An automated scoring algorithm for computerized clinical vignettes: Evaluating physician performance against explicit quality criteria

Differences in NAFLD/NASH Management by Provider Specialty: Opportunities for Optimizing Multidisciplinary Care

Purpose

Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are a part of a complex metabolic disease process requiring a multi-faceted and multidisciplinary management approach. This study was conducted to identify areas where medical education across a multidisciplinary team could be optimized in providing optimal care of patients with NAFLD/NASH.

Methods

A survey instrument including a patient case vignette was developed to understand approaches of US clinicians to diagnosis and management of patients with NAFLD/NASH. The survey was fielded via email in December 2020–January 2021. Analysis was conducted using embedded Qualtrics analytic software.

Results

There were 629 survey respondents: 318 PCPs, including physicians, NPs, and PAs, 57 hepatologists, 156 gastroenterologists, and 98 endocrinologists. Survey results demonstrated variation in likelihood to screen patients for NAFLD/NASH among specialists and PCPs as well as in the types of clinicians that respondents would involve in the initial management of a patient diagnosed with NASH. Notably, between 15% and 33% across respondent clinician types would not include any other clinicians or medical specialists in initial management. For a patient with newly diagnosed NASH, the most likely initial management recommendations included drug therapy to improve control of diabetes and therapy to lower lipids and were less likely to recommend drug therapy for weight loss, drug therapy for NASH, or bariatric surgery. Respondents rated “poor patient adherence to lifestyle modifications” and “lack of approved therapies for NASH” as the most significant barriers to optimal management of patients with NASH.

Conclusion

Variation in the evaluation and management of patients with NAFLD/NASH across PCPs and medical subspecialists was identified in this study. Education aimed at multidisciplinary roles in optimally managing patients with NAFLD/NASH, can be beneficial, particularly if focused on increasing screening, implementing guideline updates as they emerge, and incorporating new therapies as they gain approval for clinical practice.

Management of Schizophrenia with Long-Acting Injectable Antipsychotic Medications: An Assessment of the Educational Needs of Clinicians

PURPOSE

Schizophrenia is a chronic and serious mental disorder characterized by disturbances in thought, perception, and behavior that impair daily functioning and quality of life. Long-acting injectable (LAI) antipsychotic medications may improve long-term outcomes over oral medications; however, LAI antipsychotic medications are often only considered as a last resort late in the disease course. This study sought to assess current clinical practice patterns, clinicians' attitudes, and barriers to the use of LAI antipsychotic medications as well as identify unmet educational needs of psychiatric clinicians in managing patients with schizophrenia.

METHODS

A survey was distributed via email to 2330 United States-based clinicians who manage patients with schizophrenia; 379 completed the survey and were included for analysis. The survey included five patient case-based scenarios, with seven decision points. Data were analyzed with qualitative and quantitative methodologies.

RESULTS

Clinicians were most confident in determining when to initiate treatment and least confident in transitioning to injectable therapy or administering injectable therapy. Clinicians cited nonadherence, and not wanting to take daily medicine or the "hassle" of frequent treatment, as key factors for which patients were most suitable for an LAI antipsychotic medication. Patient nonadherence was considered the most important barrier to optimal management of patients with schizophrenia. A clinician's perception of relapse was a strong driver of whether or not the clinician would discuss/recommend an LAI antipsychotic medication.

CONCLUSION

This study suggests that clinicians may be reluctant to discuss or recommend switching patients to an LAI antipsychotic medication if they are perceived as doing well on current therapy. These results will inform future research and continuing education that aims to improve the confidence, knowledge, and competence of clinicians who provide care for patients with schizophrenia who may benefit from treatment with an LAI antipsychotic medication and clinicians who may be more likely to routinely offer an LAI antipsychotic medication to their patients.

