Council on Alcohol and Oxford University Press. All rights reserved.)

Importance: For patients with atrial fibrillation (AF), the decision to initiate anticoagulation involves the choice between warfarin or a direct oral anticoagulant (DOAC). How physicians engage patients in this decision is unknown., Objective: To describe the content of discussions between patients with AF and physicians regarding choice of anticoagulation., Design, Setting, and Participants: This qualitative content analysis included clinical encounters between physicians and anticoagulation-naive patients discussing anticoagulation initiation between 2014 and 2020., Main Outcomes and Measures: Themes identified through content analysis., Results: Of 37 encounters, almost all (34 [92%]) resulted in a prescription for a DOAC. Most (25 [68%]) patients were White; 15 (41%) were female and 22 (59%) were male; and 24 (65%) were aged 65 to 84 years. Twenty-one physicians conducted the included encounters, the majority of whom were cardiologists (14 [67%]) and male (19 [90%]). The analysis revealed 4 major categories and associated subcategories of themes associated with physician discussion of anticoagulation with anticoagulation-naive patients: (1) benefit vs risk of taking anticoagulation-in many cases, this involved an imbalance in completeness of discussion of stroke vs bleeding risk, and physicians often used emotional language; (2) tradeoffs between warfarin and DOACs-physicians typically discussed pros and cons, used persuasive language, and provided mixed signals, telling patients that warfarin and DOACs were basically equivalent, while simultaneously saying warfarin is rat poison; (3) medication costs-physicians often attempted to address patients' questions about out-of-pocket costs but were unable to provide concrete answers, and they often provided free samples or coupons; and (4) DOACs in television commercials-physicians used direct-to-consumer pharmaceutical advertising about DOACs to orient patients to the issue of anticoagulation as well as the advantages of DOACs over warfarin. Patients and physicians also discussed class action lawsuits for DOACs that patients had seen on television., Conclusions and Relevance: This qualitative analysis of anticoagulation discussions between physicians and patients during clinical encounters found that physicians engaged in persuasive communication to convince patients to accept anticoagulation with a DOAC, yet they were unable to address questions regarding medication costs. For patients who are ultimately unable to afford DOACs, this may lead to unnecessary financial burden or abandoning prescriptions at the pharmacy, placing them at continued risk of stroke.

Objective: Assessing changes in physician burnout over time can offer insight into the causes of burnout. Existing studies are limited by using different samples of physicians at each time point. Our objective was to assess changes in burnout between 2013-2014 and 2019-2020 overall and within a cohort of physicians who took the survey twice., Methods: This is a longitudinal cohort and cross-sectional study of physicians in a major health system. They were administered the Maslach Burnout Inventory in 2013-2014 and 2019-2020. We separately assessed differences in odds of burnout and its subscales in 2013-2014 and 2019-2020 by physician characteristics and clinical time. We then assessed differences in the odds of reporting burnout and its subscales in 2019-2020 compared with 2013-2014 overall and by physician sex, race, and change in clinical full-time employment., Results: There were 1220 respondents in 2013-2014, 503 in 2019-2020, and 149 who responded at both time points. Burnout increased from 35% to 56%. Compared with 2013-2014, physicians had 2.39 higher odds (95% confidence interval [CI] 1.92-2.98) of burnout in 2019-2020, and this change in burnout was significantly more pronounced for female versus male physicians (odds ratio 1.80; 95% CI 1.57-1.80). Compared with White physicians, non-White physicians had significantly lower odds of burnout at both time points, but their odds increased significantly more over time (odds ratio 1.36; 95% CI 1.05-1.57)., Conclusions: We found a substantial increase in burnout over time, which was particularly pronounced for non-White and female physicians. Assessment over time is essential for understanding problematic trajectories of burnout that may be obscured by cross-sectional studies.

