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Nguyen MLT, Honcharov V, Ballard D, Satterwhite S, McDermott AM, Sarkar U. Primary Care Physicians' Experiences With and Adaptations to Time Constraints. JAMA Netw Open 2024; 7:e248827. [PMID: 38687477 PMCID: PMC11061766 DOI: 10.1001/jamanetworkopen.2024.8827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/29/2024] [Indexed: 05/02/2024] Open
Abstract
Importance The primary care workforce shortage is significant and persistent, with organizational and policy leaders urgently seeking interventions to enhance retention and recruitment. Time constraints are a valuable focus for action; however, designing effective interventions requires deeper understanding of how time constraints shape employees' experiences and outcomes of work. Objective To examine how time constraints affect primary care physicians' work experiences and careers. Design, Setting, and Participants Between May 1, 2021, and September 31, 2022, US-based primary care physicians who trained in family or internal medicine were interviewed. Using qualitative analysis of in-depth interviews, this study examined how participants experience and adapt to time constraints during a typical clinic day, taking account of their professional and personal responsibilities. It also incorporates physicians' reflections on implications for their careers. Main Outcomes and Measures Thematic analysis of in-depth interviews and a measure of well-being (American Medical Association Mini-Z survey). Results Interviews with 25 primary care physicians (14 [56%] female and 11 [44%] male; median [range] age, 43 [34-63] years) practicing in 11 US states were analyzed. Two physicians owned their own practice, whereas the rest worked as employees. The participants represented a wide range of years in practice (range, 1 to ≥21), with 11 participants (44%) in their first 5 years. Physicians described that the structure of their work hours did not match the work that was expected of them. This structural mismatch between time allocation and work expectations created a constant experience of time scarcity. Physicians described having to make tradeoffs between maintaining high-quality patient care and having their work overflow into their personal lives. These experiences led to feelings of guilt, disillusionment, and dissatisfaction. To attempt to sustain long-term careers in primary care, many sought ways to see fewer patients. Conclusions and Relevance These findings suggest that organizational leaders must align schedules with work expectations for primary care physicians to mitigate physicians' withdrawal from work as a coping mechanism. Specific strategies are needed to achieve this realignment, including incorporating more slack into schedules and establishing realistic work expectations for physicians.
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Affiliation(s)
| | - Vlad Honcharov
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Dawna Ballard
- Department of Communication Studies, University of Texas at Austin, Austin
| | - Shannon Satterwhite
- Department of Family and Community Medicine, UC Davis Health, Sacramento, California
| | - Aoife M. McDermott
- School of Public Health, University of California, Berkeley
- Aston Business School, Aston University, Birmingham, UK
| | - Urmimala Sarkar
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
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Ginestra JC, Kohn R, Hubbard RA, Auriemma CL, Patel MS, Anesi GL, Kerlin MP, Weissman GE. Association of Time of Day with Delays in Antimicrobial Initiation among Ward Patients with Hospital-Onset Sepsis. Ann Am Thorac Soc 2023; 20:1299-1308. [PMID: 37166187 PMCID: PMC10502885 DOI: 10.1513/annalsats.202302-160oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/09/2023] [Indexed: 05/12/2023] Open
Abstract
Rationale: Although the mainstay of sepsis treatment is timely initiation of broad-spectrum antimicrobials, treatment delays are common, especially among patients who develop hospital-onset sepsis. The time of day has been associated with suboptimal clinical care in several contexts, but its association with treatment initiation among patients with hospital-onset sepsis is unknown. Objectives: Assess the association of time of day with antimicrobial initiation among ward patients with hospital-onset sepsis. Methods: This retrospective cohort study included ward patients who developed hospital-onset sepsis while admitted to five acute care hospitals in a single health system from July 2017 through December 2019. Hospital-onset sepsis was defined by the Centers for Disease Control and Prevention Adult Sepsis Event criteria. We estimated the association between the hour of day and antimicrobial initiation among patients with hospital-onset sepsis using a discrete-time time-to-event model, accounting for time elapsed from sepsis onset. In a secondary analysis, we fit a quantile regression model to estimate the association between the hour of day of sepsis onset and time to antimicrobial initiation. Results: Among 1,672 patients with hospital-onset sepsis, the probability of antimicrobial initiation at any given hour varied nearly fivefold throughout the day, ranging from 3.0% (95% confidence interval [CI], 1.8-4.1%) at 7 a.m. to 13.9% (95% CI, 11.3-16.5%) at 6 p.m., with nadirs at 7 a.m. and 7 p.m. and progressive decline throughout the night shift (13.4% [95% CI, 10.7-16.0%] at 9 p.m. to 3.2% [95% CI, 2.0-4.0] at 6 a.m.). The standardized predicted median time to antimicrobial initiation was 3.2 hours (interquartile range [IQR], 2.5-3.8 h) for sepsis onset during the day shift (7 a.m.-7 p.m.) and 12.9 hours (IQR, 10.9-14.9 h) during the night shift (7 p.m.-7 a.m.). Conclusions: The probability of antimicrobial initiation among patients with new hospital-onset sepsis declined at shift changes and overnight. Time to antimicrobial initiation for patients with sepsis onset overnight was four times longer than for patients with onset during the day. These findings indicate that time of day is associated with important care processes for ward patients with hospital-onset sepsis. Future work should validate these findings in other settings and elucidate underlying mechanisms to inform quality-enhancing interventions.
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Affiliation(s)
- Jennifer C. Ginestra
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | - Rachel Kohn
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Catherine L. Auriemma
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | | | - George L. Anesi
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | - Meeta Prasad Kerlin
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
| | - Gary E. Weissman
- Division of Pulmonary, Allergy and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, and
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; and
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Croskerry P, Campbell SG, Petrie DA. The challenge of cognitive science for medical diagnosis. Cogn Res Princ Implic 2023; 8:13. [PMID: 36759370 PMCID: PMC9911579 DOI: 10.1186/s41235-022-00460-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/23/2022] [Indexed: 02/11/2023] Open
Abstract
The historical tendency to view medicine as both an art and a science may have contributed to a disinclination among clinicians towards cognitive science. In particular, this has had an impact on the approach towards the diagnostic process which is a barometer of clinical decision-making behaviour and is increasingly seen as a yardstick of clinician calibration and performance. The process itself is more complicated and complex than was previously imagined, with multiple variables that are difficult to predict, are interactive, and show nonlinearity. They appear to characterise a complex adaptive system. Many aspects of the diagnostic process, including the psychophysics of signal detection and discrimination, ergonomics, probability theory, decision analysis, factor analysis, causal analysis and more recent developments in judgement and decision-making (JDM), especially including the domain of heuristics and cognitive and affective biases, appear fundamental to a good understanding of it. A preliminary analysis of factors such as manifestness of illness and others that may impede clinicians' awareness and understanding of these issues is proposed here. It seems essential that medical trainees be explicitly and systematically exposed to specific areas of cognitive science during the undergraduate curriculum, and learn to incorporate them into clinical reasoning and decision-making. Importantly, this understanding is needed for the development of cognitive bias mitigation and improved calibration of JDM in clinical practice.
