An evaluation of vignettes for predicting variation in the quality of preventive care

Patient Cognitive Status and Physician Recommendations for Cardiovascular Disease Treatment: Results of Two Nationwide, Randomized Survey Studies

BACKGROUND

Clinical guidelines recommend that older patients (65+) with mild cognitive impairment (MCI) and early-stage dementia receive similar guideline-concordant care after cardiovascular disease (CVD) events as those with normal cognition (NC). However, older patients with MCI and dementia receive less care for CVD and other conditions than those with NC. Whether physician recommendations for guideline-concordant treatments after two common CVD events, acute myocardial infarction (AMI) and acute ischemic stroke (stroke), differ between older patients with NC, MCI, and early-stage dementia is unknown.

OBJECTIVE

To test the influence of patient cognitive status (NC, MCI, early-stage dementia) on physicians' recommendations for guideline-concordant treatments for AMI and stroke.

DESIGN

We conducted two parallel, randomized survey studies for AMI and stroke in the US using clinical vignettes where the hypothetical patient's cognitive status was randomized between physicians.

PARTICIPANTS

The study included cardiologists, neurologists, and generalists who care for most patients hospitalized for AMI and stroke.

MAIN MEASURES

The primary outcome was a composite quality score representing the number of five guideline-concordant treatments physicians recommended for a hypothetical patient after AMI or stroke.

KEY RESULTS

1,031 physicians completed the study (58.5% response rate). Of 1,031 respondents, 980 physicians had complete information. After adjusting for physician factors, physicians recommended similar treatments after AMI and stroke in hypothetical patients with pre-existing MCI (adjusted ratio of expected composite quality score, 0.98 [95% CI, 0.94, 1.02]; P = 0.36) as hypothetical patients with NC. Physicians recommended fewer treatments to hypothetical patients with pre-existing early-stage dementia than to hypothetical patients with NC (adjusted ratio of expected composite quality score, 0.90 [0.86, 0.94]; P < 0.001).

CONCLUSION

In these randomized survey studies, physicians recommended fewer guideline-concordant AMI and stroke treatments to hypothetical patients with early-stage dementia than those with NC. We did not find evidence that physicians recommend fewer treatments to hypothetical patients with MCI than those with NC.

Prescriber Uncertainty as Opportunity to Improve Care of Type 2 Diabetes with Chronic Kidney Disease: Mixed Methods Study

BACKGROUND

Over 5 million patients in the United States have type 2 diabetes mellitus (T2D) with chronic kidney disease (CKD); antidiabetic drug selection for this population is complex and has important implications for outcomes.

OBJECTIVE

To better understand how providers choose antidiabetic drugs in T2D with CKD DESIGN: Mixed methods. Interviews with providers underwent qualitative analysis using grounded theory to identify themes related to antidiabetic drug prescribing. A provider survey used vignettes and direct questions to quantitatively assess prescribers' knowledge and preferences. A retrospective cohort analysis of real-world prescribing data assessed the external validity of the interview and survey findings.

PARTICIPANTS

Primary care physicians, endocrinologists, nurse-practitioners, and physicians' assistants were eligible for interviews; primary care physicians and endocrinologists were eligible for the survey; prescribing data were derived from adult patients with serum creatinine data.

MAIN MEASURES

Interviews were qualitative; for the survey and retrospective cohort, proportion of patients receiving metformin was the primary outcome.

KEY RESULTS

Interviews with 9 providers identified a theme of uncertainty about guidelines for prescribing antidiabetic drugs in patients with T2D and CKD. The survey had 105 respondents: 74 primary care providers and 31 endocrinologists. Metformin was the most common choice for patients with T2D and CKD. Compared to primary care providers, endocrinologists were less likely to prescribe metformin at levels of kidney function at which it is contraindicated and more likely to correctly answer a question about metformin's contraindications (71% versus 41%) (p < .05). Real-world data were consistent with survey findings, and further showed low rates of use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (<10%) in patients with eGFR below 60 ml/min/1.73m2.

CONCLUSIONS

Providers are unsure how to treat T2D with CKD and incompletely informed as to existing guidelines. This suggests opportunities to improve care.

General practitioners' everyday clinical decision-making on psychosocial problems of children and youth in the Netherlands

BACKGROUND

Psychosocial problems in children and youth are common and may negatively impact their lives and the lives of their families. Since general practitioners (GPs) play a crucial role in detecting and intervening in such problems, it is clinically necessary to improve our insight into their clinical decision-making (CDM). The objective of this study was to explore which mechanisms underlie GPs' everyday CDM and their options for management or referral.

MATERIAL AND METHODS

This was a mixed methods study in which qualitative (interview substudy) and quantitative (online survey substudy) data were collected from GPs. Using a question framework and vignettes representative of clinical practice, GPs' CDM was explored. GPs were selected by means of an academic research network and purposive sampling. Data collection continued in constant comparison between both substudies. Using grounded theory, data from both substudies were triangulated into a flowchart consisting of mechanisms and management/referral options.

RESULTS

CDM-mechanisms were divided into three groups. GP-related mechanisms were GPs' primary approach of the problem (somatically or psychosocially) and their self-assessed competence to solve the problem based on interest in and knowledge about youth mental health care. Mechanisms related to the child and its social context included GPs' assessment whether there was psychiatric (co)morbidity, their sense of self-limitedness of the problem and assessed complexity of the problem. Whether GPs' had existing collaboration agreements with youth care providers and how they experienced their collaboration were collaboration-related mechanisms.

CONCLUSION

The current study contributes to a relatively unexplored research area by revealing GP's in-depth thought processes regarding their CDM. However, existing research in this area supports the identified CDM mechanisms. Future initiatives should focus on validating CDM mechanisms in a larger population. If confirmed, mechanisms could be integrated into GP training and may offer guidelines for regulating proper access to mental health care services.

The Agreement Between Virtual Patient and Unannounced Standardized Patient Assessments in Evaluating Primary Health Care Quality: Multicenter, Cross-sectional Pilot Study in 7 Provinces of China

BACKGROUND

The unannounced standardized patient (USP) is the gold standard for primary health care (PHC) quality assessment but has many restrictions associated with high human and resource costs. Virtual patient (VP) is a valid, low-cost software option for simulating clinical scenarios and is widely used in medical education. It is unclear whether VP can be used to assess the quality of PHC.

OBJECTIVE

This study aimed to examine the agreement between VP and USP assessments of PHC quality and to identify factors influencing the VP-USP agreement.

METHODS

Eleven matched VP and USP case designs were developed based on clinical guidelines and were implemented in a convenience sample of urban PHC facilities in the capital cities of the 7 study provinces. A total of 720 USP visits were conducted, during which on-duty PHC providers who met the inclusion criteria were randomly selected by the USPs. The same providers underwent a VP assessment using the same case condition at least a week later. The VP-USP agreement was measured by the concordance correlation coefficient (CCC) for continuity scores and the weighted κ for diagnoses. Multiple linear regression was used to identify factors influencing the VP-USP agreement.

RESULTS

Only 146 VP scores were matched with the corresponding USP scores. The CCC for medical history was 0.37 (95% CI 0.24-0.49); for physical examination, 0.27 (95% CI 0.12-0.42); for laboratory and imaging tests, -0.03 (95% CI -0.20 to 0.14); and for treatment, 0.22 (95% CI 0.07-0.37). The weighted κ for diagnosis was 0.32 (95% CI 0.13-0.52). The multiple linear regression model indicated that the VP tests were significantly influenced by the different case conditions and the city where the test took place.

CONCLUSIONS

There was low agreement between VPs and USPs in PHC quality assessment. This may reflect the "know-do" gap. VP test results were also influenced by different case conditions, interactive design, and usability. Modifications to VPs and the reasons for the low VP-USP agreement require further study.

Primary care physicians' awareness and perceptions on adherence to primary cardiovascular disease prevention guidelines in Lebanon: A cross-sectional study

OBJECTIVES

To assess the awareness and have an insight on practice patterns of primary care physicians (PCPs) with respect to several professional primary cardiovascular diseases (CVDs) preventive guidelines.