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., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Polypharmacy, or use of multiple medications, is associated with patient factors. Less is known regarding variation in polypharmacy by individual physicians. The objective of this study was to assess patient and physician factors associated with polypharmacy among older patients., Methods: This is a cross-sectional study of patients aged ≥65 years with a primary care visit at Cleveland Clinic Health System in 2015 and their physicians. We collected patient demographics, comorbidities and current medications from the electronic health record, including potentially inappropriate medications (PIMs). We used mixed effects linear regression to estimate adjusted differences in the number of medications by patient factors. We generated adjusted prescribing rates for individual physicians and assessed differences in physician performance on quality measures by their prescribing rate., Results: Our study included 44,570 patients who were prescribed an average of 6.8 medications (standard deviation: 4.0) by 701 physicians. Female sex, higher BMI, having Medicaid insurance, current or former smoking status, comorbidities and seeing a specialist were associated with number of medications. Age was not. Among 267 physicians who saw ≥20 study-eligible patients, the adjusted mean number of medications per patient ranged from 5.2 to 9.6. Compared to physicians who prescribed above the mean, lower prescribing physicians performed significantly better on medication reconciliation ( p  = .007) and hypertension control ( p  < .001) and prescribed fewer PIMs ( p  < .001)., Conclusions: Individual physicians varied in their prescribing practices, even after adjusting for patient demographic and clinical characteristics. Interventions to reduce polypharmacy in older adults should target high prescribing physicians, as physician behavior is more actionable than patient factors.

Objective: To understand changes in physician screening practices in response to the 2009 U.S. Preventive Services Task Force recommendation supporting shared decision making (SDM) for mammography in women aged 40-49 years., Methods: We assessed screening completion rates for physicians in the Cleveland Clinic Health System pre-2009 (2006-2008) and post-2009 (2010-2015), and rates for physicians new to the system post-2009. We used mixed effects logistic regression to estimate the odds of a woman receiving screening post-2009. If physicians practiced SDM, we hypothesized their screening rates would change after 2009. To test this, we included each physician's pre-2009 screening rate as a predictor in the model., Results: Among 125 physicians, the screening rate increased from 40% to 45% from pre-2009 to post-2009. For physicians new to the health system post-2009 the rate was 32%. In the mixed effects model (N = 17,007), the strongest predictor of mammography receipt among patients post-2009 was their physician's pre-2009 screening rate (aOR:3.57 per 10% increase in pre-2009 rate; 95%CI:1.69-7.50)., Conclusions: Whether a woman received a mammogram post-2009 was highly associated with her physicians' pre-2009 screening rate, suggesting physicians are not individualizing screening decisions via SDM., Practice Implications: Physicians may need support to effectively practice SDM., Competing Interests: Declaration of interest None., (Copyright © 2021. Published by Elsevier B.V.)