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Affiliation(s)
- Pat Croskerry
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada.
| | - Samuel G. Campbell
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - David A. Petrie
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
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Kolla L, Chen J, Parikh RB. Time of Clinic Appointment and Serious Illness Communication in Oncology. Cancer Control 2023; 30:10732748231170488. [PMID: 37071969 PMCID: PMC10126780 DOI: 10.1177/10732748231170488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
INTRODUCTION Serious illness communication in oncology increases goal concordant care. Factors associated with the frequency of serious illness conversations are not well understood. Given prior evidence of the association between suboptimal decision-making and clinic time, we aimed to investigate the relationship between appointment time and the likelihood of serious illness conversations in oncology. METHODS We conducted a retrospective study of electronic health record data from 55 367 patient encounters between June 2019 to April 2020, using generalized estimating equations to model the likelihood of a serious illness conversation across clinic time. RESULTS Documentation rate decreased from 2.1 to 1.5% in the morning clinic session (8am-12pm) and from 1.2% to .9% in the afternoon clinic session (1pm-4pm). Adjusted odds ratios for Serious illness conversations documentation rates were significantly lower for all hours of each session after the earliest hour (adjusted odds ratios .91 [95% CI, .84-.97], P = .006 for overall linear trend). CONCLUSIONS Serious illness conversations between oncologists and patients decrease considerably through the clinic day, and proactive strategies to avoid missed conversations should be investigated.
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Affiliation(s)
- Likhitha Kolla
- Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jinbo Chen
- Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ravi B Parikh
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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Nguyen MLT, Schotland SV, Howell JD. From Individualized Interactions to Standardized Schedules: A History of Time Organization in U.S. Outpatient Medicine. Ann Intern Med 2022; 175:1468-1474. [PMID: 36037467 DOI: 10.7326/m22-1575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Many outpatient physicians and patients feel that current scheduling systems do not afford enough time for direct patient-physician interaction, leaving patients feeling unheard and physicians feeling demoralized. This dissatisfaction degrades patients' trust in the health care system and contributes to workforce moral injury and burnout. In the hopes of understanding the roots of this time stress and helping to guide future decisions about how to organize physicians' time, this article describes changes in the organization of U.S. outpatient physicians' time, starting from care at home in the late 19th century. It discusses the origins of the appointment system, which was invented to be highly personalized, with assistants adjusting appointment durations to accommodate clinical activities, specific patient needs, and individual physician proclivities. The article then describes how centralization of appointment scheduling became more common as U.S. medicine became increasingly consolidated into larger and larger groups and health systems. This distanced schedulers from the people and care they were organizing and necessitated standardized appointment durations, which did not accommodate individual patient and physician needs. With the rise of managerialism, schedulers became increasingly accountable to administrators rather than patients and physicians. Whereas early appointment systems depended on personal connection between schedulers and the physicians and patients they supported, today's schedulers have few such interactions. The widespread shift to centralized scheduling and standardized time slots has contributed to misalignment among time allocation, patient care, and health care workforce well-being and is likely exacerbating ongoing tensions among patients, physicians, and administrators.
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Affiliation(s)
- Michelle-Linh T Nguyen
- National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies, and Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, California (M.T.N.)
| | - Samuel V Schotland
- School of Medicine, University of Michigan, Ann Arbor, Michigan, and Program in the History of Science and Medicine, Yale University, New Haven, Connecticut (S.V.S.)
| | - Joel D Howell
- Department of Internal Medicine, Department of History, and Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan (J.D.H.)
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Graf A, Koh CH, Caldwell G, Grieve J, Tan M, Hassan J, Bakaya K, Marcus HJ, Baldeweg SE. Quality in Clinical Consultations: A Cross-Sectional Study. Clin Pract 2022; 12:545-556. [PMID: 35892444 PMCID: PMC9326638 DOI: 10.3390/clinpract12040058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/23/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
The coronavirus disease 2019 pandemic may have affected the quality of clinical consultations. The objective was to use 10 proposed quality indicator questions to assess outpatient consultation quality; to assess whether the recent shift to telemedicine during the pandemic has affected consultation quality; and to determine whether consultation quality is associated with satisfaction and consultation outcome. A cross-sectional study was used to survey clinicians and patients after outpatient consultations (1 February to 31 March 2021). The consultation quality score (CQS) was the sum of ‘yes’ responses to the survey questions. In total, 78% (538/690) of consultations conducted were assessed by a patient, clinician, or both. Patient survey response rate was 60% (415/690) and clinician 42% (291/690). Face-to-face consultations had a greater CQS than telephone (patients and clinicians < 0.001). A greater CQS was associated with higher overall satisfaction (clinicians log-odds: 0.77 ± 0.52, p = 0.004; patients log-odds: 1.35 ± 0.57, p < 0.001) and with definitive consultation outcomes (clinician log-odds: 0.44 ± 0.36, p = 0.03). In conclusion, consultation quality is assessable; the shift to telemedicine has negatively impacted consultation quality; and high-quality consultations are associated with greater satisfaction and definitive consultation outcome decisions.
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Affiliation(s)
- Anneke Graf
- Department of Endocrinology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (A.G.); (M.T.); (J.H.); (K.B.)
| | - Chan Hee Koh
- Department of Neurosurgery, University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK; (C.H.K.); (J.G.); (H.J.M.)
| | | | - Joan Grieve
- Department of Neurosurgery, University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK; (C.H.K.); (J.G.); (H.J.M.)
| | - Melissa Tan
- Department of Endocrinology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (A.G.); (M.T.); (J.H.); (K.B.)
| | - Jasmine Hassan
- Department of Endocrinology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (A.G.); (M.T.); (J.H.); (K.B.)
| | - Kaushiki Bakaya
- Department of Endocrinology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (A.G.); (M.T.); (J.H.); (K.B.)
| | - Hani J. Marcus
- Department of Neurosurgery, University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK; (C.H.K.); (J.G.); (H.J.M.)
| | - Stephanie E. Baldeweg
- Department of Endocrinology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (A.G.); (M.T.); (J.H.); (K.B.)
