Average Physician Research Articles

Venomous Bites and Stings

Approximately 8000 persons are bitten by venomous snakes in the US each year. Mortality is low (4 to 6/yr), but morbidity can be significant, treatment costly. Overuse of surgery and antivenom is common. Simply cutting the wound with attempted aspiration is not indicated. Fasciotomy should only be used for patients with elevated compartment pressures. CroFab is a highly effective (but expensive) treatment useful for serious envenomation. Antivenom should be used in patients with life-threatening symptoms (hypotension, clinical coagulopathy) or rapid advancement of local signs, and to reduce compartment pressures to avoid fasciotomy. The most significant morbidity from insect envenomation is secondary to anaphylaxis. A bite from the black widow spider can induce abdominal cramping and pain that can mimics an acute abdomen. Brown recluse envenomation can produce tissue necrosis and long-term complications. Most events are seen rarely by the average physician; this review can be a useful guide in management. Key words: antivenom, copperhead bite, CroFab, insect bite, rattlesnake bite, snakebite, water moccasin bite

The impact of provider consolidation on physician prices.

When a clinic system is acquired by an integrated delivery system (IDS), the ownership change includes both vertical integration with the hospital(s), and horizontal integration with the IDS's previously owned or "legacy" clinics, causing increased market concentration in physician services. Although there is a robust literature on the impact of hospital market concentration, the literature on physician market concentration is sparse. The objective of this study is to determine the impact on physician prices when two IDSs acquired three multispecialty clinic systems in Minneapolis-St Paul, Minnesota at the end of 2007, using commercial claims data from a large health plan (2006-2011). Using a difference-in-differences model and nonacquired clinics as controls, we found that fouryears after the acquisitions (2011), average physician price indices in the acquired clinic systems were 32-47% higher than expected in absence of the acquisitions. Average physician prices in the IDS legacy clinics were 14-20% higher in 2011 than expected. Procedure-specific prices for common office visit and inpatient procedures also increased following the acquisitions.

Financial Impact of Percutaneous Tibial Nerve Stimulation (PTNS) Treatment [10G

INTRODUCTION: To estimate average quarterly medication and physician visit costs for patients with refractory overactive bladder, before and after 12 sessions of Percutaneous Tibial Nerve Stimulation (PTNS) treatment. METHODS: This is a retrospective case series for patients undergoing PTNS for the treatment of refractory overactive bladder. 23 patients had 12 weekly sessions of initial PTNS treatment; 18 met the criteria for 3-month follow-up before and after treatment. Number of follow-up visits, PTNS maintenance visits, and medications were collected quarterly for a year before and after treatment. Using known medication and visit costs, we calculated mean quarterly costs, and standard deviations for patients, and measured their significance using a 2-tailed paired t-test. RESULTS: The average quarterly medication cost decreased from $656.40 ±292.45 to $375.51 ±331.80 after PTNS (p=0.01). The average number of quarterly provider follow-up visits decreased from 1.34 ±0.78 to 0.40 ±0.63 (p=0.001). The average quarterly total provider cost was calculated using the cost of follow-up visits in addition to PTNS maintenance visits. The average quarterly total provider cost increased from $136.96 ±81.50 to $ 181.04 ±146.34 (p=0.286). However, the total provider cost for the last quarter decreased from $169.04 ±103.69 to $55.14 ±94.62 (p=.005). CONCLUSION: PTNS treatment significantly reduced the average quarterly cost of medications and the average number of provider follow-up visits on patients with refractory overactive bladder. The average total provider cost initially increased in the first three quarters following PTNS and decreased the last quarter due to a higher number of PTNS maintenance visits immediately after treatment.