Objectives: To describe variation in and drivers of contemporary preoperative cardiac stress testing., Setting: A dedicated preoperative risk assessment and optimisation clinic at a large integrated medical centre from 2008 through 2018., Participants: A cohort of 118 552 adult patients seen by 104 physicians across 159 795 visits to a preoperative risk assessment and optimisation clinic., Main Outcome: Referral for stress testing before major surgery, including nuclear, echocardiographic or electrocardiographic-only stress testing, within 30 days after a clinic visit., Results: A total of 8303 visits (5.2%) resulted in referral for preoperative stress testing. Key patient factors associated with preoperative stress testing included predicted surgical risk, patient functional status, a previous diagnosis of ischaemic heart disease, tobacco use and body mass index. Patients living in either the most-deprived or least-deprived census block groups were more likely to be tested. Patients were tested more frequently before aortic, peripheral vascular or urologic interventions than before other surgical subcategories. Even after fully adjusting for patient and surgical factors, provider effects remained important: marginal testing rates differed by a factor-of-three in relative terms and around 2.5% in absolute terms between the 5th and 95th percentile physicians. Stress testing frequency decreased over the time period; controlling for patient and physician predictors, a visit in 2008 would have resulted in stress testing approximately 3.5% of the time, while a visit in 2018 would have resulted in stress testing approximately 1.3% of the time., Conclusions: In this large cohort of patients seen for preoperative risk assessment at a single health system, decisions to refer patients for preoperative stress testing are influenced by various factors other than estimated perioperative risk and functional status, the key considerations in current guidelines. The frequency of preoperative stress testing has decreased over time, but remains highly provider-dependent., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Identifying which patients receive referrals to and which ones attend weight management programs can provide insights into how physicians manage obesity., Objective: To describe patient factors associated with referrals, which primarily reflect physician priorities, and attendance, which reflects patient priorities. We also examine the influence of the individual physician by comparing adjusted rates of referral and attendance across physicians., Design: Retrospective cohort study., Participants: Adults with a body mass index (BMI) ≥ 30 kg/m 2 who had a primary care visit between 2015 and 2018 at a large integrated health system MAIN MEASURES: Referrals and visits to programs were collected from the EHR in 2019 and analyzed in 2019-2020. Multilevel logistic regression models were used to identify the association between patient characteristics and (1) receiving a referral, and (2) attending a visit after a referral. We compared physicians' adjusted probabilities of referring patients and of their patients attending a visit., Key Results: Our study included 160,163 adults, with a median BMI of 35 kg/m 2 . Seventeen percent of patients received ≥ 1 referral and 29% of those attended a visit. The adjusted odds of referral increased 57% for patients with a BMI 35-39 (versus 30-34) and 32% for each comorbidity (p < 0.01). Attending a visit was less strongly associated with BMI (aOR 1.18 for 35-39 versus 30-34, 95% CI 1.09-1.27) and not at all with comorbidity. For the physician-level analysis, the adjusted probability of referral had a much wider range (0 to 83%; mean = 19%) than did the adjusted probability of attendance (range 27 to 34%)., Conclusions: Few patients attended a weight management program. Physicians vary greatly in their probability of referring patients to programs but not in their patients' probability of attending., (© 2021. Society of General Internal Medicine.)

Background: Patient satisfaction measures have important implications for physicians. Patient bias against non-White physicians may impact physician satisfaction ratings, but this has not been widely studied., Objective: To assess differences in patient satisfaction by physician race/ethnicity., Design: A cross-sectional observational study., Participants: Patients seeking care on a large nationwide direct to consumer telemedicine platform between July 2016 and July 2018 and their physicians., Main Measures: Patient satisfaction was ascertained immediately following the encounter on scales of 1 to 5 stars and scored two ways: (1) top-box satisfaction (5 stars versus fewer) and (2) dissatisfaction (2 or fewer stars versus 3 or more). To approximate the information patients would use to make assumptions about physician race/ethnicity, four reviewers classified physicians into categories based on physician name and photo. These included White American, Black American, South Asian, Middle Eastern, Hispanic, and East Asian. Mixed effects logistic regression was used to assess differences in patient top-box satisfaction and patient dissatisfaction by physician race/ethnicity, controlling for patient characteristics, prescription receipt, physician specialty, and whether the physician trained in the USA versus internationally., Key Results: The sample included 119,016 encounters with 390 physicians. Sixty percent were White American, 14% South Asian, 7% Black American, 7% Hispanic, 6% Middle Eastern, and 6% East Asian. Encounters with South Asian physicians (aOR 0.70; 95% CI 0.54-0.91) and East Asian physicians (aOR 0.72; 95% CI 0.53-0.99) were significantly less likely than those with White American physicians to result in top-box satisfaction. Compared to encounters with White American physicians, those with Black American physicians (aOR 1.72; 95% CI 1.12-2.64), South Asian physicians (aOR 1.77; 95% CI 1.23-2.56), and East Asian physicians (aOR 2.10; 95% CI 1.38-3.20) were more likely to result in patient dissatisfaction., Conclusions: In our study, patients reported lower satisfaction with some groups of non-White American physicians, which may have implications for their compensation, professional reputation, and job satisfaction.