- Centre for Obesity & Metabolism, Department of Experimental & Translational Medicine, Division of Medicine, University College London, London WC1E 6BT, UK
- Correspondence: ; Tel.: +44-7966770637
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Wang AZ, Barnett ML, Cohen JL. Changes in Cancer Screening Rates Following a New Cancer Diagnosis in a Primary Care Patient Panel. JAMA Netw Open 2022; 5:e2222131. [PMID: 35838669 PMCID: PMC9287757 DOI: 10.1001/jamanetworkopen.2022.22131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Although screenings for breast and colorectal cancer are widely recommended, patient screening rates vary greatly and remain below public health targets, and primary care physicians' (PCPs') counseling and referrals play critical roles in patients' use of cancer screenings. Recent adverse events may influence PCPs' decision-making, but it remains unknown whether cancer screening rates of PCPs' patients change after PCPs are exposed to new cancer diagnoses. OBJECTIVE To investigate whether PCPs' exposures to patients with new diagnoses of breast or colorectal cancer were associated with changes in screening rates for other patients subsequently visiting the affected PCPs. DESIGN, SETTING, AND PARTICIPANTS This cohort study used stacked difference-in-differences analyses of all-payer claims data for New Hampshire and Maine in 2009 to 2015. Participants were PCPs caring for patients. Data analysis was performed from June 2020 to May 2022. EXPOSURES New diagnosis of a PCP's patient with breast cancer or colorectal cancer. MAIN OUTCOMES AND MEASURES Patients' breast and colorectal cancer screening rates within 1 year of a PCP visit. RESULTS The sample included 3158 PCPs (1819 male PCPs [57.6%]) caring for 1 920 189 patients (1 073 408 female patients [55.9%]; mean [SD] age, 41.0 [21.9] years) aged 18 to 64 years. During the study period, 898 PCPs had a patient with a new diagnosis of breast cancer and 370 PCPs had a patient with a new diagnosis of colorectal cancer. In the preexposure period, 68 837 female patients (37.3% of those visiting a PCP) underwent breast cancer screening within 1 year of the visit, and 13 137 patients (10.1% of those visiting a PCP) underwent colorectal cancer screening within 1 year of the visit. For both cancer types, after exposure to a new cancer diagnosis, PCPs' cancer screening rates displayed a rapid, sustained increase. Breast cancer screening rates increased by 4.5 percentage points (95% CI, 3.0-6.1 percentage points; P < .001). Colorectal cancer screening rates increased by 1.3 percentage points (95% CI, 0.3-2.2 percentage points; P = .01). Observed breast cancer screening increases were higher for male PCPs than for female PCPs (3.1 percentage points; 95% CI, 0.4-5.8 percentage points; P = .03). CONCLUSIONS AND RELEVANCE This study found significant, sustained increases in cancer screening rates for patients visiting PCPs recently exposed to new breast and colorectal cancer diagnoses. These findings suggest that PCPs may update practice patterns on the basis of recent patient diagnoses. Future work should assess whether salient cues to PCPs about patient diagnoses when clinically appropriate can improve screening practices.
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Affiliation(s)
- Annabel Z. Wang
- Harvard Medical School, Harvard University, Cambridge, Massachusetts
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Pignatiello GA, Tsivitse E, O’Brien J, Kraus N, Hickman RL. Decision fatigue among clinical nurses during the COVID-19 pandemic. J Clin Nurs 2022; 31:869-877. [PMID: 34291521 PMCID: PMC8447365 DOI: 10.1111/jocn.15939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/05/2021] [Accepted: 05/11/2021] [Indexed: 01/15/2023]
Abstract
AIMS AND OBJECTIVES The purpose of this study was to report the psychometric properties, including validity and reliability, of the decision fatigue scale (DFS). BACKGROUND Decision fatigue may impair nurses' ability to make sound clinical decisions and negatively impact patient care. Given the negative impact of the COVID-19 pandemic on psychological well-being and the workplace environment, decision fatigue may be even more apparent among clinical nurses. Valid assessment of this condition among clinical nurses may inform supportive interventions to mitigate the negative sequelae associated with states of decision fatigue. DESIGN This study was a secondary analysis of a parent study using a cross-sectional descriptive design. METHODS A convenience sample of 160 staff nurses was recruited online from across the United States. Participants completed a demographic questionnaire and subjective measures of decision fatigue, nursing practice environment scale and traumatic stress. Exploratory factor analysis (EFA), correlation coefficients and internal consistency reliability coefficients were computed to examine the DFS's validity and reliability within this sample. RESULTS The EFA yielded a single factor, 9-item version of the DFS. The DFS scores were strongly correlated with traumatic stress and moderately correlated with the nursing practice environment, and the scale displayed appropriate internal consistency. CONCLUSIONS This is the first known study to provide evidence of the DFS's validity and reliability in a sample of registered nurses working during the COVID-19 pandemic. The results of this study provide evidence of a reliable and valid assessment instrument for decision fatigue that can be used to measure the burden of decision-making among registered nurses. RELEVANCE TO CLINICAL PRACTICE Given the relationship between traumatic stress and the nursing work environment, decision fatigue may be a modifiable target for interventions that can enhance the quality of decision-making among clinical nurses.