METHODS

This is a cross-sectional study, questionnaire-based using a non-probability convenience sampling. Data collection occurred at the annual conferences of the Lebanese Societies of General Practice, Family Medicine, and Internal Medicine in Lebanon. 104 PCPs were recruited.

MAIN OUTCOME MEASURES

Awareness and practices of CVDs preventive guidelines.

RESULTS

The response rate was 37%. Awareness of the various CVD preventive guidelines was high among PCPs (&gt;81%). Around 69% of PCPs reported that they always calculate the total cardiovascular risk assessment score. Gaps in managing patients according to guidelines' recommendations were higher in statin initiation compared to antihypertensive initiation. There is over prescription of statin in low risk patients and underutilization in high risk patients. Around 20% of PCPs would initiate aspirin for a low risk patient. Around 17% of physicians do not perform abdominal aortic aneurysm screening.

DISCUSSION

Although PCPs demonstrated high level of awareness regarding CVD preventive guidelines, gaps remain present in managing patients according to guidelines' recommendations. Less adherence to guidelines will increase mortality and affect patient care.

Teacher Educational Decision Making for Children With Specific Language Impairment

PURPOSE

Children with specific language impairment (SLI) are underidentified, despite a robust literature on their language abilities and a clinical grammar marker. Adlof and Hogan (2019) call for school systems to assess oral language and provide supports through response to intervention (RTI), with the aim of identifying and supporting children with SLI and other language impairments. However, it is unknown how teachers make educational decisions for children with SLI.

METHOD

A web-based survey was distributed to public school teachers nationwide (N = 304). In this observational study, teachers read six vignettes featuring profiles of children systematically varying in the linguistic characteristics relevant to SLI (e.g., difficulty with verb tense) and responded to items on the educational decisions that they would make in the absence of workplace constraints.

RESULTS

Teachers were likely to identify that the children in the vignettes needed language for classroom success and to indicate that they would provide in-class intervention. However, teachers were unlikely to recommend speech-language pathology services. These outcomes were mostly consistent across all child characteristics and teacher characteristics.

CONCLUSIONS

Findings show that teachers were sensitive to the language-based needs of children with SLI and elected to provide in-class intervention. Future work is needed to understand how workplace characteristics, including opportunities for interprofessional collaboration, and the heterogeneity of children with SLI, inform teacher educational decision making.

Decision-Making in Implantology-A Cross-Sectional Vignette-Based Study to Determine Clinical Treatment Routines for the Edentulous Atrophic Mandible

This cross-sectional study aimed to investigate the influence of possible factors in the patient history on decision making in the therapy for a severely atrophied edentulous mandible. A vignette-based survey among 250 maxillofacial and oral surgeons was conducted. Determinants that could influence the therapy decision were patient age, smoking, fear of surgery, and radiotherapy in the head and neck area (the implant region is not in the direct radiation area). To achieve a suitable implant site, the options offered to the surgeons were bone split, bone block, augmentation with bone substitute material, and bone resection. There also was the option of rejecting any therapy. The response rate was 47%. Patient age, radiotherapy, and fear of surgery did not influence the approval of a therapy. Smoking was associated with a significantly lower endorsement of a treatment. Resection was preferred by a large majority to all other forms of therapy, regardless of the four determinants. Surgeons tend to refrain from bone block transplants in older patients. In summary, it can be said that, of the four determinants, only smoking influenced treatment refusal. Bone resection is the preferred therapy independent of all determinants.

Preliminary evidence of linguistic bias in academic reviewing

Recent years have seen a spirited debate over whether there is linguistic injustice in academic publishing. One way that linguistic injustice might occur is if gatekeepers (e.g., peer reviewers and editors) judge the scholarly quality of academic writing more harshly if the writing does not meet expectations for international academic English, even if the content is good. We tested this with a randomized control study in which scholars judged the scientific quality of several scientific abstracts. Each abstract had two versions with identical scientific content, such that the language in one version conformed to standards for international academic English, and the language in the other version did not (but was still comprehensible). While the data are preliminary and the effects statistically inconclusive, both pre-registered and exploratory analyses of the data suggest that scholars may give abstracts lower ratings of scientific quality when the writing does not conform to standards of international academic English. These results suggest that linguistic bias may occur in academic peer reviewing and motivate further study to better understand and address this phenomenon.

Improving the accuracy of medical diagnosis with causal machine learning

Machine learning promises to revolutionize clinical decision making and diagnosis. In medical diagnosis a doctor aims to explain a patient's symptoms by determining the diseases causing them. However, existing machine learning approaches to diagnosis are purely associative, identifying diseases that are strongly correlated with a patients symptoms. We show that this inability to disentangle correlation from causation can result in sub-optimal or dangerous diagnoses. To overcome this, we reformulate diagnosis as a counterfactual inference task and derive counterfactual diagnostic algorithms. We compare our counterfactual algorithms to the standard associative algorithm and 44 doctors using a test set of clinical vignettes. While the associative algorithm achieves an accuracy placing in the top 48% of doctors in our cohort, our counterfactual algorithm places in the top 25% of doctors, achieving expert clinical accuracy. Our results show that causal reasoning is a vital missing ingredient for applying machine learning to medical diagnosis.

Comparing reactions to written leaflets, online information and real-time Doppler images among South Asian patients with rheumatoid arthritis

Objective

There is poor adherence to medication in patients of South Asian origin with RA. There are limited numbers of interventions to improve patient engagement. The objective of this study was to explore how patients of South Asian origin make sense of their disease after receiving written leaflets compared with online information or visualizing real-time Doppler US images of their inflamed joints.

Methods

Patients of South Asian origin with RA were recruited from two National Health Service hospitals in the West Midlands, UK. In-depth semi-structured interviews were undertaken after exposure to vignettes designed to elicit patients’ perspectives on: written leaflets; online information to complement face-to-face interaction with health-care professionals; and Doppler US during the early stages of the disease journey. Data were analysed thematically until data saturation was reached in 20 individuals.

Results

The responses to vignette scenarios were described by the patients. Overall, patients found real-time Doppler US more valuable in understanding RA and RA medications compared with other methods. Patients reported that Doppler US reduced anxiety and helped to address misconceptions about the long-term disease and its ability to be controlled.

Conclusion

We have developed new understanding regarding the educational utility of a Doppler US session in patients of South Asian origin and how these sessions can be optimized to increase patient engagement and adherence to medication.

Variation in Diabetes Management: A National Assessment of Primary Care Providers

BACKGROUND

Glucose control is monitored primarily through ordering HbA1c levels, which is problematic in patients with glycemic variability. Herein, we report on the management of these patients by board-certified primary care providers (PCPs) in the United States.

METHODS

We measured provider practice in a representative sample of 156 PCPs. All providers cared for simulated patients with diabetes presenting with symptoms of glycemic variability. Provider responses were reviewed by trained clinicians against evidence-based care standards and accepted standard of care protocols.

RESULTS

Care varied widely-overall quality of care averaged 51.3%±10.6%-with providers performing just over half the evidence-based practices necessary for their cases. More worryingly, provider identified the underlying etiology of the poor glycemic control only 36.3% of the time. HbA1c was routinely ordered in 91.3% of all cases but often (59.5%) inappropriately. Ordering other tests of glycemic control (done in 15% of cases) led to significant increases in identifying the etiology of the hyperglycemia. Correctly modifying their patient's treatment was more likely to occur if doctors first identified the underlying etiology (65.9% vs 49.0%, P<0.001). We conservatively estimated a US $65/patient/visit in unnecessary testing and US $389 annually in additional care costs when the etiology was missed, translating potentially into millions of dollars of wasteful spending.

CONCLUSION

Despite established evidence that HbA1c misses short-term changes in diabetes, we found PCPs consistently ordered HbA1c, rarely using other available blood tests. However, if the factors leading to poor glycemic control were recognized, PCPs were more likely to correctly alter their patient's hypoglycemic therapy.

Variability in triage practices for critically ill cancer patients: A randomized controlled trial

PURPOSE

Intensive care triage practices and end-user interpretation of triage guidelines have rarely been assessed. We evaluated agreement between providers on the prioritization of patients for ICU admission using different triage guidelines.