Importance: Primary care physicians have limited time to discuss preventive care, but it is unknown how they prioritize recommended services., Objective: To understand primary care physicians' prioritization of preventive services., Design, Setting, and Participants: This online survey was administered to primary care physicians in a large health care system from March 17 to May 12, 2017. Physicians were asked whether they prioritize preventive services and which factors contribute to their choice (5-point Likert scale). Results were analyzed from July 8, 2017, to September 19, 2019., Exposures: A 2 × 2 factorial design of 2 hypothetical patients: (1) a 50-year-old white woman with hypertension, type 2 diabetes, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of breast cancer; and (2) a 45-year-old black man with hypertension, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of colorectal cancer. Two visit lengths (40 minutes vs 20 minutes) were given. Each patient was eligible for at least 11 preventive services., Main Outcomes and Measures: Physicians rated their likelihood of discussing each service during the visit and reported their top 3 priorities for patients 1 and 2. Physician choices were compared with the preventive services most likely to improve life expectancy, using a previously published mathematical model., Results: Of 241 physicians, 137 responded (57%), of whom 74 (54%) were female and 85 (62%) were younger than 50 years. Physicians agreed they prioritized preventive services (mean score, 4.27 [95% CI, 4.12-4.42] of 5.00), mostly by ability to improve quality (4.56 [95% CI, 4.44-4.68] of 5.00) or length (4.53 [95% CI, 4.40-4.66] of 5.00) of life. Physicians reported more prioritization in the 20- vs 40-minute visit, indicating that they were likely to discuss fewer services during the shorter visit (median, 5 [interquartile range {IQR}, 3-8] vs 11 [IQR, 9-13] preventive services for patient 1, and 4 [IQR, 3-6] vs 9 [IQR, 8-11] for patient 2). Physicians reported similar top 3 priorities for both patients: smoking cessation, hypertension control, and glycemic control for patient 1 and smoking cessation, hypertension control, and colorectal cancer screening for patient 2. Physicians' top 3 priorities did not usually include diet and exercise or weight loss (ranked in their top 3 recommendations for either patient by only 48 physicians [35%]), although these were among the 3 preventive services most likely to improve life expectancy based on the mathematical model., Conclusions and Relevance: In this survey study, physicians prioritized preventive services under time constraints, but priorities did not vary across patients. Physicians did not prioritize lifestyle interventions despite large potential benefits. Future research should consider whether physicians and patients would benefit from guidance on preventive care priorities.

Objective: The most effective forms of emergency contraception (EC) require a prescription or a medical procedure; therefore, provider willingness to offer EC remains critical to patient access. This study seeks to assess whether political alignment of a provider's county is associated with provider attitudes and behaviors regarding EC., Study Design: We analyzed survey data collected from 1313 healthcare providers from February 2013 to April 2014 at 14 academic medical centers in the United States. Using logistic regression, we estimated associations between the county political alignment of a provider's practice and his or her EC-related beliefs and practices: 1) if the provider is aware of the most effective EC methods; 2) if knowing that a hypothetical EC method prevented implantation would make a provider less likely to prescribe that method because of personal ethical or religious reasons; and 3) if the provider prescribes any form of EC in his or her practice., Results: In multivariate models, a one percentage-point increase in county Republican vote share was associated with a 2.9% decrease in the odds of a provider prescribing EC, after accounting for provider knowledge and attitudes about EC., Conclusions: EC provides a critical last chance to prevent pregnancy after unprotected sex, yet women living in Republican-leaning counties may face difficulty obtaining EC from healthcare providers. Programs seeking to improve access to EC should focus on areas likely to have fewer providers willing to prescribe EC, which may be those that are more Republican-leaning., Implications: The most effective forms of emergency contraception require a prescription or a medical procedure; therefore, provider willingness to offer EC remains critical to patient access. Women living in Republican-leaning counties may face difficulty obtaining emergency contraception from healthcare providers., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To identify correlates of physician empathy and determine whether physician empathy is related to standardized measures of patient experience., Method: Demographic, professional, and empathy data were collected during 2013-2015 from Cleveland Clinic Health System physicians prior to participation in mandatory communication skills training. Empathy was assessed using the Jefferson Scale of Empathy. Data were also collected for seven measures (six provider communication items and overall provider rating) from the visit-specific and 12-month Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS) surveys. Associations between empathy and provider characteristics were assessed by linear regression, ANOVA, or a nonparametric equivalent. Significant predictors were included in a multivariable linear regression model. Correlations between empathy and CG-CAHPS scores were assessed using Spearman rank correlation coefficients., Results: In bivariable analysis (n = 847 physicians), female sex (P < .001), specialty (P < .01), outpatient practice setting (P < .05), and DO degree (P < .05) were associated with higher empathy scores. In multivariable analysis, female sex (P < .001) and four specialties (obstetrics-gynecology, pediatrics, psychiatry, and thoracic surgery; all P < .05) were significantly associated with higher empathy scores. Of the seven CG-CAHPS measures, scores on five for the 583 physicians with visit-specific data and on three for the 277 physicians with 12-month data were positively correlated with empathy., Conclusions: Specialty and sex were independently associated with physician empathy. Empathy was correlated with higher scores on multiple CG-CAHPS items, suggesting improving physician empathy might play a role in improving patient experience.