Venomous Bites and Stings

Approximately 8000 persons are bitten by venomous snakes in the US each year. Mortality is low (4 to 6/yr), but morbidity can be significant, treatment costly. Overuse of surgery and antivenom is common. Simply cutting the wound with attempted aspiration is not indicated. Fasciotomy should only be used for patients with elevated compartment pressures. CroFab is a highly effective (but expensive) treatment useful for serious envenomation. Antivenom should be used in patients with life-threatening symptoms (hypotension, clinical coagulopathy) or rapid advancement of local signs, and to reduce compartment pressures to avoid fasciotomy. The most significant morbidity from insect envenomation is secondary to anaphylaxis. A bite from the black widow spider can induce abdominal cramping and pain that can mimics an acute abdomen. Brown recluse envenomation can produce tissue necrosis and long-term complications. Most events are seen rarely by the average physician; this review can be a useful guide in management. Key words: antivenom, copperhead bite, CroFab, insect bite, rattlesnake bite, snakebite, water moccasin bite

Abstract 26: Impact of Physician Payment Variation on Breast Reconstruction Method: A National Claims Database Analysis

PURPOSE: Despite associations with greater quality of life, autologous transfer represents a declining proportion of US breast reconstructions. Poor physician reimbursement relative to prosthetic reconstructions may be a barrier contributing to this trend. The study aims to evaluate the impact of relative physician payments for common methods of immediate breast reconstruction (IBR). METHODS: Following IRB approval, the Blue Health Intelligence (BlueCross/BlueShield) national claims database was analyzed from 2009 through 2013. Procedural volume and payments for plastic surgeon professional services were calculated for two common IBR methods: tissue expander (TE) and free flap (FF). RESULTS: Of 25,209 patients who had IBR, 84.4% received tissue expanders (TE) and 15.6% underwent free flaps(FF). Five-year growth-rate in TE: FF was 4.3%. Average physician payment increased 18% for TE versus 14% for FF. Payment variation, expressed as the standard deviation relative to mean, was significantly greater for FF (116%) than TE(59%). Markets that experienced a $1,000 gain in TE payment, increased the TE:FF on average 103% (p<.05). The same gains in FF payment increased the FF:TE by 74% (p<.05). CONCLUSION: Physician payments are increasing at a greater rate for TE than FF. Markets are significantly more responsive to payment changes in TE than FF, suggesting larger scale changes in payment would be needed to influence flap growth. An alternative interpretation is that barriers beyond reimbursement may influence the number of FF performed. Larger payment variation for FF supports greater room for reimbursement negotiation.

Patient autonomy within real or valid consent: Samira Kohli's case.

In bioethics literature, the primary justification for the requirement of informed consent has been the protection of autonomous choices. To allow patients to be autonomous decision-makers, physicians are supposed to disclose and share information related to all treatment, procedures and risks. Advocates of the autonomy-based informed consent model argue that in informed consent cases, the disclosure of information should be according to the reasonable person standard or reasonable patient standard, rather than the average competent physician standard. In the Indian medicolegal context, the concept of consent has evolved through the discussion of informed consent and by referring to the concepts of informed consent in other countries, such as the USA, the UK and Canada. In cases of medical negligence in India, the concept of "real or valid consent" has been adopted from British case law rather than the "informed consent" of the USA. This paper examines the doctrinal rules of the concept of real or valid consent through an analysis of Samira Kohli's case - a landmark court case and a major precedent case in India that referred to "real or valid consent". In analysing this case, the paper will examine the judiciary's decision on the nature of and standard for the disclosure of information. Thus, the paper will reflect on the underlying ethical and legal principles of the doctrine of real or valid consent in the Indian context. This paper uses a hermeneutic approach to the landmark case to provide a qualitative interpretation of the Indian medical judiciary's concept of consent and the autonomy of the patient.

Neurological Complications in Eosinophilic Granulomatosis with Polyangiitis (EGPA): The Roles of History and Physical Examinations in the Diagnosis of EGPA.