MATERIALS AND METHODS

A multi-centered randomized study on providers from 18 different countries was conducted using clinical vignettes of oncological patients. The level of agreement between providers was measured using two different guidelines, with one being cancer specific.

RESULTS

Amongst 257 providers, 52.5% randomly received the Society of Critical Care Prioritization Model, and 47.5% received a cancer specific flowchart as a guide. In the Prioritization Model arm the average entropy was 1.193, versus 1.153 in the flowchart arm (P = .095) indicating similarly poor agreement. The Fleiss' kappa coefficients were estimated to be 0.2136 for the SCCMPM arm and 0.2457 for the flowchart arm, also similarly implying poor agreement.

CONCLUSIONS

The low agreement amongst practitioners on the prioritization of cancer patient cases for ICU admission existed using both general triage guidelines and guidelines tailored only to cancer patients. The lack of consensus on intensive care unit triage practices in the oncological population exposes a potential barrier to appropriate resource allocation that needs to be addressed.

Physician Beliefs and Patient Preferences: A New Look at Regional Variation in Health Care Spendingf

There is considerable controversy about the causes of regional variations in health care expenditures. Using vignettes from patient and physician surveys linked to fee-for-service Medicare expenditures, this study asks whether patient demand-side factors or physician supply-side factors explain these variations. The results indicate that patient demand is relatively unimportant in explaining variations. Physician organizational factors matter, but the most important factor is physician beliefs about treatment. In Medicare, we estimate that 35 percent of spending for end-of-life care and 12 percent of spending for heart attack patients (and for all enrollees) is associated with physician beliefs unsupported by clinical evidence. (JEL D83, H75, I11, I18).

Testing Young Adults' Reactions to Facebook Cues and Their Associations with Alcohol Use

Background: Alcohol cues on social media may influence young adults' drinking patterns, these cues may be pro-social or pro-alcohol in nature. The influence of individual Facebook cues on young adults' drinking intentions and behaviors remains unknown. Objectives: The purpose of this study was to assess how Facebook cues influence intention to drink, and how intention was associated with Theory of Reasoned Action constructs including alcohol-related attitudes and norms, and future behavior. Methods: Incoming university students completed a pre-college and a 2-year follow-up phone interview. A vignette presented individual Facebook cues representing "pro-social" or "pro-alcohol" sentiments. Participants indicated intention to drink alcohol and their rationale for this intention after each cue. Additional measures included TRA constructs of alcohol-related attitudes and norms, and problem alcohol use. Analyses included a qualitative approach to examine rationales for intention to drink in response to Facebook cues, and linear mixed effects models. Results: Of 338 participants, 56.1% were female, 74.8% were Caucasian. Alcohol-related attitudes and norms were positively associated with intention to drink in response to pro-social and pro-alcohol Facebook cues. Participants' intention to drink in response to pro-alcohol cues was positively associated with problem alcohol use two years later. Conclusions/importance: Findings illuminate the influence of social media on alcohol-related behaviors and highlight potential future screening approaches.

Using smartphone-based virtual patients to assess the quality of primary healthcare in rural China: protocol for a prospective multicentre study

INTRODUCTION

Valid and low-cost quality assessment tools examining care quality are not readily available. The unannounced standardised patient (USP), the gold standard for assessing quality, is costly to implement while the validity of clinical vignettes, as a low-cost alternative, has been challenged. Computerised virtual patients (VPs) create high-fidelity and interactive simulations of doctor-patient encounters which can be easily implemented via smartphone at low marginal cost. Our study aims to develop and validate smartphone-based VP as a quality assessment tool for primary care, compared with USP.

METHODS AND ANALYSIS

The study will be implemented in primary health centres (PHCs) in rural areas of seven Chinese provinces, and physicians practicing at township health centres and village clinics will be our study population. The development of VPs involves three steps: (1) identifying 10 VP cases that can best represent rural PHCs' work, (2) designing each case by a case-specific development team and (3) developing corresponding quality scoring criteria. After being externally reviewed for content validity, these VP cases will be implemented on a smartphone-based platform and will be tested for feasibility and face validity. This smartphone-based VP tool will then be validated for its criterion validity against USP and its reliability (ie, internal consistency and stability), with 1260 VP/USP-clinician encounters across the seven study provinces for all 10 VP cases.

ETHICS AND DISSEMINATION

Sun Yat-sen University: No. 2017-007. Study findings will be published and tools developed will be freely available to low-income and middle-income countries for research purposes.

Estimates of Side Effects Counseling in Family Planning Using Three Data Sources: Implications for Monitoring and Survey Design

With growing attention to monitoring and improving quality of care, it is critical to have evidence-based recommendations to measure quality of care indicators and guidelines to interpret estimates from different data sources. This study facilitates methodological discussion regarding measurement of counseling for side effects in family planning, a critical component of quality. The study assesses and compares estimates of side effects counseling based on three data sources. Data came from nationally representative facility and household surveys, Service Provision Assessments, and Demographic and Health Surveys in four countries. The level of side effects counseling was unacceptably low and varied systematically by data source. Compared to observation data in the facility survey, exit interview data from the survey overestimated the level substantially, and its reporting had poor predictive value. Estimates from household surveys were comparable with the observation-based estimates applying the minimum definition of counseling. In monitoring quality of care, data sources should be carefully reviewed, and estimates may need to be adjusted if the sources are inconsistent.

Advanced imaging for the diagnosis of age-related macular degeneration: a case vignettes study

Background

The aim of this study is to evaluate the diagnosis, staging, imaging and management preferences, and the effect of advanced imaging among practising optometrists in age‐related macular degeneration (AMD).

Methods

Up to 20 case vignettes (computer‐based case simulations) were completed online in a computer laboratory in random order by 81 practising optometrists of Australia. Each case presented findings from a randomly selected patient seen previously at the Centre for Eye Health for a macular assessment in the following order: case history, preliminary tests and colour fundus photography. Participants were prompted to provide their diagnosis, management and imaging preference. One additional imaging result (either modified fundus photographs and infrared images, fundus autofluorescence, or optical coherence tomography [OCT]) was then provided and the questions repeated. Finally, all imaging results were provided and the questions repeated a third time.

Results

A total of 1,436 responses were analysed. The presence of macular pathology in AMD was accurately detected in 94 per cent of instances. The overall diagnostic accuracy of AMD was 61 per cent using colour fundus photography. This improved by one per cent using one additional imaging modality and a further four per cent using all imaging. Across all responses, a greater improvement in the diagnostic accuracy of AMD occurred following the presentation of OCT findings (versus other modalities). OCT was the most preferred imaging modality for AMD, while multimodal imaging was of greatest benefit in cases more often misdiagnosed using colour fundus photography alone. Overall, the cohort also displayed a tendency to underestimate disease severity.

Conclusion

Despite reports that imaging technologies improve the stratification of AMD, our findings suggest that this effect may be small when applied among practising optometrists without additional or specific training.

Physician Preferences for Aggressive Treatment at the End of Life and Area-Level Health Care Spending: The Johns Hopkins Precursors Study

Objective: To determine whether physician preferences for end-of-life care were associated with variation in health care spending. Method: We studied 737 physicians who completed the life-sustaining treatment questionnaire in 1999 and were linked to end-of-life care data for the years 1999 to 2009 from Medicare-eligible beneficiaries from the Dartmouth Atlas of Health Care (in hospital-related regions [HRRs]). Using latent class analysis to group physician preferences for end-of-life treatment into most, intermediate, and least aggressive categories, we examined how physician preferences were associated with health care spending over a 7-year period. Results: When all HRRs in the nation were arrayed in quartiles by spending, the prevalence of study physicians who preferred aggressive end-of-life care was greater in the highest spending HRRs. The mean area-level intensive care unit charges per patient were estimated to be US$1,595 higher in the last 6 months of life and US$657 higher during the hospitalization in which death occurred for physicians who preferred the most aggressive treatment at the end of life, when compared with average spending. Conclusions: Physician preference for aggressive end-of-life care was correlated with area-level spending in the last 6 months of life. Policy measures intended to minimize geographic variation in health care spending should incorporate physician preferences and style.