Their outpatient notes stack up well, according to this small, retrospective review. Scribes' notes were rated slightly higher in overall quality than physicians' notes-- at least for certain patient encounters.

Background: Identifying which patients receive referrals to and which ones attend weight management programs can provide insights into how physicians manage obesity. Objective: To describe patient factors associated with referrals, which primarily reflect physician priorities, and attendance, which reflects patient priorities. We also examine the influence of the individual physician by comparing adjusted rates of referral and attendance across physicians. Design: Retrospective cohort study. Participants: Adults with a body mass index (BMI) ≥ 30 kg/m2 who had a primary care visit between 2015 and 2018 at a large integrated health system Main Measures: Referrals and visits to programs were collected from the EHR in 2019 and analyzed in 2019–2020. Multilevel logistic regression models were used to identify the association between patient characteristics and (1) receiving a referral, and (2) attending a visit after a referral. We compared physicians' adjusted probabilities of referring patients and of their patients attending a visit. Key Results: Our study included 160,163 adults, with a median BMI of 35 kg/m2. Seventeen percent of patients received ≥ 1 referral and 29% of those attended a visit. The adjusted odds of referral increased 57% for patients with a BMI 35–39 (versus 30–34) and 32% for each comorbidity (p < 0.01). Attending a visit was less strongly associated with BMI (aOR 1.18 for 35–39 versus 30–34, 95% CI 1.09–1.27) and not at all with comorbidity. For the physician-level analysis, the adjusted probability of referral had a much wider range (0 to 83%; mean = 19%) than did the adjusted probability of attendance (range 27 to 34%). Conclusions: Few patients attended a weight management program. Physicians vary greatly in their probability of referring patients to programs but not in their patients' probability of attending. [ABSTRACT FROM AUTHOR]

Background: Alcohol use disorder (AUD) imposes a high mortality and economic burden. Effective treatment is available, though underutilized. Objective: Describe trends in AUD pharmacotherapy, variation in prescribing, and associated patient factors. Design: Retrospective cohort using electronic health records from 2010 to 2019. Participants: Primary care patients from 39 clinics in Ohio and Florida with diagnostic codes for alcohol dependence or abuse plus social history indicating alcohol use. PCPs in family or internal medicine with at least 20 AUD patients. Main Measures: Pharmacotherapy for AUD (naltrexone, acamprosate, and disulfiram), abstinence from alcohol, patient demographics, and comorbidities. Generalized linear mixed models were used to identify patient factors associated with prescriptions and the association of pharmacotherapy with abstinence. Key Results: We identified 13,250 patients; average age was 54 years, 66.9% were male, 75.0% were White, and median household income was $51,776 per year. Over 10 years, the prescription rate rose from 4.4 to 5.6%. Patients who were Black (aOR 0.74; 95% CI 0.58, 0.94) and insured by Medicare versus commercial insurance (aOR 0.61; 95% CI 0.48, 0.78) were less likely to be treated. Higher median household income ($10,000 increment, aOR 1.06; 95% CI 1.03, 1.10) and Medicaid versus commercial insurance (aOR 1.52; 95% CI 1.24, 1.87) were associated with treatment. Receiving pharmacotherapy was associated with subsequent documented abstinence from alcohol (aOR 1.60; 95% CI 1.33, 1.92). We identified 236 PCPs. The average prescription rate was 3.6% (range 0 to 24%). The top decile prescribed to 14.6% of their patients. The bottom 4 deciles had no prescriptions. Family physicians had higher rates of pharmacotherapy than internists (OR 1.50; 95% CI 1.21, 1.85). Conclusions: Medications for AUD are infrequently prescribed, but there is considerable variation among PCPs. Increasing the use of pharmacotherapy by non-prescribers may increase abstinence from alcohol. [ABSTRACT FROM AUTHOR]