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Affiliation(s)
- Grant A. Pignatiello
- Frances Payne Bolton School of NursingCase Western Reserve UniversityClevelandOHUSA
| | - Emily Tsivitse
- Frances Payne Bolton School of NursingCase Western Reserve UniversityClevelandOHUSA
| | - Julia O’Brien
- Frances Payne Bolton School of NursingCase Western Reserve UniversityClevelandOHUSA
| | - Noa Kraus
- Frances Payne Bolton School of NursingCase Western Reserve UniversityClevelandOHUSA
| | - Ronald L. Hickman
- Frances Payne Bolton School of NursingCase Western Reserve UniversityClevelandOHUSA
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Sayon-Orea C, Carlos S, Rico-Campà A, Fernández-Montero A, de la Fuente-Arrillaga C, Toledo E, Kales S, Martínez-González MA. Physicians' characteristics and practices associated with the provision of cancer screening advice to their patients: the Spanish SUN cohort study. BMJ Open 2022; 12:e048498. [PMID: 35022167 PMCID: PMC8756273 DOI: 10.1136/bmjopen-2020-048498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate the association between cancer screening counselling provided by medical doctors to their patients and each doctor's own anthropometrics, lifestyle, cancer screening practices, and personal and family history of cancer. DESIGN Prospective cohort study. SETTING Substudy including physicians participating in a Spanish cohort study with open enrolment. PARTICIPANTS Among 22 800 participants in the cohort as of May 2018, there were 2371 physicians who had replied to the cohort baseline questionnaire, had an email account and were younger than 65 years (retirement age in Spain). From this subsample, 890 replied to an online questionnaire focused on their clinical practices related to the counselling provided to their patients and to their prescription practices of preventive medications. Their mean age was 51.7 (SD 9.4) years and 48% were women. OUTCOME MEASURES Frequency of counselling given to their patients on specific practices of breast, colorectal and prostate cancer screenings. RESULTS Counselling on cancer screening to their patients was provided by 65% of physicians in a scenario of colorectal cancer, 59% for prostate cancer and 58% for breast cancer. More frequent cancer screening counselling was associated with the specialties of family medicine (OR=9.4, 95% CI 5.1 to 17.1) and internal medicine (OR=2.9, 95% CI 1.5 to 5.7) as compared with other specialties. Recommending cancer screening was associated with more frequent counselling on smoking cessation (OR=3.7, 95% CI 2.6 to 5.4), having personally attended colorectal cancer screening (OR=2.2, 95% CI 1.1 to 4.7) and prescribing blood pressure medication more often than their colleagues (OR=2.1, 95% CI 1.2 to 3.7). CONCLUSIONS Among medical doctors, cancer screening counselling was provided to their patients more frequently for doctors with family medicine or internal medicine specialties and for physicians who regularly offered counselling on certain lifestyle behaviours, and those having personally attended colorectal cancer screening. Doctors' own personal practices and knowledge of healthy lifestyles may help doctors to more frequently provide counselling on cancer screening to their patients.
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Affiliation(s)
- Carmen Sayon-Orea
- Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra, IdiSNA, Pamplona, Spain
| | - Silvia Carlos
- Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra, IdiSNA, Pamplona, Spain
| | - Anaïs Rico-Campà
- Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
| | - Alejandro Fernández-Montero
- Instituto de Investigación Sanitaria de Navarra, IdiSNA, Pamplona, Spain
- Occupational Medicine, University of Navarra, Pamplona, Navarra, Spain
| | - Carmen de la Fuente-Arrillaga
- Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra, IdiSNA, Pamplona, Spain
| | - Estefanía Toledo
- Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra, IdiSNA, Pamplona, Spain
| | - Stefanos Kales
- Environmental Health, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Miguel Angel Martínez-González
- Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra, IdiSNA, Pamplona, Spain
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Park J, Zhong X, Dong Y, Barwise A, Pickering BW. Investigating the cognitive capacity constraints of an ICU care team using a systems engineering approach. BMC Anesthesiol 2022; 22:10. [PMID: 34983402 PMCID: PMC8724599 DOI: 10.1186/s12871-021-01548-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022] Open
Abstract
Background ICU operational conditions may contribute to cognitive overload and negatively impact on clinical decision making. We aimed to develop a quantitative model to investigate the association between the operational conditions and the quantity of medication orders as a measurable indicator of the multidisciplinary care team’s cognitive capacity. Methods The temporal data of patients at one medical ICU (MICU) of Mayo Clinic in Rochester, MN between February 2016 to March 2018 was used. This dataset includes a total of 4822 unique patients admitted to the MICU and a total of 6240 MICU admissions. Guided by the Systems Engineering Initiative for Patient Safety model, quantifiable measures attainable from electronic medical records were identified and a conceptual framework of distributed cognition in ICU was developed. Univariate piecewise Poisson regression models were built to investigate the relationship between system-level workload indicators, including patient census and patient characteristics (severity of illness, new admission, and mortality risk) and the quantity of medication orders, as the output of the care team’s decision making. Results Comparing the coefficients of different line segments obtained from the regression models using a generalized F-test, we identified that, when the ICU was more than 50% occupied (patient census > 18), the number of medication orders per patient per hour was significantly reduced (average = 0.74; standard deviation (SD) = 0.56 vs. average = 0.65; SD = 0.48; p < 0.001). The reduction was more pronounced (average = 0.81; SD = 0.59 vs. average = 0.63; SD = 0.47; p < 0.001), and the breakpoint shifted to a lower patient census (16 patients) when at a higher presence of severely-ill patients requiring invasive mechanical ventilation during their stay, which might be encountered in an ICU treating patients with COVID-19. Conclusions Our model suggests that ICU operational factors, such as admission rates and patient severity of illness may impact the critical care team’s cognitive function and result in changes in the production of medication orders. The results of this analysis heighten the importance of increasing situational awareness of the care team to detect and react to changing circumstances in the ICU that may contribute to cognitive overload. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01548-7.
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Affiliation(s)
- Jaeyoung Park
- Department of Industrial and Systems Engineering, University of Florida, 482 Weil Hall, P.O. Box 116595, Gainesville, FL, 32611-6595, USA
| | - Xiang Zhong
- Department of Industrial and Systems Engineering, University of Florida, 482 Weil Hall, P.O. Box 116595, Gainesville, FL, 32611-6595, USA.
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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11
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Barash M, Nanchal RS. Enhancing Analytical Reasoning in the Intensive Care Unit. Crit Care Clin 2021; 38:51-67. [PMID: 34794631 DOI: 10.1016/j.ccc.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clinical reasoning is prone to errors in judgment. Error is comprised of 2 components-bias and noise; each has an equally important role in the promulgation of error. Biases or systematic errors in reasoning are the product of misconceptions of probability and statistics. Biases arise because clinicians frequently rely on mental shortcuts or heuristics to make judgments. The most frequently used heuristics are representativeness, availability, and anchoring/adjustment which lead to the common biases of base rate neglect, misconceptions of regression, insensitivities to sample size, and fallacies of conjunctive, and disjunctive events. Bayesian reasoning is the framework within which posterior probabilities of events is identified. Familiarity with these mathematical concepts will likely enhance clinical reasoning. Noise is defined as inter or intraobserver variability in judgment that should be identical. Guidelines in medicine are a technique to reduce noise.