An assessment of the continuing medical education needs of US physicians in the management of patients with beta thalassemia

Patients with beta thalassemia are benefitting from longer life expectancies, highlighting the importance of appropriate transition from pediatric to adult care. Data are limited regarding continuity of care and adult hematologists’ management of patients with beta thalassemia. We conducted a survey of practicing US hematologists to identify practice gaps, attitudes, and barriers to optimal patient management among US-practicing hematologists. A total of 42 responses were collected, with 19 (45%) practicing at a beta thalassemia center of excellence (CoE). Nearly 90% of CoE physicians said they had a transition protocol or plan in place versus 30% of non-CoE physicians. Most physicians said parents should remain actively involved in medical visits. Adherence was rated as the most important patient education topic during transition. The most significant barrier cited was patient reluctance to transition away from pediatric care. Physicians in CoEs as compared with non-CoE physicians reported greater knowledge of beta thalassemia and familiarity with butyrates, gene therapy, and luspatercept. Highly rated topics for beta thalassemia-focused CME activities included management of complications and clinical trial updates. These findings suggest practice gaps and barriers to optimal care in the transition from pediatric to adult care, the ongoing management of adult patients, knowledge of the disease state, and familiarity with emerging treatments. Differences CoE vs non-CoE physician responses suggest variations in knowledge, practice, and attitudes that may be helpful in tailoring CME activities to different learner audiences. The small sample size used in some sub-analyses may not be representative of all hematologists treating beta thalassemia patients.

Improving mental health through integration with primary care in rural Karnataka: study protocol of a cluster randomized control trial

BACKGROUND

People who are diagnosed with both mental and chronic medical illness present unique challenges for the health care system. In resource-limited settings, such as rural India, people with depression and anxiety are often under-served, due to both stigma and lack of trained providers and resources. These challenges can lead to complications in the management of chronic disease as well as increased suffering for patients, families and communities. In this study, we evaluate the effects of integrating mental health and chronic disease treatment of patients in primary health care (PHC) settings using a collaborative care model to improve the screening, diagnosis and treatment of depression in rural India.

METHODS

This study is a multi-level randomized controlled trial among patients with depression or anxiety and co-morbid diabetes, or cardiovascular disease. Aim 1 examines whether patients screened at community health-fairs are more likely to be diagnosed and treated for these co-morbid conditions than patients screened after presenting at PHCs. Aim 2 evaluates the impact of collaborative care compared to usual care in a cluster RCT, randomizing at the level of the PHCs. Intervention arm PHC staff are trained in mental health diagnoses, treatment, and the collaborative care model. The intervention also involves community-based "Healthy Living groups" co-led by Ashas, using cognitive-behavioral strategies to promote healthy behaviors. The primary outcome is severity of common mental disorders, with secondary outcomes being diabetes and cardiovascular risk, staff knowledge and patient perceptions.

DISCUSSION

If effective, our results will contribute to the field in five ways: 1) expand on implementation research in low resource settings by examining how multiple chronic diseases can be treated using integrated low-cost, evidence-based strategies, 2) build the capacity of PHC staff to diagnose and treat mental illness within their existing clinic structure and strengthen referral linkages; 3) link community members to primary care through community-based health fairs and healthy living groups; 4) increase mental health awareness in the community and reduce mental health stigma; 5) demonstrate the potential for intervention scale-up and sustainability.

TRIAL REGISTRATION

http://Clinicaltrials.gov : NCT02310932 registered December 8, 2014 URL: https://clinicaltrials.gov/ct2/show/record/NCT02310932 ; Clinical Trials Registry India: CTRI/2018/04/013001 retrospectively registered on April 4, 2018.

Educational needs in the diagnosis and management of pediatric functional constipation: a US survey of specialist and primary care clinicians

OBJECTIVES

The goal of this study was to identify opportunities among gastroenterologists and gastroenterology nurse practitioners (NPs)/physician assistants (PAs) for continuing medical education (CME) related to functional constipation.

METHODS

An online, case-vignette survey was designed to identify and quantify practice patterns of pediatric gastroenterology clinicians. Case vignettes are a validated method for assessing clinician practice patterns. The survey consisted of three patient cases: a 3-year-old female with a 6-month history of constipation; a 6-year-old male with a 1-year history of constipation refractory to treatment and a sacral dimple with nearby tuft of hair; and a 16-year-old male with a 10-year history of constipation, and a sullen, depressed mood. Survey responses were compared to NASPGHAN guideline recommendations for diagnosis and management to identify areas where additional education may be beneficial.