To our knowledge, our study is the first to examine differences in APC and physician practice content. As the population ages amid growing shortages in primary care practitioners, expanding the supply of advanced practice clinicians (APC) - nurse practitioners and physician assistants - may offer a low-cost way to increase primary care access.[1] Given differences in training, states have traditionally limited APC scope of practice, with 22 states requiring full physician oversight. [Extracted from the article]

Background: Patient satisfaction measures have important implications for physicians. Patient bias against non-White physicians may impact physician satisfaction ratings, but this has not been widely studied. Objective: To assess differences in patient satisfaction by physician race/ethnicity. Design: A cross-sectional observational study. Participants: Patients seeking care on a large nationwide direct to consumer telemedicine platform between July 2016 and July 2018 and their physicians. Main Measures: Patient satisfaction was ascertained immediately following the encounter on scales of 1 to 5 stars and scored two ways: (1) top-box satisfaction (5 stars versus fewer) and (2) dissatisfaction (2 or fewer stars versus 3 or more). To approximate the information patients would use to make assumptions about physician race/ethnicity, four reviewers classified physicians into categories based on physician name and photo. These included White American, Black American, South Asian, Middle Eastern, Hispanic, and East Asian. Mixed effects logistic regression was used to assess differences in patient top-box satisfaction and patient dissatisfaction by physician race/ethnicity, controlling for patient characteristics, prescription receipt, physician specialty, and whether the physician trained in the USA versus internationally. Key Results: The sample included 119,016 encounters with 390 physicians. Sixty percent were White American, 14% South Asian, 7% Black American, 7% Hispanic, 6% Middle Eastern, and 6% East Asian. Encounters with South Asian physicians (aOR 0.70; 95% CI 0.54–0.91) and East Asian physicians (aOR 0.72; 95% CI 0.53–0.99) were significantly less likely than those with White American physicians to result in top-box satisfaction. Compared to encounters with White American physicians, those with Black American physicians (aOR 1.72; 95% CI 1.12–2.64), South Asian physicians (aOR 1.77; 95% CI 1.23–2.56), and East Asian physicians (aOR 2.10; 95% CI 1.38–3.20) were more likely to result in patient dissatisfaction. Conclusions: In our study, patients reported lower satisfaction with some groups of non-White American physicians, which may have implications for their compensation, professional reputation, and job satisfaction. [ABSTRACT FROM AUTHOR]