Clinical Utility of a Comprehensive, Whole Genome CMA Testing Platform in Pediatrics: A Prospective Randomized Controlled Trial of Simulated Patients in Physician Practices

BACKGROUND

Developmental disorders (DD), including autism spectrum disorder (ASD) and intellectual disability (ID), are a common group of clinical manifestations caused by a variety of genetic abnormalities. Genetic testing, including chromosomal microarray (CMA), plays an important role in diagnosing these conditions, but CMA can be limited by incomplete coverage of genetic abnormalities and lack of guidance for conditions rarely seen by treating physicians.

METHODS

We conducted a longitudinal, randomized controlled trial investigating the impact of a higher resolution 2.8 million (MM) probe-CMA test on the quality of care delivered by practicing general pediatricians and specialists. To overcome the twin problems of finding an adequate sample size of multiple rare conditions and under/incorrect diagnoses, we used standardized simulated patients known as CPVs. Physicians, randomized into control and intervention groups, cared for the CPV pediatric patients with DD/ASD/ID. Care responses were scored against evidence-based criteria. In round one, participants could order diagnostic tests including existing CMA tests. In round two, intervention physicians could order the 2.8MM probe-CMA test. Outcome measures included overall quality of care and quality of the diagnosis and treatment plan.

RESULTS

Physicians ordering CMA testing had 5.43% (p<0.001) higher overall quality scores than those who did not. Intervention physicians ordering the 2.8MM probe-CMA test had 7.20% (p<0.001) higher overall quality scores. Use of the 2.8MM probe-CMA test led to a 10.9% (p<0.001) improvement in the diagnosis and treatment score. Introduction of the 2.8MM probe-CMA test led to significant improvements in condition-specific interventions including an 8.3% (p = 0.04) improvement in evaluation and therapy for gross motor delays caused by Hunter syndrome, a 27.5% (p = 0.03) increase in early cognitive intervention for FOXG1-related disorder, and an 18.2% (p<0.001) improvement in referrals to child neurology for Dravet syndrome.

CONCLUSION

Physician use of the 2.8MM probe-CMA test significantly improves overall quality as well as diagnosis and treatment quality for simulated cases of pediatric DD/ASD/ID patients, and delivers additional clinical utility over existing CMA tests.

Misdiagnosis of obstetrical cases and the clinical and cost consequences to patients: a cross-sectional study of urban providers in the Philippines

BACKGROUND

Misdiagnosis may be a significant and under-recognized quality of care problem. In birthing facilities located in anurban Philippine setting, we investigated the diagnostic accuracy for three obstetric conditions: cephalopelvic disproportion (CPD), post-partum hemorrhage (PPH), and pre-eclampsia.

DESIGN

Identical simulated cases were used to measure diagnostic accuracy for every provider (n=103). We linked misdiagnosis - identified by the simulated cases - to obstetrical complications of the patients at the participating facilities. Patient-level data on health outcomes and costs were obtained from medical records and follow-home in-person interviews.

RESULTS

The prevalence of misdiagnosis among obstetric providers was 29.8% overall, 25% for CPD, 33% for PPH, and 31% for pre-eclampsia. Linking provider decision-making to patients, we found those who misdiagnosed the simulated cases were more likely to have patients with a complication (OR 2.96; 95% CI 1.39-3.77) compared with those who did not misdiagnose. Complicated patients were significantly less likely to be referred to a hospital immediately, were more likely to be readmitted to a hospital after delivery, had significantly higher medical costs, and lost more income than non-complicated patients.

CONCLUSION

Diagnosis is arguably the most important task a clinician performs because it determines the subsequent course of evaluation and treatment, with the direct and indirect costs of diagnostic error, placing large financial burdens on the patient.

Association of Liability Concerns with Decisions to Order Echocardiography and Cardiac Stress Tests with Imaging

BACKGROUND

Professional societies have made efforts to curb overuse of cardiac imaging and decrease practice variation by publishing appropriate use criteria. However, little is known about the impact of physician-level determinants such as liability concerns and risk aversion on decisions to order testing.

METHODS

A web-based survey was administered to cardiologists and general practice physicians affiliated with two academic institutions. The survey consisted of four clinical scenarios in which appropriate use criteria rated echocardiography or stress testing as "may be appropriate." Respondents' degree of liability concerns and risk aversion were measured using validated tools. The primary outcome variable was tendency to order imaging, calculated as the average likelihood to order an imaging test across the clinical scenarios (1 = very unlikely, 6 = very likely). Linear regression models were used to evaluate the association between tendency to order imaging and physician characteristics.

RESULTS

From 420 physicians invited to participate, 108 complete responses were obtained (26% response rate, 54% cardiologists). There was no difference in tendency to order imaging between cardiologists and general practice physicians (3.46 [95% CI, 3.12-3.81] vs 3.15 [95% CI, 2.79-3.51], P = .22). On multivariate analysis, a higher degree of liability concerns was the only significant predictor of decisions to order imaging (mean difference in tendency to order imaging, 0.36; 95% CI, 0.09-0.62; P = .01).

CONCLUSION

In clinical situations in which performance of cardiac imaging is rated as "may be appropriate" by appropriate use criteria, physicians with higher liability concerns ordered significantly more testing than physicians with lower concerns.

Do Health Reforms to Improve Quality Have Long-Term Effects? Results of a Follow-Up on a Randomized Policy Experiment in the Philippines

We tracked doctors who had previously participated in a randomized policy experiment in the Philippines. The original experiment involved 30 district hospitals divided equally into one control site and two intervention sites that increased insurance payments (full insurance support for children under 5 years old) or made bonus payments to hospital staff. During the 3 years of the intervention, quality-as measured by clinical performance and value vignettes-improved and was sustained in both intervention sites compared with controls. Five years after the interventions were discontinued, we remeasured the quality of care of the doctors. We found that the intervention sites continued to have significantly higher quality compared with the control sites. The previously documented quality improvement in intervention sites appears to be sustained; moreover, it was subject to a very low (less than 1% per year) rate of decay in quality scores.

Methods of Observing Variations in Physicians' Decisions: The Opportunities of Clinical Vignettes

To support their efforts to promote high quality and efficient care, policymakers need to better understand the key factors associated with variations in physicians' decisions, and in particular, physician deviations from evidence-based care. Clinical vignette survey instruments hold potential for research in this area as an approach that both allows for practical, large-scale study and overcomes the data quality challenges posed by analysis of clinical data. These surveys present respondents with a narrative description of a hypothetical patient case and solicit responses to one or more questions regarding the care of the patient. In this review, we describe various methods for measuring variations in physicians' decisions and highlight a range of design features researchers should consider when developing a clinical vignette survey. We conclude by identifying areas for future research.

Facebook Displays as Predictors of Binge Drinking: From the Virtual to the Visceral

Given the prevalence of social media, a nascent but important area of research is the effect of social media posting on one's own self. It is possible that an individual's social media posts may have predictive capacity, especially in relation to health behavior. Researchers have long utilized concepts from the Theory of Reasoned Action (TRA) to predict health behaviors. The theory does not account for social media, which may influence or predict health behaviors. The purpose of this study was to test a model including Facebook alcohol displays and constructs from the TRA to predict binge drinking. Incoming college freshmen from two schools (312 participants between the ages of 18 and 19) were interviewed prior to (T1) and one year into college (T2), and their Facebook profiles were evaluated for displayed alcohol content. Path modeling was used to evaluate direct and indirect paths predicting binge drinking. Path analysis suggested that Facebook alcohol displays at T1 directly predict binge drinking at T2, while alcohol attitude both directly and indirectly predicts binge drinking. Based on these results, a preliminary model of social media presentation and action is discussed.

An innovative peer assessment approach to enhance guideline adherence in physical therapy: single-masked, cluster-randomized controlled trial

BACKGROUND

Clinical practice guidelines (CPGs) are not readily implemented in clinical practice. One of the impeding factors is that physical therapists do not hold realistic perceptions of their adherence to CPGs. Peer assessment (PA) is an implementation strategy that aims at improving guideline adherence by enhancing reflective practice, awareness of professional performance, and attainment of personal goals.

OBJECTIVE

The purpose of this study was to compare the effectiveness of PA with the usual case discussion (CD) strategy on adherence to CPGs for physical therapist management of upper extremity complaints.