RESULTS

Responses were collected from 197 gastroenterologists, 116 gastroenterology NPs/PAs, and 206 pediatrician/primary care clinicians. Several of the practice patterns observed suggest opportunities for future CME: low use of applicable Rome III diagnostic criteria; approximately 85% recommended testing beyond what is recommended for the 3-year-old patient; over 1/3 did not perform several recommended tests for the 6-year-old patient; and over 25% did not refer the 16-year-old patient for psychological evaluation. Further, there was little consensus in treatment approach among the three clinician groups. Primary care familiarity with NASPGHAN guidelines was low.

CONCLUSIONS

CME programs focusing on applying diagnostic criteria, matching diagnostic workup to patient presentation, treatment selection, and identifying patients who may benefit from psychological evaluation may fill knowledge and practice gaps of clinicians who manage pediatric patients with functional constipation.

Quality of care: measuring a neglected driver of improved health

The quality of care provided by health systems contributes towards efforts to reach sustainable development goal 3 on health and well-being. There is growing evidence that the impact of health interventions is undermined by poor quality of care in lower-income countries. Quality of care will also be crucial to the success of universal health coverage initiatives; citizens unhappy with the quality and scope of covered services are unlikely to support public financing of health care. Moreover, an ethical impetus exists to ensure that all people, including the poorest, obtain a minimum quality standard of care that is effective for improving health. However, the measurement of quality today in low- and middle-income countries is inadequate to the task. Health information systems provide incomplete and often unreliable data, and facility surveys collect too many indicators of uncertain utility, focus on a limited number of services and are quickly out of date. Existing measures poorly capture the process of care and the patient experience. Patient outcomes that are sensitive to health-care practices, a mainstay of quality assessment in high-income countries, are rarely collected. We propose six policy recommendations to improve quality-of-care measurement and amplify its policy impact: (i) redouble efforts to improve and institutionalize civil registration and vital statistics systems; (ii) reform facility surveys and strengthen routine information systems; (iii) innovate new quality measures for low-resource contexts; (iv) get the patient perspective on quality; (v) invest in national quality data; and (vi) translate quality evidence for policy impact.

Physician knowledge about and perceptions of obesity management

OBJECTIVE

Approximately 35% of US adults are obese. The purpose of this study was to assess the knowledge and practice patterns of primary care physicians (PCPs), endocrinologists (ENDOs), cardiologists (CARDs) and bariatricians (BARIs) regarding obesity.

METHODS

A case vignette survey was distributed to 1625 US-based PCPs, ENDOs, CARDs, and BARIs via email and fax in February 2013. Results were analysed with PASW Statistics 18.

RESULTS

Respondents included 100 PCPs, 100 ENDOs, 70 CARDs, and 30 BARIs. The majority agreed obesity is a disease as defined by the AMA, however, half of PCPs, ENDOs, and CARDs also agreed obesity results from a lack of self-control. Familiarity with select obesity guidelines was low. Nearly all respondents used body mass index for obesity screening. No consensus as to when to initiate weight-loss medication was observed. Many physicians expected a larger weight loss with pharmacotherapy than is realistic (∼ 30%) or were unsure (∼ 22%). A majority of PCPs, ENDOs and CARDs expected less excess weight loss with gastric bypass surgery than is realistic, BARIs had a more reasonable expectation.

CONCLUSIONS

Overall, respondents demonstrated knowledge gaps for obesity guidelines and pathophysiology and generally lacked understanding of obesity medication efficacy, safety and MOA.