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Affiliation(s)
- Mark Barash
- Division of Pulmonary and Critical Care Medicine, Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, 8th Floor, Milwaukee, WI 53226, USA
| | - Rahul S Nanchal
- Division of Pulmonary and Critical Care Medicine, Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, 8th Floor, Milwaukee, WI 53226, USA.
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12
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Trinh P, Hoover DR, Sonnenberg FA. Time-of-day changes in physician clinical decision making: A retrospective study. PLoS One 2021; 16:e0257500. [PMID: 34534247 PMCID: PMC8448311 DOI: 10.1371/journal.pone.0257500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/02/2021] [Indexed: 11/18/2022] Open
Abstract
Background Time of day has been associated with variations in certain clinical practices such as cancer screening rates. In this study, we assessed how more general process measures of physician activity, particularly rates of diagnostic test ordering and diagnostic assessments, might be affected by time of day. Methods We conducted a retrospective chart review of 3,342 appointments by 20 attending physicians at five outpatient clinics, matching appointments by physician and comparing the average diagnostic tests ordered and average diagnoses assessed per appointment in the first hour of the day versus the last hour of the day. Statistical analyses used sign tests, two-sample t-tests, Wilcoxon tests, Kruskal Wallis tests, and multivariate linear regression. Results Examining physicians individually, four and six physicians, respectively, had statistically significant first- versus last-hour differences in the number of diagnostic tests ordered and number of diagnoses assessed per patient visit (p ≤ 0.04). As a group, 16 of 20 physicians ordered more tests on average in the first versus last hour (p = 0.012 for equal chance to order more in each time period). Substantial intra-clinic heterogeneity was found in both outcomes for four of five clinics (p < 0.01). Conclusions There is some statistical evidence on an individual and group level to support the presence of time-of-day effects on the number of diagnostic tests ordered per patient visit. These findings suggest that time of day may be a factor influencing fundamental physician behavior and processes. Notably, many physicians exhibited significant variation in the primary outcomes compared to same-specialty peers. Additional work is necessary to clarify temporal and inter-physician variation in the outcomes of interest.
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Affiliation(s)
- Peter Trinh
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ, United States of America
| | - Donald R Hoover
- Department of Statistics and Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, United States of America
| | - Frank A Sonnenberg
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States of America
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Storholm ED, Siconolfi D, Huang W, Towner W, Grant DL, Martos A, Chang JM, Hechter R. Project SLIP: Implementation of a PrEP Screening and Linkage Intervention in Primary Care. AIDS Behav 2021; 25:2348-2357. [PMID: 33624193 PMCID: PMC8556139 DOI: 10.1007/s10461-021-03197-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 01/16/2023]
Abstract
Nearly a decade after becoming formally available in the U.S., HIV pre-exposure prophylaxis (PrEP) remains underutilized by populations at risk for HIV acquisition. The next generation of PrEP research is pivoting toward implementation research in order to identify the most impactful avenues for scaling up PrEP uptake. Rapid identification of patients who may be at risk for HIV in primary care settings and the ability to provide brief consultation and prescription or referral for PrEP could help to increase PrEP uptake. The current study aimed to develop and pilot-test a PrEP screening instrument that could be integrated into the workflow of busy primary care clinics to help facilitate PrEP uptake among at-risk men. During the study, PrEP screening occurred for 12 months in two primary care clinics nested within a large integrated healthcare delivery system in Southern California. An interrupted time series analysis found a significant increase in PrEP referrals overall during the screening intervention period as compared to the preceding 12 months. Findings suggest that brief HIV risk screening in primary care is acceptable, feasible, and shows preliminary effects in increasing PrEP referral rates for Black and Hispanic/Latinx men.
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Affiliation(s)
- Erik D Storholm
- School of Public Health, San Diego State University, San Diego, CA, USA.
- RAND Corporation, Santa Monica, CA, USA.
- Center for HIV Identification, Prevention, and Treatment Services, University of California, Los Angeles, CA, USA.
| | | | | | - William Towner
- Research and Evaluation, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Deborah Ling Grant
- Research and Evaluation, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Alexander Martos
- Southern California Permanente Medical Group, Los Angeles Medical Center Department of Consulting Services, Los Angeles, CA, USA
| | - John M Chang
- Research and Evaluation, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Rulin Hechter
- Research and Evaluation, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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14
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Hunt TC, Ambrose JP, Haaland B, Kawamoto K, Dechet CB, Lowrance WT, Hanson HA, O'Neil BB. Decision fatigue in low-value prostate cancer screening. Cancer 2021; 127:3343-3353. [PMID: 34043813 DOI: 10.1002/cncr.33644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/22/2021] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Low-value prostate-specific antigen (PSA) testing is common yet contributes substantial waste and downstream patient harm. Decision fatigue may represent an actionable target to reduce low-value urologic care. The objective of this study was to determine whether low-value PSA testing patterns by outpatient clinicians are consistent with decision fatigue. METHODS Outpatient appointments for adult men without prostate cancer were identified at a large academic health system from 2011 through 2018. The authors assessed the association of appointment time with the likelihood of PSA testing, stratified by patient age and appropriateness of testing based on clinical guidelines. Appointments included those scheduled between 8:00 am and 4:59 pm, with noon omitted. Urologists were examined separately from other clinicians. RESULTS In 1,581,826 outpatient appointments identified, the median patient age was 54 years (interquartile range, 37-66 years), 1,256,152 participants (79.4%) were White, and 133,693 (8.5%) had family history of prostate cancer. PSA testing would have been appropriate in 36.8% of appointments. Clinicians ordered testing in 3.6% of appropriate appointments and in 1.8% of low-value appointments. Appropriate testing was most likely at 8:00 am (reference group). PSA testing declined through 11:00 am (odds ratio [OR], 0.57; 95% CI, 0.50-0.64) and remained depressed through 4:00 pm (P < .001). Low-value testing was overall less likely (P < .001) and followed a similar trend, declining steadily from 8:00 am (OR, 0.48; 95% CI, 0.42-0.56) through 4:00 pm (P < .001; OR, 0.23; 95% CI, 0.18-0.30). Testing patterns in urologists were noticeably different. CONCLUSIONS Among most clinicians, outpatient PSA testing behaviors appear to be consistent with decision fatigue. These findings establish decision fatigue as a promising, actionable target for reducing wasteful and low-value practices in routine urologic care. LAY SUMMARY Decision fatigue causes poorer choices to be made with repetitive decision making. This study used medical records to investigate whether decision fatigue influenced clinicians' likelihood of ordering a low-value screening test (prostate-specific antigen [PSA]) for prostate cancer. In more than 1.5 million outpatient appointments by adult men without prostate cancer, the chances of both appropriate and low-value PSA testing declined as the clinic day progressed, with a larger decline for appropriate testing. Testing patterns in urologists were different from those reported by other clinicians. The authors conclude that outpatient PSA testing behaviors appear to be consistent with decision fatigue among most clinicians, and interventions may reduce wasteful testing and downstream patient harms.