Background: The impact of physician-patient relationship factors, such as physician empathy and burnout, on antibiotic prescribing has not been characterised.Aim: To assess associations between physician empathy and burnout and antibiotic prescribing for acute respiratory infections (ARIs) in primary care.Design and Setting: Cross-sectional study of primary care practices in the Cleveland Clinic Health System in the US.Method: Patient and prescribing data were obtained from the medical record. All patients with primary diagnoses of ARIs from 1 January 2012 to 31 December 2013, except those with chronic obstructive pulmonary disease (COPD) or who were immunocompromised, were included. Physician empathy was measured using the Jefferson Scale of Empathy while physician burnout was measured using the Maslach Burnout Inventory. The relationship between empathy and burnout and antibiotic prescribing, adjusted for patient and provider characteristics, was analysed using multiple linear regression.Results: In 5937 ARI visits to 102 primary care physicians, the median proportion resulting in antibiotic prescribing was 48.6% (interquartile range [IQR] 24.1% to 70.0%). Neither physician empathy (correlation coefficient [β] 0.005, 95% confidence interval [CI] = -0.001 to 0.010, P = 0.07) nor any burnout measures were significantly associated with antibiotic prescribing: emotional exhaustion (β 0.001, 95% CI = -0.005 to 0.006, P = 0.79), tendency to depersonalise patients (β -0.009, 95% CI = -0.021 to 0.003, P = 0.13), and sense of personal accomplishment (β -0.004, 95% CI = -0.014 to 0.006, P = 0.44).Conclusion: The authors found no significant association between empathy or burnout measures and antibiotic prescribing for ARIs in primary care. Other physician characteristics should be investigated to explain individual variation in antibiotic prescribing. [ABSTRACT FROM AUTHOR]

Background: Adults who use wheelchairs have difficulty accessing physicians and receive less preventive care than their able-bodied counterparts. Objective: To learn about the accessibility of medical and surgical subspecialist practices for patients with mobility impairment. Design: A telephone survey was used to try to make an appoint-ment for a fictional patient who was obese and hemiparetic, used a wheelchair, and could not self-transfer from chair to examination table. Setting: 256 endocrinology, gynecology, orthopedic surgery, rheu-matology, urology, ophthalmology, otolaryngology, and psychiatry practices in 4 U.S. cities. Patients: None. Measurements: Accessibility of the practice, reasons for lack of accessibility, and planned method of transfer of the patient to an examination table. Results: Of 256 practices, 56 (22%) reported that they could not accommodate the patient, 9 (4%) reported that the building was inaccessible, 47 (18%) reported inability to transfer a patient from a wheelchair to an examination table, and 22 (9%) reported use of height-adjustable tables or a lift for transfer. Gynecology was the subspecialty with the highest rate of inaccessible practices (44%). Limitation: Small numbers of practices in 8 subspecialties in 4 cities and use of a fictional patient with obesity and hemiparesis limit generalizability. Conclusion: Many subspecialists could not accommodate a patient with mobility impairment because they could not transfer the pa-tient to an examination table. Better awareness among providers about the requirements of the Americans with Disabilities Act and the standards of care for patients in wheelchairs is needed. Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Background: Internet-based social networking tools that allow users to share content have enabled a new form of public reporting of physician performance: the physician-rating website.Objective: To describe the structure and content of physician-rating websites and to assess the extent to which a patient might find them valuable.Methods: We searched Google for websites that allowed patients to review physicians in the US. We included websites that met predetermined criteria, identified common elements of these websites, and recorded website characteristics. We then searched the websites for reviews of a random sample of 300 Boston physicians. Finally, we separately analyzed quantitative and narrative reviews.Results: We identified 33 physician-rating websites, which contained 190 reviews for 81 physicians. Most reviews were positive (88%). Six percent were negative, and six percent were neutral. Generalists and subspecialists did not significantly differ in number or nature of reviews. We identified several narrative reviews that appeared to be written by the physicians themselves.Conclusion: Physician-rating websites offer patients a novel way to provide feedback and obtain information about physician performance. Despite controversy surrounding these sites, their use by patients has been limited to date, and a majority of reviews appear to be positive. [ABSTRACT FROM AUTHOR]