Objective To investigate the clinical symptoms, the physical and neurological findings, and the clinical course of neurological complications in eosinophilic granulomatosis with polyangiitis (EGPA). Methods A retrospective chart review of EGPA cases managed by two referral hospitals was performed, with a focus on the neurological findings. The study analyzed the symptoms at the onset of EGPA and investigated their chronological relationship. The patient delay (the delay between the onset of symptoms and the initial consultation), and the physician delay (the delay from consultation to the initiation of therapy) were determined and compared. The involved nerves were identified thorough a neurological examination. The cases with central nervous system (CNS) involvement were described. Results The average duration of symptoms prior to the initiating of therapy for sensory disturbances, motor deficits, rash, edema, and fever was 23, 5, 21, 18, and 24 days, respectively. Among the EGPA-specific symptoms, sensory disturbance was often the first symptom (63%), and was usually followed by the appearance of rash within four days (63%). The average physician delay (32.9±38.3 days) was significantly longer than the average patient delay (7.9±7.8 days; p=0.010). Reduced touch sensation in the superficial peroneal area, and weakness of dorsal flexion of the first toe secondary to deep peroneal nerve involvement, were highly sensitive for identifying the presence of peripheral nerve involvement in our series of patients with EGPA. Two cases, with CNS involvement, had multiple skin lesions over their hands and feet (Janeway lesions). Conclusion Japanese physicians are not always familiar with EGPA. It is important for us to consider this disease, when an asthmatic patient complains about the new onset of an abnormal sensation in the distal lower extremities, which is followed several days later by rash.

A Day at the Office: Political Advocacy and Private Practice

A Day at the Office: Political Advocacy and Private Practice

Quantifying and Predicting Surgeon Work Effort for Primary and Revision Total Knee Arthroplasty

BackgroundThe objectives of this study were to quantify increased utilization of resources in revision total knee arthroplasty (TKA) compared with primary TKA, determine preoperative factors that predict outcome measures, and compare Medicare reimbursement for each procedure. MethodsSeventy-eight revision TKA patients were compared with 80 primary TKA patients. Outcomes measured were surgical time, estimated blood loss, length of stay, and complications. ResultsRevision TKA showed 49% increased surgical time compared with primary TKA. Estimated blood loss was increased 91%. Tibial and femoral bone loss was associated with increased surgical time as was use of longer stemmed tibial components. Average Medicare hospital payment increased 29% ($13,464 for primary, $17,331 for revision). Average physician reimbursement represented a 36% increase. Relative value units were increased to 31%. ConclusionThere was substantial increase in work effort not commensurate with current Medicare reimbursement, which may limit patient access to revision TKA.

Clinical efficacy of autologous fat grafting with platelet-rich plasma for facial rejuvenation

Objective This single-center prospective, case-controlled study was carried out to investigate clinical effects on patients with aging face who underwent facial autologous fat grafting with platelet-rich plasma (PRP). Methods Thirty patients with facial sagging or partial depression and requiring autologous fat grafting were randomly selected for the study. Photograph and 3D scanning were taken before and 3-month after the operation. Patient and physician satisfaction was rated using Visual Analogue Scale (VAS) ranging from 1 (most unsatisfactory) to 10 (most satisfactory) 3 months after the operation. Statistical difference between the patient and physician satisfactory scores was analyzed. Results The average physician VAS score was 7.9±1.0 while the average patient VAS score was 8.0±1.2. The scores between two groups had no significant difference (P> 0.05). Four patients developed bruising and swelling postoperatively that disappeared less than 7 days later. There was no feed back of serious complications from patients. Further investigation of patients with scores less than 7 showed the main reason of low patient satisfaction was that the improvement of facial depression did not meet the requirements of the patient, and fat absorption led to unsatisfactory filling. Conclusions The high satisfactory scores indicate good aesthetic result of facial autologous fat grafting with PRP. PRP may lead to higer survival rate of fat and satisfaction. Key words: Fat granule; Fat grafting, autologous; Platelet-rich plasma; Soft tissue; Facial rejuvenation

Relationship Between Physician Assistant Program Length and Physician Assistant National Certifying Examination Pass Rates.

This study was conducted to examine the relationship between physician assistant (PA) educational program length and PA programs' 5-year average Physician Assistant National Certifying Examination (PANCE) first-time pass rates. This was a retrospective correlational study that analyzed previously collected data from a nonprobability purposive sample of accredited PA program Web sites. Master's level PA programs (n = 108) in the United States with published average PANCE scores for 5 consecutive classes were included. Provisional and probationary programs were excluded (n = 4). Study data were not normally distributed per the Kolmogorov-Smirnov test, P = .00. There was no relationship between program length and PANCE pass rates, ρ (108) = -0.04, P = .68. Further analyses examining a possible relationship between program phase length (didactic and clinical) and PANCE pass rates also demonstrated no differences (ρ [107] = -0.05, P = .60 and ρ [107] = 0.02, P = .80, respectively). The results of this study suggest that shorter length PA programs perform similarly to longer programs in preparing students to pass the PANCE. In light of rapid expansion of PA educational programs, educators may want to consider these findings when planning the length of study for new and established programs.