DESIGN

A single-masked, cluster-randomized controlled trial with pretest-posttest design was conducted.

INTERVENTION

Twenty communities of practice (n=149 physical therapists) were randomly assigned to groups receiving PA or CD, with both interventions consisting of 4 sessions over 6 months. Both PA and CD groups worked on identical clinical cases relevant to the guidelines. Peer assessment focused on individual performance observed and evaluated by peers; CD focused on discussion.

OUTCOMES

Guideline adherence was measured with clinical vignettes, reflective practice was measured with the Self-Reflection and Insight Scale (SRIS), awareness of performance was measured via the correlation between perceived and assessed improvement, and attainment of personal goals was measured with written commitments to change.

RESULTS

The PA groups improved more on guideline adherence compared with the CD groups (effect=22.52; 95% confidence interval [95% CI]=2.38, 42.66; P=.03). The SRIS scores did not differ between PA and CD groups. Awareness of performance was greater for the PA groups (r=.36) than for the CD groups (r=.08) (effect=14.73; 95% CI=2.78, 26.68; P=.01). The PA strategy was more effective than the CD strategy in attaining personal goals (effect=0.50; 95% CI=0.04, 0.96; P=.03).

LIMITATIONS

Limited validity of clinical vignettes as a proxy measure of clinical practice was a limitation of the study.

CONCLUSIONS

Peer assessment was more effective than CD in improving adherence to CPGs. Personal feedback may have contributed to its effectiveness. Future research should address the role of the group coach.

Patient and physician gender concordance in preventive care in university primary care settings

OBJECTIVE

To assess the quality of preventive care according to physician and patient gender in a country with universal health care coverage.

METHODS

We assessed a retrospective cohort study of 1001 randomly selected patients aged 50-80 years followed over 2 years (2005-2006) in 4 Swiss university primary care settings (Basel, Geneva, Lausanne, Zürich). We used indicators derived from RAND's Quality Assessment Tools and examined percentages of recommended preventive care. Results were adjusted using hierarchical multivariate logistic regression models.

RESULTS

1001 patients (44% women) were followed by 189 physicians (52% women). Female patients received less preventive care than male patients (65.2% vs. 72.1%, p<0.001). Female physicians provided significantly more preventive care than male physicians (p=0.01) to both female (66.7% vs. 63.6%) and male patients (73.4% vs. 70.7%). After multivariate adjustment, differences according to physician (p=0.02) and patient gender (p<0.001) remained statistically significant. Female physicians provided more recommended cancer screening than male physicians (78.4 vs. 71.9%, p=0.01).

CONCLUSIONS

In Swiss university primary care settings, female patients receive less preventive care than male patients, with female physicians providing more preventive care than male physicians. Greater attention should be paid to female patients in preventive care and to why female physicians tend to provide better preventive care.

Factors influencing veterinarian referral to oncology specialists for treatment of dogs with lymphoma and osteosarcoma in Ontario, Canada

OBJECTIVE

To elucidate factors influencing practitioner decisions to refer dogs with cancer to veterinary oncology specialists.

DESIGN

Cross-sectional study.

SAMPLE

2,724 Ontario primary care companion animal veterinarians.

PROCEDURES

Practitioners were invited to participate in a survey involving clinical scenarios of canine cancer patients, offered online and in paper format from October 2010 through January 2011. Analyses identified factors associated with the decision to refer patients to veterinary oncology specialists.

RESULTS

1,071 (39.3%) veterinarians responded, of which 603 (56.3%) recommended referral for dogs with multicentric lymphoma and appendicular osteosarcoma. Most (893/1,059 [84.3%]) practiced within < 2 hours' drive of a specialty referral center, and most (981/1,047 [93.7%]) were completely confident in the oncology service. Few (230/1,056 [21.8%] to 349/1,056 [33.0%]) were experienced with use of chemotherapeutics, whereas more (627/1,051 [59.7%]) were experienced with amputation. Referral was associated with practitioner perception of patient health status (OR, 1.54; 95% confidence interval [CI], 1.15 to 2.07), the interaction between the client's bond with the dog and the client's financial status, practitioner experience with treating cancer (OR, 2.79; 95% CI, 1.63 to 4.77), how worthwhile practitioners considered treatment to be (OR, 1.66 to 3.09; 95% CI, 1.08 to 4.72), and confidence in the referral center (OR, 2.20; 95% CI, 1. 11 to 4.34).

CONCLUSIONS AND CLINICAL RELEVANCE

Several factors influenced practitioner decisions to refer dogs with lymphoma or osteosarcoma for specialty care. Understanding factors that influence these decisions may enable practitioners to appraise their referral decisions and ensure they act in the best interests of patients, clients, and the veterinary profession.

A systematic process for creating and appraising clinical vignettes to illustrate interprofessional shared decision making

Vignettes and written case simulations have been widely used by educators and health services researchers to illustrate plausible situations and measure processes in a wide range of practice settings. We devised a systematic process to create and appraise theory-based vignettes for illustrating an interprofessional approach to shared decision making (IP-SDM) for health professionals. A vignette was developed in six stages: (1) determine IP-SDM content elements; (2) choose true-to-life clinical scenario; (3) draft script; (4) appraise IP-SDM concepts illustrated using two evaluation instruments and an interprofessional concept grid; (5) peer review script for content validity; and (6) retrospective pre-/post-test evaluation of video vignette by health professionals. The vignette contained six scenes demonstrating the asynchronous involvement of five health professionals with an elderly woman and her daughter facing a decision about location of care. The script scored highly on both evaluation scales. Twenty-nine health professionals working in home care watched the vignette during IP-SDM workshops in English or French and rated it as excellent (n = 6), good (n = 20), fair (n = 0) or weak (n = 3). Participants reported higher knowledge of IP-SDM after the workshops compared to before (p < 0.0001). Our video vignette development process resulted in a product that was true-to-life and as part of a multifaceted workshop it appears to improve knowledge among health professionals. This could be used to create and appraise vignettes targeting IP-SDM in other contexts.

Asthma treatment decisions by pediatric residents do not consistently conform to guidelines or improve with level of training

OBJECTIVE

To compare asthma treatment decisions by pediatric residents to current asthma guidelines and to learn whether treatment decisions vary by postgraduate year in training.

METHODS

We conducted a Web-based survey of residents from 10 training programs through the Continuity Research Network of the Academic Pediatric Association (CORNET). Surveys included 6 vignettes of patients receiving low-dose inhaled steroids with guideline- and non-guideline-based indicators of asthma status and 1 stable patient on high-intensity medication.

RESULTS

There were 369 resident respondents (65% response rate), 26% postgraduate year (PGY) 1, 38% PGY2, and 36% PGY3+. Seventy-five percent of each resident group reported seeing fewer than 1 asthma patient per continuity clinic session. A majority of residents made appropriate treatment recommendations in 2 of 4 vignettes of guideline-based indicators of asthma status: first, 97% overall stepping up treatment for mild persistent asthma; and second, 52% overall stepping down treatment for a patient with well-controlled asthma on high-intensity medications. Inconsistent with guideline recommendations, 82% of residents overall did not step down treatment for a patient with well-controlled asthma receiving low-intensity therapy; 75% of residents did not step up treatment for a patient with a recent hospitalization for asthma. Of the 3 vignettes evaluating non-guideline-based indicators of asthma status, a majority of residents (60%) stepped up treatment for parental reports of worse asthma, while a minority did so for a parental report of being bothered by their child's asthma (27%) or when wheezing was reported at physical examination (43%). There were no statistically significant differences for any of the comparisons by year in training.

CONCLUSIONS

Pediatric residents' management of asthma is consistent with national guidelines in some cases but not in others. There were no differences in the outpatient asthma management decisions between residents by years in training. Educational efforts should be focused on strategies to facilitate pediatric resident adherence to national asthma guideline recommendations for outpatient asthma management.

Guideline-inconsistent breast cancer screening for women over 50: a vignette-based survey

BACKGROUND

Professional organizations have issued guidelines recommending breast cancer screening for women 50 years of age.

OBJECTIVE

This study examines the percent of U.S. primary care physicians who report breast cancer screening practices that are not consistent with guidelines, and the characteristics of physicians who reported offering extra test modalities.