Validation of a new method for testing provider clinical quality in rural settings in low- and middle-income countries: the observed simulated patient

Background

Assessing the quality of care provided by individual health practitioners is critical to identifying possible risks to the health of the public. However, existing assessment methods can be inaccurate, expensive, or infeasible in many developing country settings, particularly in rural areas and especially for children. Following an assessment of the strengths and weaknesses of the existing methods for provider assessment, we developed a synthesis method combining components of direct observation, clinical vignettes, and medical mannequins which we have termed “Observed Simulated Patient” or OSP. An OSP assessment involves a trained actor playing the role of a ‘mother’, a life-size doll representing a 5-year old boy, and a trained observer. The provider being assessed was informed in advance of the role-playing, and told to conduct the diagnosis and treatment as he normally would while verbally describing the examinations.

Methodology/Principal Findings

We tested the validity of OSP by conducting parallel scoring of medical providers in Myanmar, assessing the quality of their diagnosis and treatment of pediatric malaria, first by direct observation of true patients and second by OSP. Data were collected from 20 private independent medical practitioners in Mon and Kayin States, Myanmar between December 26, 2010 and January 12, 2011. All areas of assessment showed agreement between OSP and direct observation above 90% except for history taking related to past experience with malaria medicines. In this area, providers did not ask questions of the OSP to the same degree that they questioned real patients (agreement 82.8%).

Conclusions/Significance

The OSP methodology may provide a valuable option for quality assessment of providers in places, or for health conditions, where other assessment tools are unworkable.

Development of a documentation instrument for the conservative treatment of spinal disorders in the International Spine Registry, Spine Tango

Spine Tango is the first and only International Spine Registry in operation to date. So far, only surgical spinal interventions have been recorded and no comparable structured and comprehensive documentation instrument for conservative treatments of spinal disorders is available. This study reports on the development of a documentation instrument for the conservative treatment of spinal disorders by using the Delphi consensus method. It was conducted with a group of international experts in the field. We also assessed the usability of this new assessment tool with a prospective feasibility study on 97 outpatients and inpatients with low back or neck pain undergoing conservative treatment. The new 'Spine Tango conservative' questionnaire proved useful and suitable for the documentation of pathologies, conservative treatments and outcomes of patients with low back or neck problems. A follow-up questionnaire seemed less important in the predominantly outpatient setting. In the feasibility study, between 43 and 63% of patients reached the minimal clinically important difference in pain relief and Core Outcome Measures Index at 3 months after therapy; 87% of patients with back pain and 85% with neck pain were satisfied with the received treatment. With 'Spine Tango conservative' a first step has been taken to develop and implement a complementary system for documentation and evaluation of non-surgical spinal interventions and outcomes within the framework of the International Spine Registry. It proved useful and feasible in a first pilot study, but it will take the experience of many more cases and therapists to develop a version similarly mature as the surgical instruments of Spine Tango.

Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events

Background

Adherence to clinical practice guidelines for management of cardiovascular disease (CVD) is suboptimal. The purposes of this study were to identify practice patterns and barriers among U.S. general internists and family physicians in regard to cardiovascular risk management, and examine the association between physician characteristics and cardiovascular risk management.

Methods

A case vignette survey focused on cardiovascular disease risk management was distributed to a random sample of 12,000 U.S. family physicians and general internists between November and December 2006.

Results

Responses from a total of 888 practicing primary care physicians who see 60 patients per week were used for analysis. In an asymptomatic patient at low risk for cardiovascular event, 28% of family physicians and 37% of general internists made guideline-based preventive choices for no antiplatelet therapy (p < .01). In a patient at high risk for cardiovascular event, 59% of family physicians and 56% of general internists identified the guideline-based goal for serum fasting LDL level (< 100 mg/dl). Guideline adherence was inversely related to years in practice and volume of patients seen. Cost of medications (87.7%), adherence to medications (74.1%), adequate time for counseling (55.7%), patient education tools (47.1%), knowledge and skills to recommend dietary changes (47.8%) and facilitate patient adherence (52.0%) were cited as significant barriers to CVD risk management.

Conclusion

Despite the benefits demonstrated for managing cardiovascular risks, gaps remain in primary care practitioners' management of risks according to guideline recommendations. Innovative educational approaches that address barriers may facilitate the implementation of guideline-based recommendations in CVD risk management.