Use of 308 nm excimer laser for the treatment of chronic hand and foot eczema.

Chronic hand and foot eczema (CHFE), a prevalent debilitating disorder affecting approximately 15% of the population, presents a socioeconomic and psychosocial burden for patients and often follows a chronic course, refractory to conventional therapies. Thus, a large need exists for more effective therapeutics; the excimer laser (308 nm) is effective for some inflammatory skin diseases, but its efficacy has not been evaluated for CHFE. The study is a retrospective chart review conducted on 30 patients with recalcitrant CHFE (19 with hand involvement, four with foot involvement, and seven with both) treated twice weekly with excimer laser (308 nm) single wavelength ultraviolet (UV)B radiation between January 2013 and December 2014. Improvements in clinical scores included a 69% reduction in average physician's global assessment (PGA) scores (from 2.77 at baseline to 0.87 after treatment, P < 0.0001) with a parallel reduction in average modified total lesion/symptom scores of 70% (from 10.2 to 3.1, P < 0.0001). Only mild sunburn-like reactions were observed. This report evaluates excimer laser for patients with refractory CHFE and shows excellent and sustained efficacy for this treatment. Compared to other UV therapies, excimer laser offers lower cumulative doses of UV radiation by targeting specific areas. This effective treatment should be considered alone or in combination with other established or newer therapies.

Abstract TP339: Operations Director, Neurosciences Clinical Program, Intermountain Healthcare

Introduction: Beginning January 2014, a 245-bed Intermountain Healthcare primary stroke center was using a private Telestroke (SOC) service. On April 1, 2015, Intermountain implemented its own centralized, internal Telestroke service to provide coverage at this primary stroke center and five other hospitals. The Intermountain Telestroke service uses an internal telemedicine platform with employed physicians providing coverage. To clarify, the Intermountain system has a physician answer calls directly; the SOC model uses an intermediary before connecting to the physician. Hypothesis: Implementation of a centralized, internal Telestroke service will result in improved physician response and improved time to treatment compared to the private service. Methods: The Intermountain Healthcare enterprise data warehouse and SOC summary reports provided the data for this analysis. Wilcoxon-Mann-Whitney test was used to compare physician response time, DTN time, and door to CT time in patients treated during the 15-month SOC era to patients treated by the in house telestroke service. Results: From Jan 2014-Mar 2015, 27 patients received IV TPA at the facility, but only 2/27 had door to needle (DTN) time of &lt;60m. The median DTN time in 2014 was 84 min and the median door to CT time was 18 min, strongly suggesting that the neurologist response time of this service was too long to meet AHA standards. Since implementing the Intermountain service, there has been a statistically significant improvement in DTN time. During the SOC time period, the median DTN time was 92.5 min (N = 35). After implementation, the Intermountain service provided a significantly lower median DTN time of 62.5 min (N=4; p = 0.03). The SOC median technician call-back time was 9.2 min (N=85), with an average physician video response time of 32 min (N=79). Intermountain median physician response time is 4 min (N=91). The door to CT time was not significantly different (Jan 2014-March 2015 was 18 min. vs Mar-May 2015, 14 min, N=31). Conclusions: The Intermountain Telestroke service outperformed SOC in response time and times to treatment. For healthcare systems that have the resources and expertise, an internal Telestroke service may result in faster times to treatment and better patient outcomes.

Using stroke thrombolysis to describe the role of repetition in learning a cognitive skill.