DESIGN

We analyzed a subset of a 2008 cross-sectional Women's Health Care survey sent to primary care physicians randomly selected from the national American Medical Association (AMA) Physician Masterfile. A subset of physicians received a survey that presented a vignette of a health maintenance visit for an asymptomatic 51-year-old woman who was not at high risk for breast cancer. Responses were weighted to represent physicians nationally.

PARTICIPANTS

1,654 U.S. family physicians, general internists, and obstetrician-gynecologists under age 65, who practiced in office or hospital based settings (62.8 % response rate). After exclusions, 553 study physicians remained for analysis.

MAIN MEASURE

Physician self-report of breast cancer screening practices that are not consistent with the recommendations of the U.S. Preventive Services Task Force (USPSTF), the American College of Obstetrics and Gynecology (ACOG), and the American Cancer Society (ACS), defined as almost always offering mammography.

KEY RESULTS

36.0 % (95 % CI: 31.8 %-40.5 %) of physicians reported offering breast cancer screening tests inconsistent with national guidelines, with most offering extra tests (magnetic resonance imaging [MRI] and/or ultrasound) (33.2 %, 95 % CI 29.1 %-37.6 %). In adjusted analysis, risk-averse physicians and those who believed in the clinical effectiveness of MRI were more likely to offer extra breast cancer screening tests.

CONCLUSIONS

Physicians often report offering breast cancer screening test modalities beyond those recommended for a 51-year-old woman. Strategies, such as academic detailing regarding appropriate use of technology and provision of clinical decision support for breast cancer screening, could decrease overuse of resources.

Accuracy of dialysis medical records in determining patients' interest in and suitability for transplantation

BACKGROUND

We sought to determine the accuracy of dialysis medical records in identifying patients' interest in and suitability for transplantation.

STUDY DESIGN

Cluster randomized controlled trial.

SETTING AND PARTICIPANTS

A total of 167 patients recruited from 23 hemodialysis facilities.

INTERVENTION

Navigators met with intervention patients to provide transplant information and assistance. Control patients continued to receive usual care.

OUTCOMES

Agreement at study initiation between medical records and (i) patient self-reported interest in transplantation and (ii) study assessments of medical suitability for transplant referral.

MEASUREMENTS

Medical record assessments, self-reports, and study assessments of patient's interest in and suitability for transplantation.

RESULTS

There was disagreement between medical records and patient self-reported interest in transplantation for 66 (40%) of the 167 study patients. In most of these cases, patients reported being more interested in transplantation than their medical records indicated. The study team determined that all 92 intervention patients were medically suitable for transplant referral. However, for 38 (41%) intervention patients, medical records indicated that they were not suitable. About two-thirds of these patients successfully moved forward in the transplant process.

CONCLUSION

Dialysis medical records are frequently inaccurate in determining patient's interest in and suitability for transplantation.

Impact of rheumatoid arthritis disease activity test on clinical practice

Background

Variability exists in the assessment of disease activity in rheumatoid arthritis (RA) patients that may affect quality of care.

Objectives

To measure the impact on quality of care of a Multi-Biomarker Disease Activity (MBDA) test that quantitatively assesses RA disease activity.

Methods

Board-certified rheumatologists without prior experience with the MBDA test (N = 81) were randomized into an intervention or control group as part of a longitudinal randomized-control study. All physicians were asked to care for three simulated RA patients, using Clinical Performance and Value (CPV™) vignettes, in a before and after design. CPV™ vignettes have been validated to assess the quality of clinical practice and identify variation in care. The vignettes covered all domains of a regular patient visit; scores were determined as a percentage of explicit predefined criteria completed. Three vignettes, representing typical RA cases, were administered each round. In the first round, no physician received information about the MBDA test. In the second round, only physicians in the intervention group were given educational materials about the test and hypothetical test results for each of the simulated patients. The outcome measures were the overall quality of care, disease assessment and treatment.

Results

The overall quality scores in the intervention group improved by 3 percent (p = 0.02) post-intervention compared with baseline, versus no change in the control group. The greatest benefit in the intervention group was to the quality of disease activity assessment and treatment decisions, which improved by 12 percent (p<0.01) compared with no significant change in the control group. The intervention was associated with more appropriate use of biologic and/or combination DMARDs in the co-morbidity case type (p<0.01).

Conclusions

Based on these results, use of the MBDA test improved the assessment and treatment decisions for simulated cases of RA and may prove useful for rheumatologists in clinical practice.

Physicians' beliefs about breast cancer surveillance testing are consistent with test overuse

BACKGROUND

Overuse of surveillance testing for breast cancer survivors is an important problem but its extent and determinants are incompletely understood. The objectives of this study were to determine the extent to which physicians' breast cancer surveillance testing beliefs are consistent with test overuse, and to identify factors associated with these beliefs.

METHODS

During 2009-2010, a cross-sectional survey of US medical oncologists and primary care physicians (PCPs) was carried out. Physicians responded to a clinical vignette ascertaining beliefs about appropriate breast cancer surveillance testing. Multivariable analyses examined the extent to which test beliefs were consistent with overuse and associated with physician and practice characteristics and physician perceptions, attitudes, and practices.

RESULTS

A total of 1098 medical oncologists and 980 PCPs completed the survey (response rate 57.5%). Eighty-four percent of PCPs [95% confidence interval (CI), 81.4%-86.5%] and 72% of oncologists (95% CI, 69.8%-74.7%) reported beliefs consistent with blood test overuse, whereas 50% of PCPs (95% CI, 47.3%-53.8%) and 27% of oncologists (95% CI, 23.9%-29.3%) reported beliefs consistent with imaging test overuse. Among PCPs, factors associated with these beliefs included smaller practice size, lower patient volume, and practice ownership. Among oncologists, factors included older age, international medical graduate status, lower self-efficacy (confidence in knowledge), and greater perceptions of ambiguity (conflicting expert recommendations) regarding survivorship care.

CONCLUSIONS

Beliefs consistent with breast cancer surveillance test overuse are common, greater for PCPs and blood tests than for oncologists and imaging tests, and associated with practice characteristics and perceived self-efficacy and ambiguity about testing. These results suggest modifiable targets for efforts to reduce surveillance test overuse.

Nonrecommended breast and colorectal cancer screening for young women: a vignette-based survey

BACKGROUND

Little is known about the prevalence of physicians offering nonrecommended breast or colorectal cancer screening for young women.

PURPOSE

The goal of the current paper was to examine the percentage of primary care physicians nationally who self-report offering breast or colorectal cancer screening tests for young women, and physician/practice characteristics associated with such recommendations.

METHODS

Analysis was performed in 2011 on data from a 2008 cross-sectional survey presenting a vignette of a health maintenance visit by an asymptomatic woman aged 35 years. This study included surveys sent to 1546 U.S. family physicians, general internists, and obstetrician-gynecologists aged <65 years, randomly selected from the AMA Physician Masterfile (60.6% response rate). Relevant respondent subsamples were used for the breast (n=505) and colorectal (n=721) cancer screening analyses. Responses were weighted to represent physicians nationally. The main outcome was physician self-report of offering breast or colorectal cancer screening tests.

RESULTS

75.3% (95% CI =71.0%, 79.2%) of physicians offered breast cancer screening tests; most commonly these physicians reported offering mammography alone (76.5%, 95% CI= 71.6%, 80.8%). A total of 39.3% (95% CI=35.5%, 43.2%) of physicians offered colorectal cancer screening tests; most commonly these physicians reported offering FOBT alone (43.3%, 95% CI=37.2%, 49.6%). In adjusted analysis, physician factors associated with offering breast and colorectal cancer screening tests were: estimating higher patient breast/colorectal cancer risk, and not listing the U.S. Preventive Services Task Force as a top influential organization.

CONCLUSIONS

A high percentage of physicians report offering nonrecommended breast or colorectal cancer screening tests for young women. Physicians' higher cancer-risk estimation accounted for some overscreening, but even physicians who estimated the patient to be at the same risk as the general population reported offering nonrecommended screening tests.