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Affiliation(s)
- Trevor C Hunt
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jacob P Ambrose
- Population Sciences, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Benjamin Haaland
- Division of Biostatistics, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Christopher B Dechet
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - William T Lowrance
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Heidi A Hanson
- Population Sciences, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Brock B O'Neil
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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15
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Hare AJ, Adusumalli S, Park S, Patel MS. Assessment of Primary Care Appointment Times and Appropriate Prescribing of Statins for At-Risk Patients. JAMA Netw Open 2021; 4:e219050. [PMID: 33974057 PMCID: PMC8114131 DOI: 10.1001/jamanetworkopen.2021.9050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This cohort study examines whether there is an association between primary care appointment times and statin prescribing rates for patients with elevated risk of major adverse cardiovascular events.
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Affiliation(s)
- Allison J. Hare
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Srinath Adusumalli
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Saehwan Park
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
| | - Mitesh S. Patel
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Wharton School, University of Pennsylvania, Philadelphia
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16
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Oakes AH, Patel MS. Time to address disparities in care by appointment time. Healthcare (Basel) 2021; 9:100507. [DOI: 10.1016/j.hjdsi.2020.100507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/24/2020] [Accepted: 12/05/2020] [Indexed: 11/29/2022] Open
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Yager J. Sleepy Psychotherapists: How Clinicians' Biological Factors May Affect the Conduct of Psychotherapy. Am J Psychother 2021; 74:30-35. [PMID: 33715396 DOI: 10.1176/appi.psychotherapy.20200030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Numerous therapist variables and cognitive biases can affect the quality of the therapeutic alliance and the conduct and outcomes of psychotherapy. This article aims to examine factors that potentially affect clinician performance, including chronobiological variables of clinicians and patients. METHODS The author reviewed literature pertaining to biological influences on human cognitive performance and considered how these factors may apply to the practice of psychotherapy. RESULTS Biological factors potentially affecting the conduct and quality of psychotherapy were identified. These factors include decision fatigue, hunger, sleep deficit, shift work, and several chronobiological issues related to circadian rhythms and episodic ultradian rhythms. In addition, misaligned scheduling of psychotherapy sessions in relation to therapist and patient evening-morning chronotypes may impede the effectiveness of psychotherapy. CONCLUSIONS The practice of psychotherapy is cognitively demanding, requiring that clinicians remain constantly alert and in command of their executive functions. Decreases in clinician alertness resulting from homeostatic depletion, chronobiologically misaligned schedules, and illness-associated factors may reduce the quality and benefit of psychotherapy sessions. Mitigation strategies are available. Investigations of these factors are needed.
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Affiliation(s)
- Joel Yager
- Department of Psychiatry, University of Colorado School of Medicine, Aurora
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18
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Abstract
OBJECTIVE To determine whether patient mortality after surgery differs between surgeries performed on surgeons' birthdays compared with other days of the year. DESIGN Retrospective observational study. SETTING US acute care and critical access hospitals. PARTICIPANTS 100% fee-for-service Medicare beneficiaries aged 65 to 99 years who underwent one of 17 common emergency surgical procedures in 2011-14. MAIN OUTCOME MEASURES Patient postoperative 30 day mortality, defined as death within 30 days after surgery, with adjustment for patient characteristics and surgeon fixed effects. RESULTS 980 876 procedures performed by 47 489 surgeons were analyzed. 2064 (0.2%) of the procedures were performed on surgeons' birthdays. Patient characteristics, including severity of illness, were similar between patients who underwent surgery on a surgeon's birthday and those who underwent surgery on other days. The overall unadjusted 30 day mortality on the operating surgeon's birthday was 7.0% (145/2064) and that on other days was 5.6% (54 824/978 812). After adjusting for patient characteristics and surgeon fixed effects (effectively comparing outcomes of patients treated by the same surgeon on different days), patients who underwent surgery on a surgeon's birthday exhibited higher mortality compared with patients who underwent surgery on other days (adjusted mortality rate, 6.9% v 5.6%; adjusted difference 1.3%, 95% confidence interval 0.1% to 2.5%; P=0.03). Event study analysis of patient mortality by day of surgery relative to a surgeon's birthday found similar results. CONCLUSIONS Among Medicare beneficiaries who underwent common emergency surgeries, those who received surgery on the surgeon's birthday experienced higher mortality compared with patients who underwent surgery on other days. These findings suggest that surgeons might be distracted by life events that are not directly related to work.