To empirically describe how independent physicians develop a new cognitive clinical skill through repetition using the initiation of a stroke thrombolysis programme as a model. This was a retrospective cohort study from April 2009 to March 2013. The setting was a single-centre, Canadian tertiary-care community hospital. The participants were 52 physicians with no prior formal training in stroke thrombolysis assuming a new role of being front-line hyperacute stroke physicians. The main outcome measures were: time needed to accrue experience, door-to-needle time (DTN), with achievement of expertise defined as an average of ≤ 60 minutes, computed tomography (CT)-to-needle time (CTN), with achievement of expertise defined as an average of ≤ 35 minutes, usage of an outside expert stroke telemedicine service, and complication rates with intracranial haemorrhage (ICH). Seven hundred and fifteen cases of hyperacute stroke were seen over the 4-year study period. On average, a physician saw 0.025 cases per hour of code stroke coverage provided; only seven (13.5%) accrued more than 20 code stroke cases and only six (11.6%) ordered thrombolysis more than 10 times. By regression analysis, the average first DTN was 81.0 minutes (95% confidence interval [CI], 77.1-84.9 minutes) and incrementally improved linearly by 0.259 minutes per case seen (95% CI, 0.182-0.337 minutes per case). An estimated 71 cases needed to be seen for the average physician to achieve expertise. Results using CTN were highly similar. Overall, physicians used the external stroke telemedicine providers 23.2% of the time for their first five cases, a rate that decreased to about 5% by the 45th case. Over time, ICH rates were kept at expected benchmarks. Accruing sufficient experience of a new cognitive clinical skill can be challenging for independent physicians, with expertise gradually emerging in a largely linear fashion only after much repetition.

States’ implementation of the Affordable Care Act and the supply of physicians waivered to prescribe buprenorphine for opioid dependence

BackgroundAlthough the Affordable Care Act (ACA) is anticipated to affect substance use disorder (SUD) treatment, its impact on the supply of physicians waivered to treat opioid dependence with buprenorphine has not been considered. This study examined whether states more supportive of ACA, meaning those that had opted to expand Medicaid and establish a state-based health insurance exchange, experienced greater growth in physician supply than less supportive states. MethodsBuprenorphine physician supply, including total physician supply, supply of 30-patient physicians, and supply of 100-patient physicians per 100,000 state residents, was measured from June 2013 to May 2015. State characteristics were drawn from multiple secondary sources, with states categorized as ACA-supportive, ACA-hybrid (where states either expanded Medicaid or established a state-based exchange), or ACA-resistant (where states took neither action). Mixed effects regression was used to estimate state-level growth curves to test whether rates of growth varied by states’ approaches to implementing ACA. ResultsThe supply of waivered physicians grew significantly over the two-year period. Rates of growth were significantly lower in ACA-hybrid and ACA-resistant states relative to growth in ACA-supportive states. Average buprenorphine physician supply at baseline varied by region, the percentage of residents covered by Medicaid, and the supply of specialty SUD treatment programs. ConclusionsThis study found a positive impact of the ACA on growth in the supply of buprenorphine-waivered physicians in US states. Future research should address whether the ACA affects the number of patients receiving buprenorphine, Medicaid spending, and the quality of treatment services delivered.

Less Physician Practice Competition Is Associated With Higher Prices Paid For Common Procedures

Concentration among physician groups has been steadily increasing, which may affect prices for physician services. We assessed the relationship in 2010 between physician competition and prices paid by private preferred provider organizations for fifteen common, high-cost procedures to understand whether higher concentration of physician practices and accompanying increased market power were associated with higher prices for services. Using county-level measures of the concentration of physician practices and county average prices, and statistically controlling for a range of other regional characteristics, we found that physician practice concentration and prices were significantly associated for twelve of the fifteen procedures we studied. For these procedures, counties with the highest average physician concentrations had prices 8-26percent higher than prices in the lowest counties. We concluded that physician competition is frequently associated with prices. Policies that would influence physician practice organization should take this into consideration.

A Census of Actively Licensed Physicians in the United States, 2014

Marked changes have occurred in health care delivery in the United States with the implementation of the Affordable Care Act (ACA), including the advancement of integrated health systems, the introduction of patient centered medical homes and the creation of accountable care organizations. With millions of Americans newly insured, never has there been a more pressing need for accurate physician workforce information and planning. Opinions vary about the nature and degree of anticipated physician shortages, and health care workforce determinations are fraught with variables and uncertainties that are challenging to address definitively. Identifying accurate information about the nation's currently licensed physician workforce, however, is an important starting point. This article reviews data received in 2014 by the Federation of State Medical Boards from the nation's state medical and osteopathic boards about the current supply of actively licensed physicians in the United States and the District of Columbia. Our census data demonstrates the total population of licensed physicians (916,264) has increased by 4% since 2012, and the nation, on average, added 12,168 more licensed physicians annually than it lost. The average physician is now older (by a year), predominantly male (but increasingly female at entry level) and increasingly a graduate of a medical school in the Caribbean. Meanwhile, the percentage of physicians with a single state medical license has remained constant at 79%.