Pharmacists' provision of information to Spanish-speaking patients: a social cognitive approach

BACKGROUND

Hispanics with limited English proficiency face communication challenges that affect medication use and outcomes. Pharmacists are poised to help patients' use medications safely and effectively; however, scant research has explored factors that may impact pharmacists' communication with Spanish-speaking patients (SSPs).

OBJECTIVE

Guided by social cognitive theory (SCT), the purpose of this study was to examine the relationships between pharmacy environmental factors, pharmacists' cognition, and pharmacists' communication with SSPs.

METHODS

A cross-sectional survey used a vignette to quantify the amount of information pharmacists would provide to an SSP. Pharmacy environmental factors (language-assistance resources, Spanish-speaking staff, and number of SSPs) and pharmacists' cognition (self-efficacy beliefs and cultural sensitivity) that may influence communication also were assessed. The relationships between environmental factors, cognition, and pharmacists' communication with SSPs, including indirect relationships, were examined using composite indicator structural equation (CISE) modeling.

RESULTS

Of the 183 respondents, most were white (91%) and male (63%) with a mean age of 47 years (SD = 12.77). The CISE modeling revealed that the number of SSPs served by the pharmacy and the pharmacist's self-efficacy in communicating with SSPs were significantly directly associated with pharmacist's provision of information to SSPs. Two environmental factors (presence of interpreter services and Spanish-speaking staff) operated indirectly through self-efficacy to significantly impact the provision of information.

CONCLUSIONS

Study findings identify both environmental factors and cognition that could contribute to pharmacists' communication behavior with SSPs. Thus, future interventions to improve pharmacists' communication with SSPs may include training pharmacists to integrate interpretative services and Spanish-speaking staff into service delivery and strengthening pharmacists' self-efficacy beliefs.

Attention to body mass index by child psychiatry providers when prescribing second-generation antipsychotic medication to children: a survey study using a clinical vignette

AIM

We sought to determine whether weight and body mass index measurement were taken into consideration when prescribing second-generation antipsychotic (SGA) medication to a child.

METHODS

Two hundred clinicians were surveyed using a hypothetical clinical case vignette at a child psychopharmacology, postgraduate medical education course. The vignette described an overweight 10-year-old boy who was about to be prescribed an SGA medication to control psychotic symptoms. The reference to the patient's being 'overweight' was purposefully included to determine if providers would assess the patient's risk of morbidity from the metabolic side effects of the SGAs at the time of prescribing.

RESULTS

Only 7.0% of prescribers listed either 'body mass index' or a combination of 'height' and 'weight' as part of their next treatment steps for an overweight child before prescribing an SGA.

CONCLUSIONS

These results suggest the need for education as to the importance of body mass index monitoring when prescribing second-generation antipsychotic medications to children.

How Do Perceptions of Asthma Control and Severity Relate to Indicators of Asthma Status and Treatment Recommendations by Pediatricians?

BACKGROUND: According to National Institutes of Health (NIH) guidelines, asthma control and severity are unique constructs. Little is known about how asthma control and severity are distinguished by pediatricians and if they influence treatment recommendations. METHODS: We conducted a random-sample survey of 500 pediatricians using patient vignettes with different asthma status indicators (recent hospitalization, parental report of bother from asthma, frequent symptoms, parental report of worsening asthma, and wheeze during physical exam) and a visual analog scale (VAS) to rate control and severity. Regression models assessed the independent effects of these indicators on asthma control and severity ratings, and the effects of these ratings on treatment recommendations. RESULTS: A total of 270 respondents provided usable data. Compared to patients with well-controlled asthma: (1) medication intensity influenced only severity ratings; (2) frequent symptoms and recent hospitalization influenced control and severity ratings; (3) wheeze and bother influenced control ratings only (p<0.001 for all comparisons); (4) a report of worse asthma did not significantly affect any ratings (p>0.2). Poorer VAS control ratings were associated with recommendations to step-up treatment (odds ratio [OR] 2.61, 95% confidence interval [CI], 2.2-3.1, p<0.001), but more severe VAS ratings were not (OR 1.02, 95% CI, 0.9-1.2, p=0.8). Recommendations to step-down treatment were associated with poorer VAS control ratings (OR 0.70, 95% CI, 0.6-0.8, p<0.001) and more severe VAS ratings (OR 0.82, 95% CI, 0.7-0.9, p<0.001). CONCLUSIONS: Pediatricians who step-up asthma treatment base their assessments on asthma control, while assessments of both control and severity factor into their decision to step-down asthma therapy.

Prevalence, predictors, and patient outcomes associated with physician co-management: findings from the Los Angeles Women's Health Study

BACKGROUND

Physician co-management, representing joint participation in the planning, decision-making, and delivery of care, is often cited in association with coordination of care. Yet little is known about how physicians manage tasks and how their management style impacts patient outcomes.

OBJECTIVES

To describe physician practice style using breast cancer as a model. We characterize correlates and predictors of physician practice style for 10 clinical tasks, and then test for associations between physician practice style and patient ratings of care.

METHODS

We queried 347 breast cancer physicians identified by a population-based cohort of women with incident breast cancer regarding care using a clinical vignette about a hypothetical 65-year-old diabetic woman with incident breast cancer. To test the association between physician practice style and patient outcomes, we linked medical oncologists' responses to patient ratings of care (physician n=111; patient n=411).

RESULTS

After adjusting for physician and practice setting characteristics, physician practice style varied by physician specialty, practice setting, financial incentives, and barriers to referrals. Patients with medical oncologists who co-managed tasks had higher patient ratings of care.

CONCLUSION

Physician practice style for breast cancer is influenced by provider and practice setting characteristics, and it is an important predictor of patient ratings. We identify physician and practice setting factors associated with physician practice style and found associations between physician co-management and patient outcomes (e.g., patient ratings of care).

Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States

OBJECTIVE

Guidelines recommend when the human papillomavirus (HPV) and Papanicolaou tests are used together (HPV co-test) for routine cervical cancer screening, screening intervals can be extended to 3 years. We assessed HPV test practices and Papanicolaou test screening interval recommendations of US providers.

STUDY DESIGN

Using a multistage probability design, we analyzed nationally representative data that were collected in 2006 through the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.

RESULTS

Approximately 51% of providers ordered the HPV co-test; however, clinical vignettes found that <15% of providers who ordered the HPV test recommend the next Papanicolaou test in 3 years for women with concurrent normal HPV co-test results and a documented normal screening history.

CONCLUSION

Overall, annual cervical cancer screening continues to be a common recommendation, regardless of whether a screening history has been established or an HPV test has been ordered.

Chart documentation quality and its relationship to the validity of administrative data discharge records

The validity of administrative data may be vulnerable to how well physicians document medical charts. The objective of this study is to determine the relationship between chart documentation quality and the validity of administrative data. The charts for patients who underwent carotid endarterectomy were re-abstracted and rated for the quality of documentation. Poorly and well-documented charts were compared by patient, physician, and hospital variables, as well as on agreement between the administrative and re-abstracted data. Of the 2061 charts reviewed, 42.6 per cent were rated well documented. The proportion of charts well documented varied from 14.6 to 87.5 per cent across 17 hospitals, but did not vary significantly by patient characteristics. The kappa statistic was generally higher for well-documented charts than for poorly documented charts, but varied across comorbidities. In conclusion, poorly documented hospital charts tend to be translated into invalid administrative data, which reduces the communication of clinical information among healthcare providers.

The quality of primary care in a country with universal health care coverage

BACKGROUND

Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage.

OBJECTIVE

To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage.

DESIGN AND PARTICIPANTS

Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings.

MAIN MEASURES

We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator.

KEY RESULTS

Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including >75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients <65 years (70.1% vs 68.0% in those ≥ 65 years, p = 0.047).

CONCLUSIONS

Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.