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Affiliation(s)
- Hirotaka Kato
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 1100 Glendon Avenue Suite 850, Los Angeles, CA, 90024, USA
- Graduate School of Business Administration, Keio University, Yokohama, Japan
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- USC Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 1100 Glendon Avenue Suite 850, Los Angeles, CA, 90024, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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19
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Vail D, Pan C, Pershing S, Mruthyunjaya P. Association of Rhegmatogenous Retinal Detachment and Outcomes With the Day of the Week That Patients Undergo a Repair or Receive a Diagnosis. JAMA Ophthalmol 2020; 138:156-163. [PMID: 31855233 DOI: 10.1001/jamaophthalmol.2019.5253] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Importance Because variation in care on weekends has been reported in many surgical fields, it is of interest if variations were noted for care patterns of rhegmatogenous retinal detachments (RRDs). Objective To assess the association between modality of RRD repair and day of the week that patients receive a diagnosis or undergo RRD repair. Design, Setting, and Participants A retrospective claims-based cohort analysis was performed of primary RRD surgery for 38 144 commercially insured patients in the United States who received a diagnosis of incident RRD between January 1, 2008, and December 31, 2016, and underwent repair within 14 days of diagnosis. Multinomial regression models were used to assess patients' likelihood of repair with different modalities, logistic regression models were used to assess patients' likelihood of reoperation, and linear regression models were used to assess time from diagnosis to repair. Data analysis was performed from March 9 to September 5, 2019. Exposures Day of the week that the patient received a diagnosis of RRD or underwent RRD repair. Main Outcome and Measures Modality of repair, time from diagnosis to repair, and 30-day reoperation rate. Results Among the 38 144 patients in the study (23 031 men [60.4%]; mean [SD] age at diagnosis, 56.8 [13.4] years), pneumatic retinopexy (PR) was more likely to occur when patients received a diagnosis of RRD on Friday (relative risk ratio [RRR], 1.37; 95% CI, 1.17-1.60), Saturday (RRR, 1.73; 95% CI, 1.36-2.20), or Sunday (RRR, 1.53; 95% CI, 1.08-2.17) compared with Wednesday. Pneumatic retinopexy was more likely to be used for surgical procedures on Friday (RRR, 1.55; 95% CI, 1.33-1.80), Saturday (RRR, 2.03; 95% CI, 1.61-2.56), Sunday (RRR, 2.28; 95% CI, 1.55-3.35), or Monday (RRR, 1.70; 95% CI, 1.46-1.98). Patients undergoing PR on Sundays were more likely to receive another procedure (PR, scleral buckle, or pars plana vitrectomy) within 30 days (odds ratio, 1.62; 95% CI, 1.07-2.45). An association between the need for reoperation for repairs performed via scleral buckle or pars plana vitrectomy and the day of the week of the initial repair was not identified. Patients who received a diagnosis on a Friday waited a mean of 0.28 days (95% CI, 0.20-0.36 days) longer for repair than patients who received a diagnosis on a Wednesday. Conclusions and Relevance These findings suggest that management of RRD varies according to the day of the week that diagnosis and repair occurs, with PR disproportionately likely to be used to repair RRDs during the weekend. Ophthalmologists should be aware that these results suggest that patients undergoing PR on Sundays may be more likely to require reoperation within 30 days.
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Affiliation(s)
- Daniel Vail
- Byers Eye Institute, Department of Ophthalmology, Stanford University, Stanford, California
| | - Carolyn Pan
- Byers Eye Institute, Department of Ophthalmology, Stanford University, Stanford, California
| | - Suzann Pershing
- Byers Eye Institute, Department of Ophthalmology, Stanford University, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Prithvi Mruthyunjaya
- Byers Eye Institute, Department of Ophthalmology, Stanford University, Stanford, California
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Adusumalli S, Aragam G, Patel M. A Nudge Towards Cardiovascular Health: Applications of Behavioral Economics for Primary and Secondary Cardiovascular Prevention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00824-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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21
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Changolkar S, Rewley J, Balachandran M, Rareshide CAL, Snider CK, Day SC, Patel MS. Phenotyping physician practice patterns and associations with response to a nudge in the electronic health record for influenza vaccination: A quasi-experimental study. PLoS One 2020; 15:e0232895. [PMID: 32433678 PMCID: PMC7239439 DOI: 10.1371/journal.pone.0232895] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/23/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Health systems routinely implement changes to the design of electronic health records (EHRs). Physician behavior may vary in response and methods to identify this variation could help to inform future interventions. The objective of this study was to phenotype primary care physician practice patterns and evaluate associations with response to an EHR nudge for influenza vaccination. METHODS AND FINDINGS During the 2016-2017 influenza season, 3 primary care practices at Penn Medicine implemented an active choice intervention in the EHR that prompted medical assistants to template influenza vaccination orders for physicians to review during the visit. We used latent class analysis to identify physician phenotypes based on 9 demographic, training, and practice pattern variables, which were obtained from the EHR and publicly available sources. A quasi-experimental approach was used to evaluate response to the intervention relative to control practices over time in each of the physician phenotype groups. For each physician latent class, a generalized linear model with logit link was fit to the binary outcome of influenza vaccination at the patient visit level. The sample comprised 45,410 patients with a mean (SD) age of 58.7 (16.3) years, 67.1% were white, and 22.1% were black. The sample comprised 56 physicians with mean (SD) of 24.6 (10.2) years of experience and 53.6% were male. The model segmented physicians into groups that had higher (n = 41) and lower (n = 15) clinical workloads. Physicians in the higher clinical workload group had a mean (SD) of 818.8 (429.1) patient encounters, 11.6 (4.7) patient appointments per day, and 4.0 (1.1) days per week in clinic. Physicians in the lower clinical workload group had a mean (SD) of 343.7 (129.0) patient encounters, 8.0 (2.8) patient appointments per day, and 3.1 (1.2) days per week in clinic. Among the higher clinical workload group, the EHR nudge was associated with a significant increase in influenza vaccination (adjusted difference-in-difference in percentage points, 7.9; 95% CI, 0.4-9.0; P = .01). Among the lower clinical workload group, the EHR nudge was not associated with a significant difference in influenza vaccination rates (adjusted difference-in-difference in percentage points, -1.0; 95% CI, -5.3-5.8; P = .90). CONCLUSIONS A model-based approach categorized physician practice patterns into higher and lower clinical workload groups. The higher clinical workload group was associated with a significant response to an EHR nudge for influenza vaccination.
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Affiliation(s)
- Sujatha Changolkar
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Jeffrey Rewley
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, United States of America
| | - Mohan Balachandran
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Charles A. L. Rareshide
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Christopher K. Snider
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Susan C. Day
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Mitesh S. Patel
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, United States of America
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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22
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Hunt TC, O'Neil BB. Leveraging Behavioral Economics to Reduce Low-value Prostate Cancer Screening. Eur Urol 2020; 77:400-402. [PMID: 31959547 DOI: 10.1016/j.eururo.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 01/02/2020] [Indexed: 10/25/2022]
Abstract
Behavioral economic principles model decision-making behavior, and offer promising and unexplored mechanisms for understanding the etiology of low-value care in urologic oncology. Clinical decision support built around these principles is poised to substantially reduce wasteful spending in prostate cancer screening.