Understanding Pay Differentials Among Health Professionals, Nonprofessionals, And Their Counterparts In Other Sectors.

About half of the $2.1 trillion of US health services spending constitutes compensation to employees. We examined how the wages paid to health-sector employees compared to those paid to workers with similar qualifications in other sectors. Overall, we found that health care workers are paid only slightly more than workers elsewhere in the US economy, but the patterns are starkly different for nonprofessional and professional employees. Nonprofessional health care workers earn slightly less than their counterparts elsewhere in the economy. By contrast, the average nurse earns about 40 percent more than the median comparable worker in a different sector. The average physician earns about 50 percent more than a comparable worker in another sector of the economy, and this differential has increased sharply since 1993. Cost containment is likely to lead to reductions in the earnings of health care professionals, but it will also require using fewer or less skilled employees to produce a given service.

Enhanced External Counterpulsation Is Cost-Effective in Reducing Hospital Costs in Refractory Angina Patients.

Enhanced external counterpulsation (EECP) is effective in the treatment of refractory angina, a condition suffered by 1.7 million Americans. Declining cardiovascular mortality and appropriate use criteria may further increase this number. EECP is hypothesized to be cost-effective in reducing hospitalizations in refractory angina patients. The data used in this analysis were collected in phase II of the International EECP Patient Registry (IEPR-II). Data were collected on changes in Canadian Cardiovascular Society functional class, Duke Activity Status Index, and number of hospitalizations in the 6 months prior to EECP and in the 6- and 12-month intervals following EECP. Estimates of the changes in annual cost of all-cause hospitalization before and after EECP therapy were calculated by the product of the differences in hospitalization rates in the 6-month interval before and after EECP treatment and estimated hospitalization and physician charges after subtracting the average cost of EECP. Data for 1015 patients were analyzed. Hospitalization occurred in 55.2% of patients, an average of 1.7 ± 1.4 hospitalizations/patient, in the 6-month period before 35 hours of EECP; and in 24.4%, an average of 1.4 ± 1.0 hospitalizations/patient, during the 6- to 12-month period after EECP. The average hospitalization and physician charge in the US was $17,995, and the average EECP cost was $4880, yielding an annual cost savings/patient of $17,074. Treatment of refractory angina patients with EECP resulted in improvement in angina and functional class accompanied by a sustained reduction in health care costs over 1 year of follow-up.

Developing emergency department physician shift schedules optimized to meet patient demand.

1) To assess temporal patterns in historical patient arrival rates in an emergency department (ED) to determine the appropriate number of shift schedules in an acute care area and a fast-track clinic and 2) to determine whether physician scheduling can be improved by aligning physician productivity with patient arrivals using an optimization planning model. Historical data were statistically analyzed to determine whether the number of patients arriving at the ED varied by weekday, weekend, or holiday weekend. Poisson-based generalized additive models were used to develop models of patient arrival rate throughout the day. A mathematical programming model was used to produce an optimal ED shift schedule for the estimated patient arrival rates. We compared the current physician schedule to three other scheduling scenarios: 1) a revised schedule produced by the planning model, 2) the revised schedule with an additional acute care physician, and 3) the revised schedule with an additional fast-track clinic physician. Statistical modelling found that patient arrival rates were different for acute care versus fast-track clinics; the patterns in arrivals followed essentially the same daily pattern in the acute care area; and arrival patterns differed on weekdays versus weekends in the fast-track clinic. The planning model reduced the unmet patient demand (i.e., the average number of patients arriving at the ED beyond the average physician productivity) by 19%, 39%, and 69% for the three scenarios examined. The planning model improved the shift schedules by aligning physician productivity with patient arrivals at the ED.