Background: Chronic kidney disease (CKD) is a growing problem among the elderly. Early detection is considered essential to ensure proper treatment and to avoid drug toxicity, but detection is challenging because elderly patients with CKD often have normal serum creatinine levels. We hypothesized that most cases of CKD in the elderly would go undetected, resulting in inappropriate prescribing.Objective: To determine whether recognition of CKD is associated with more appropriate treatmentDesign: Retrospective chart reviewParticipants: All patients aged >/=65 years with a measured serum creatinine in the past 3 years at 2 inner city academic health centers.Measurements: Estimated glomerular filtration rate (eGFR) calculated using the Modified Diet in Renal Disease equation, and for patients with eGFR < 60, documentation of CKD by the provider, diagnostic testing, nephrology referral and prescription of appropriate or contraindicated medications.Results: Of 814 patients with sufficient information to estimate eGFR, 192 (33%) had moderate (eGFR < 60 mL/min) and 5% had severe (eGFR < 30 mL/min) CKD. Providers identified 38% of moderate and 87% of severe CKD. Compared to patients without recognized CKD, recognized patients were more likely to receive an ACE/ARB (80% vs 61%, p = .001), a nephrology referral (58% vs 2%, p < .0001), or urine testing (75% vs 47%, p < .0001), and less likely to receive contraindicated medications (26% vs 40%, p = .013).Conclusions: Physicians frequently fail to diagnose CKD in the elderly, leading to inappropriate treatment. Efforts should focus on helping physicians better identify patients with low GFR. [ABSTRACT FROM AUTHOR]

It's true we had a larger proportion of Internal versus Family Medicine physicians and a moderately different case mix of patients, but our finding of no association between empathy and diabetes outcomes was consistent in all multivariable and sensitivity analyses. Whether using their empathy cut points, analyzing scores continuously to maximize statistical power, or looking at subsets of patients with poorly controlled diabetes, we found no relationship between JSE and outcomes. Finally, the authors cite our "error in judgment" for acknowledging that the two studies that found correlations between empathy and diabetes outcomes were conducted by the same group. [Extracted from the article]

The author reflects on the Accreditation Council for Graduate Medical Education in the U.S. program which facilitates residents' doctors and physicians' participation in scholarly activities. He mentions that resident research will promote advancement in evidence based medicine, quality of patients care and develop critical thinking. Also investigated are several ways to avail research grants and appropriate time for conducting research by resident clinicians.

Objectives: Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes.Methods: This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic.Results: Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt.Conclusions: Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI. [ABSTRACT FROM AUTHOR]

Objectives: A physician's advice is among the strongest predictors of efforts toward weight management made by obese patients, yet only a minority receives such advice. One contributor could be the physician's failure to recognize true obesity. The objectives of this study were to assess physicians' ability to recognize obesity and to identify factors associated with recognition and documentation of obesity. Methods: Internal medicine residents and attending physicians at three academic urban primary care clinics and their adult patients participated in a study using recognition and documentation of patient obesity as the main measures. Results: A total of 52 physicians completed weight assessments for 400 patients. The mean patient age was 51 years, 56% were women, 77% were Hispanic, and 67% had one or more obesity-related comorbidity. There were 192 (48%) patients, of whom 66% were correctly identified by physicians as being obese, 86% of those with a body mass index (BMI) ≥35, but only 49% of those with a BMI of 30 to 34.9 (P < 0.0001). Fewer obese Hispanic patients were identified than were non-Hispanic patients (62% vs 76%; P = 0.03). No physician characteristics were significantly associated with recognition of obesity. Physicians documented obesity as a problem for 51% of patients. Attending physicians documented obesity more frequently than did residents (64% vs 43%, odds ratio 2.5, 95% confidence interval 1.3-4.6) and normal-weight physicians documented obesity more frequently than overweight physicians (58% vs 41%, odds ratio 2.0, 95% confidence interval 1.0-4.0). Documentation was more common for patients with a BMI ≥35 and for non-Hispanics. Documentation was not more common for patients with obesity-related comorbidities. Conclusions: Physicians have difficulty recognizing obesity unless patients' BMI is ≥35. Training physicians to recognize true obesity may increase rates of documentation, a first step toward treatment. [ABSTRACT FROM AUTHOR]

The article presents information on a retrospective study which determines the characteristics of patients associated with overtreatment and undertreatment of hyperlipidemia. It reports that according to Quality-of-care studies patients at high risk of coronary heart disease (CHD) are undertreated. It concludes that both overtreatment and undertreatment are common, and the decisions of physicians reflect the low density lipoprotein (LDL) value and the number of risk factors. INSET: Key Points.