Postpartum mental health screening and diagnosis by obstetrician-gynecologists

Postpartum depression (PPD) and postpartum psychosis (PPP) can impact mother, infant, and family. Obstetrician-gynecologists (ob-gyns) are often the most frequent medical contact for postpartum women, and so are in a position to identify women needing psychological care. This study assessed ob-gyns' knowledge, attitudes, and practices regarding diagnosing PPD/PPP. A survey was sent to 400 members of the American College of Obstetricians and Gynecologists who have volunteered to participate in research. Response rate was 56%. Routine screening for PPD and PPP is conducted by 72% and 30% of respondents, respectively. Personal experience (through friend, family, or self) was associated with increased screening. Perceived PPP screening barriers are similar to those found in the PPD literature: time constraints, lack of training, and lack of knowledge of diagnostic criteria. In responding to standardised vignettes, physicians were more likely to over-diagnose, than under diagnose PPD/PPP. This study is the first to provide exploratory data of ob-gyns' knowledge, attitudes, and practice regarding PPD and PPP. Ob-gyns are screening for PPD/PPP, though not universally so. Future research should identify ways to mitigate screening barriers.

Multiple clinical practice guidelines for breast and cervical cancer screening: perceptions of US primary care physicians

BACKGROUND

Multiple clinical practice guidelines exist for breast and cervical cancer screening, and differ in aggressiveness with respect to the recommended frequency and target populations for screening.

OBJECTIVES

To determine (1) US primary care physicians' (PCPs) perceptions of the influence of different clinical practice guidelines; (2) the relationship between the number, aggressiveness, and agreement of influential guidelines and the aggressiveness of physicians' screening recommendations; and (3) factors associated with guideline perceptions.

RESEARCH DESIGN AND METHODS

A nationally representative sample of 1212 PCPs was surveyed in 2006-2007. Cross-sectional analyses examined physicians' perceptions of the influence of different breast and cervical cancer screening guidelines, the relationship of guideline perceptions to screening recommendations in response to hypothetical vignettes, and the predictors of guideline perceptions.

RESULTS

American Cancer Society and American College of Obstetricians and Gynecologists guidelines were perceived as more influential than other guidelines. Most physicians (62%) valued multiple guidelines, and conflicting and aggressive rather than conservative guideline combinations. The number, aggressiveness, and agreement of influential guidelines were associated with the aggressiveness of screening recommendations (P < 0.01)-which was highest for physicians valuing multiple-aggressive, lowest for physicians valuing multiple-conservative, and intermediate for physicians valuing multiple-conflicting, single, and no guidelines. Obstetrician/gynecologists specialty predicted valuation of aggressive guidelines (P < 0.001).

CONCLUSIONS

PCPs' perceptions of cancer screening guidelines vary, relate to screening recommendations in logically-consistent ways, and are predicted by specialty and other factors. The number, aggressiveness, and agreement of valued guidelines are associated with screening recommendations, suggesting that guideline multiplicity is an important problem in clinical decision-making.

U.S. primary care physicians' lung cancer screening beliefs and recommendations

BACKGROUND

No high-quality study to date has shown that screening reduces lung cancer mortality, and expert groups do not recommend screening for asymptomatic individuals. Nevertheless, lung cancer screening tests are available in the U.S., and primary care physicians (PCPs) may have a role in recommending them to patients.

PURPOSE

This study describes U.S. PCPs' beliefs about and recommendations for lung cancer screening and examines characteristics of PCPs who recommend screening.

METHODS

A nationally representative survey of practicing PCPs was conducted in 2006-2007. Mailed questionnaires were used to assess PCPs' beliefs about lung cancer screening guidelines and the effectiveness of screening tests and to determine whether PCPs would recommend screening for asymptomatic patients. Data were analyzed in 2009.

RESULTS

Nine hundred sixty-two PCPs completed the survey (absolute response rate=70.6%; cooperation rate=76.8%). One quarter said that major guidelines support lung cancer screening. Two thirds said that low-radiation dose spiral computed tomography (LDCT) screening is very or somewhat effective in reducing lung cancer mortality in current smokers; LDCT was perceived as more effective than chest x-ray or sputum cytology. Responding to vignettes describing asymptomatic patients of varying smoking exposure, 67% of PCPs recommended lung cancer screening for at least one of the vignettes. Most PCPs recommending screening said they would use chest x-ray; up to 26% would use LDCT. In adjusted analyses, PCPs' beliefs and practice style were strongly associated with their lung cancer screening recommendations.

CONCLUSIONS

Many PCPs' lung cancer screening beliefs and recommendations are inconsistent with current evidence and guidelines. Provider education regarding the evidence base and guideline content of lung cancer screening is indicated.

A comparison of standardised patients, record abstraction and clinical vignettes for the purpose of measuring clinical practice

BACKGROUND

A recent review found standardised patient (SP) methodology to be the gold standard method for evaluating clinical care. Alternative methods include record abstraction and computerised clinical vignettes. SPs were compared to clinical records and to computerised vignettes in order to assess whether record abstraction and vignettes are accurate measures of clinical care provided within optometry.

METHODS

A total of 111 community optometrists in the south east of the UK consented to be visited by unannounced actors for an eye examination. The SPs received extensive training to enable accurate reporting of the content of the eye examinations using checklists. Clinical records were requested from optometrists who chose to receive feedback following the SP visits. The SP checklists were used as a guide to extract relevant information from the clinical records. An opportunity was made available to all UK qualified optometrists, through publicity in the College of Optometrists' monthly newsletter, the Association of Optometrists' monthly newsletter (Blink) and the UK optometry e-mail discussion list to complete three computerised clinical vignettes by performing a virtual eye examination using an on-line optometric record card. The average differences were calculated between the record abstraction and vignette results compared to the standardised patient encounter findings for different domains of an eye examination. Chi-square analyses were performed on the tests which were of the greatest clinical significance for each scenario.

RESULTS

The average overall difference for information gathered from record abstraction compared to the standardised patient encounter ranged from +2 to -26% (positive values indicate items that were recorded on the clinical records but not reported by the SP). For history and symptoms, the average difference ranged from -9 to -26%; for the proportion of tests performed during the examination this value ranged from +2 to -24% and for management issues the difference ranged from -1 to -4%. The average overall difference for the vignette data compared to the standardised patient encounter ranged from 0 to +26% (positive values indicate items that were not carried out in a clinical setting, as recorded by the SP, but were described by optometrists who completed the vignette as tests they would have carried out). For history and symptoms, the average difference for the vignette data ranged from +2 to +26%; from 0 to +20% for tests performed during the eye examination and from 0 to +11% for management.

CONCLUSION

Different methods of measuring clinical care capture different elements of clinical practice and are prone to different biases. This three-way comparison indicates that clinical records tend to under-estimate actual care provided, while vignette scores tend to over-estimate clinical performance. Low participation rates mean that the participating optometrists could be described as a 'self-selected sample'. This is a limitation of the research and the conclusions should be considered with this in mind. The significance of these findings for future research and for litigation and disciplinary cases is discussed.

Bullying in children who stutter: speech-language pathologists' perceptions and intervention strategies

Bullying in school-age children is a global epidemic. School personnel play a critical role in eliminating this problem. The goals of this study were to examine speech-language pathologists' (SLPs) perceptions of bullying, endorsement of potential strategies for dealing with bullying, and associations among SLPs' responses and specific demographic and practice-oriented variables. A survey was developed and mailed to 1000 school-based SLPs. Six vignettes describing episodes of physical, verbal, and relational bullying of hypothetical 10-year students who stutter were developed. Three vignettes described bullying specifically mentioning stuttering behaviors, while three described bullying without mentioning stuttering behavior. The data from 475 SLPs were analyzed. SLPs rated physical bullying as most serious and in need of intervention, followed by verbal bullying. Relational bullying was rated as not serious or in need of intervention. SLPs also responded to the likelihood of using strategies for dealing with bullying. Physical and verbal bullying elicited the use of "talking with the teacher", "working with school personnel", and "reassuring the child of his safety" strategies. Relational bullying elicited "ignore the problem" and "be more assertive" strategies. Correlations among variables are reported. The seriousness of physical and verbal bullying, likelihood of intervention, and the lack of knowledge about relational bullying is discussed.

EDUCATIONAL OBJECTIVES

Readers should be able to: (1) summarize the research describing the negative effects of three major types of bullying, (2) summarize the research describing bullying and children with communication disorders, especially stuttering, (3) report results of a survey of speech-language pathologists' (SLPs) perceptions of bullying in school-age children, (4) explain the perceived seriousness of the problem by SLPs and likelihood of intervention, and (5) describe the need for continued prevention and intervention activities for children who stutter.