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Affiliation(s)
- Trevor C Hunt
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Brock B O'Neil
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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23
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Platts-Mills TF, Nagurney JM, Melnick ER. Tolerance of Uncertainty and the Practice of Emergency Medicine. Ann Emerg Med 2019; 75:715-720. [PMID: 31874767 DOI: 10.1016/j.annemergmed.2019.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - Justine M Nagurney
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, and the Institute for Aging Research, Hebrew Senior Life, Boston, MA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, CT
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Variation in Patient Experience Across the Clinic Day: a Multilevel Assessment of Four Primary Care Practices. J Gen Intern Med 2019; 34:2536-2541. [PMID: 31520229 PMCID: PMC6848585 DOI: 10.1007/s11606-019-05336-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/05/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patient satisfaction with healthcare is associated with clinical outcomes, provider satisfaction, and success of healthcare organizations. As the clinic day progresses, provider fatigue, deterioration with communication within the care team, and appointment spillover may decrease patient experience. OBJECTIVE To understand the relationship between likelihood to recommend a primary care practice and scheduled appointment time across multiple practice settings. DESIGN Retrospective cohort. PARTICIPANTS A retrospective cohort was created of all patients seen within four primary care practices between July 1, 2016, and September 30, 2017. MAIN MEASURES We looked at scheduled appointment time against patient likelihood to recommend a practice as a measure of overall patient experience collected routinely for clinical practice improvement by the Press Ganey Medical Practice Survey®. Adjusted mixed effects logistic regression models were created to understand the relationship between progressing appointment time on patient likelihood to recommend a practice. We constructed locally weighted smoothing (LOESS) curves to understand how reported patient experience varied over the clinic day. RESULTS We had a response rate of 14.0% (n = 3172), 80.2% of whom indicated they would recommend our practice to others. Appointment time scheduling during the last hour (4:00-4:59 PM) had a 45% lower odds of recommending our practice when compared to the first clinic hour (adjusted OR = 0.55, 95% CI 0.35-0.86) which is similar when controlling for patient-reported wait time (aOR = 0.59, 95% CI 0.37-0.95). LOESS plots demonstrated declining satisfaction with subsequent appointment times compared with the first session hour, with no effect just after the lunch hour break. CONCLUSIONS In primary care, appointment time of day is associated with patient-reported experience.
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Hsiang EY, Mehta SJ, Small DS, Rareshide CAL, Snider CK, Day SC, Patel MS. Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests. JAMA Netw Open 2019; 2:e1915619. [PMID: 31730186 PMCID: PMC6902810 DOI: 10.1001/jamanetworkopen.2019.15619] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Early cancer detection can lead to improved outcomes, but cancer screening tests are often underused. OBJECTIVE To evaluate the association of an active choice intervention in the electronic health record directed to medical assistants with changes in clinician ordering and patient completion of breast and colorectal cancer screening tests. DESIGN, SETTING, AND PARTICIPANTS A retrospective quality improvement study was conducted among 69 916 patients eligible for breast or colorectal cancer screening at 25 primary care practices at the University of Pennsylvania Health System between September 1, 2014, and August 31, 2017. Data analysis was conducted from January 21 to July 8, 2019. INTERVENTIONS From 2016 to 2017, 3 primary care practices at the University of Pennsylvania Health System implemented an active choice intervention in the electronic health record that prompted medical assistants to inform patients about cancer screening during check-in and template orders for clinicians to review during the visit. MAIN OUTCOMES AND MEASURES The primary outcome was clinician ordering of cancer screening tests. The secondary outcome was patient completion of cancer screening tests within 1 year of the primary care visit. RESULTS The sample eligible for breast cancer screening comprised 26 269 women with a mean (SD) age of 60.4 (6.9) years; 15 873 (60.4%) were white and 7715 (29.4%) were black. The sample eligible for colorectal cancer screening comprised 43 647 patients with a mean (SD) age of 59.4 (7.5) years; 24 416 (55.9%) were women, 19 231 (44.1%) were men, 29 029 (66.5%) were white, and 9589 (22.0%) were black. For breast cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (22.2 percentage points; 95% CI, 17.2-27.6 percentage points; P < .001) but no change in patient completion (0.1 percentage points; 95% CI, -4.0 to 4.3 percentage points; P = .45). For colorectal cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (13.7 percentage points; 95% CI, 8.0-18.9 percentage points; P < .001) but no change in patient completion (1.0 percentage points; 95% CI, -3.2 to 4.6 percentage points; P = .36). CONCLUSIONS AND RELEVANCE An active choice intervention in the electronic health record directed to medical assistants was associated with a significant increase in clinician ordering of breast and colorectal cancer screening tests. However, it was not associated with a significant change in patient completion of either cancer screening test during a 1-year follow-up.
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Affiliation(s)
| | - Shivan J. Mehta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Dylan S. Small
- Wharton School, University of Pennsylvania, Philadelphia
| | | | | | - Susan C. Day
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mitesh S. Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Wharton School, University of Pennsylvania, Philadelphia
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
- Department of Medicine, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Abstract
IMPORTANCE Time pressure to provide a quick fix is commonly cited as a reason why opioids are frequently prescribed in the United States, but there is little evidence of an association between appointment timing and clinical decision-making. As the workday progresses and appointments run behind schedule, physicians may be more likely to prescribe opioids. OBJECTIVE To estimate whether characteristics of appointment timing are associated with clinical decision-making about pain treatment. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of physician behavior used data from electronic health record systems in primary care offices in the United States to analyze primary care appointments occurring in 2017 for patients with a new painful condition who had not received an opioid prescription within the past year. MAIN OUTCOMES AND MEASURES The association between treatment decisions and 2 dimensions of appointment timing (order of appointment occurrence and delay relative to scheduled start time) were assessed. The rates of opioid prescribing were measured and compared with rates of nonopioid pain medication (ie, nonsteroidal anti-inflammatory drugs) prescribing and referral to physical therapy. All rates were estimated within the same physician using physician fixed effects, adjusting for patient, appointment, and seasonal characteristics. RESULTS Among 678 319 primary care appointments (642 262 patients; 392 422 [61.1%] women) with 5603 primary care physicians, the likelihood that an appointment resulted in an opioid prescription increased by 33% as the workday progressed (1st to 3rd appointment, 4.0% [95% CI, 3.9%-4.1%] vs 19th to 21st appointment, 5.3% [95% CI. 5.1%-5.6%]; P < .001) and by 17% as appointments ran behind schedule (0-9 minutes late, 4.4% [95% CI, 4.3%-4.6%] vs ≥60 minutes late, 5.2% [95% CI, 5.0%-5.4%]; P < .001). Prescribing of nonsteroidal anti-inflammatory drugs and referral to physical therapy did not display similar patterns. CONCLUSIONS AND RELEVANCE These findings suggest that, even within an individual physician's schedule, clinical decision-making for opioid prescribing varies by the timing and lateness of appointments.
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Affiliation(s)
- Hannah T. Neprash
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Affiliation(s)
- David T Liss
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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rb. [Not Available]. MMW Fortschr Med 2019; 161:9. [PMID: 31129845 DOI: 10.1007/s15006-019-0532-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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