Family Practice Providers Research Articles

Systematic review of Indigenous cultural safety training interventions for healthcare professionals in Australia, Canada, New Zealand and the United States

ObjectiveTo synthesise and appraise the design and impact of peer-reviewed evaluations of Indigenous cultural safety training programmes and workshops for healthcare workers in Australia, Canada, New Zealand and/or the United...

Screening for pediatric behavioral health in primary care in rural and urban clinics.

The prevalence of behavioral health disorders in children is approximately 15%-20%, yet less than half of the children ever receive treatment for these conditions. The lack of access to behavioral health care is common in urban areas but even more difficult to access in rural areas. Screening for behavioral health in a primary care setting is one of the first strategies to reduce this problem and improve access to care. The primary goal of this study was to examine behavioral health screening practices of pediatric primary care providers in a rural midwestern state. A survey that queried family practice/internal medicine and pediatric providers who provide care to pediatric patients was delivered to over 300 primary care providers across the state. The number of surveys returned was 112. The Modified Checklist for Autism tool was administered by 80% of pediatric providers and 30% of family practice primary care providers. The Patient Health Questionnaire for depression was administered by 72% of pediatric and 80% of family practice providers. Most of the primary care providers had a behavioral health provider present in the clinic, which likely resulted in higher screening rates compared to the national average. The screening practices of the family practice and pediatric subspecialities reflect their respective current professional organization recommendations. Although most providers believe it is important to screen for developmental and behavioral disorders, further system changes are needed to support screening for development and broader behavioral problems along with depression among family practice providers. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Help wanted: low provider density is associated with advanced stage cervical cancer

BackgroundPatients in rural areas have a higher incidence of cervical cancer with increased rates of metastatic disease than their urban counterparts.ObjectiveTo evaluate whether medical provider density, acting as a surrogate...

Policy Considerations for Routine Screening for Adverse Childhood Events (ACEs)

In October of 2021, California enacted SB 428, the ACEs Equity Act, which mandates commercial insurance coverage of adverse childhood experiences (ACEs) screening in addition to ACEs screening already covered for the state's Medicaid enrollees. California is the first state to expand ACEs screening coverage, but it is possible other states may follow similar paths given the increasing interest in policy action to address ACEs. Increase in stress and trauma among Americans and evidence of the disproportionate impact ACEs have on historically marginalized and disadvantaged communities has increased the urgency with which policy makers, clinicians and researchers have sought to address ACEs and encourage trauma-informed care delivery to better meet the needs of patients. Family practice and other primary care providers are at the core of prevention and are arguably the largest group of stakeholders at the forefront of movements toward increasing ACEs screenings. However, debate persists among policy makers, clinicians, and researchers on whether the ACEs screening approach improves outcomes and avoids harms. In this health policy article, we describe key issues under debate with regards to ACEs screening and estimate potential change in screening utilization and expenditures due to the new ACEs legislation in California. The lessons being learned in California are applicable to other states and the US as a whole.

Possible misdiagnosis, inappropriate empiric treatment, and opportunities for increased diagnostic testing for patients with vulvovaginal candidiasis-United States, 2018.

Vulvovaginal candidiasis (VVC) is a common cause of vaginitis, but the national burden is unknown, and clinical diagnosis without diagnostic testing is often inaccurate. We aimed to calculate rates and evaluate diagnosis and treatment practices of VVC and recurrent vulvovaginal candidiasis (RVVC) in the United States. We used the 2018 IBM® MarketScan® Research Databases, which include health insurance claims data on outpatient visits and prescriptions for >28 million people. We used diagnosis and procedure codes to examine underlying conditions, vaginitis-related symptoms and conditions, diagnostic testing, and antibacterial and antifungal treatment among female patients with VVC. Among 12.3 million female patients in MarketScan, 149,934 (1.2%) had a diagnosis code for VVC; of those, 3.4% had RVVC. The VVC rate was highest in the South census region (14.3 per 1,000 female patients) and lowest in the West (9.9 per 1000). Over 60% of patients with VVC did not have codes for any diagnostic testing, and microscopy was the most common test type performed in 29.5%. Higher rates of diagnostic testing occurred among patients who visited an OB/GYN (53.4%) compared with a family practice or internal medicine provider (24.2%) or other healthcare provider types (31.9%); diagnostic testing rates were lowest in the South (34.0%) and highest in the Midwest (41.0%). Treatments on or in the 7 days after diagnosis included systemic fluconazole (70.0%), topical antifungal medications (19.4%), and systemic antibacterial medications (17.2%). The low frequencies of diagnostic testing for VVC and high rates of antifungal and antibacterial use suggest substantial empiric treatment, including likely overprescribing of antifungal medications and potentially unnecessary antibacterial medications. These findings support a need for improved clinical care for VVC to improve both patient outcomes and antimicrobial stewardship, particularly in the South and among non-OB/GYN providers.

Motivational interviewing and vaccine acceptance in children: The MOTIVE study

Background and ObjectiveVaccine coverage have been less than desired in young children in part due to parental vaccine hesitancy. Addressing health beliefs through patient-centered communication approaches such as motivational interviewing (MI) may improve vaccine confidence. Thus, the objective of this study was to determine the difference in paediatric vaccination coverage rates based on the Advisory Committee on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC) recommended schedule in children 0–6 years of age after an educational intervention for providers and integration of an MI-based communication tool, MOTIVE (MOtivational Interviewing Tool to Improve Vaccine AcceptancE). MethodsPaediatric and family practice providers in a federally qualified health center in the United States completed an educational intervention regarding vaccine hesitancy and use of the MOTIVE tool. Providers then implemented the MOTIVE tool to address common health beliefs using strong, presumptive vaccine recommendations and an MI framework during encounters with patients 0–6 years of age. Data were collected from 1-year pre-educational intervention (July 2018-June 2019, N = 2504) and post-intervention (July 2019-March 2020, N = 1954) to examine differences in vaccination coverage rates and documented vaccine refusals. ResultsUse of the MOTIVE tool was associated with a statistically significant increase in IIV vaccination coverage rate in children 6 months to 6 years of age (32.4% versus 43.9%, p < 0.01). A significantly increased Hib vaccination coverage rate was observed in children 0–18 months of age. Patients with commercial insurance also had significantly higher vaccination coverage rates for the DTaP, IPV, and VAR vaccines during the intervention period. Use of the MOTIVE tool was associated with a decrease in documented vaccine refusals per 100 patients in children 0–6 years of age (31.5 versus 17.6, p < 0.01). ConclusionUse of an MI-based communication tool may decrease vaccine refusals and improve childhood vaccination coverage rates, particularly for IIV.Clinical Trial Registration: ClinicalTrials.gov, NCT03934008, https://clinicaltrials.gov/ct2/show/NCT03934008, deidentified individual participant data will not be made available.

Lessons Learned From Human Papillomavirus Vaccination to Increase Uptake of Adolescent COVID-19 Vaccination

Lessons Learned From Human Papillomavirus Vaccination to Increase Uptake of Adolescent COVID-19 Vaccination

Help wanted: low provider density is associated with advanced-stage at presentation for cervical cancer

<h3>Objectives:</h3> Prior studies suggest that geographic disparities exist for patients with cervical cancer, with a higher incidence and a higher rate of advanced stage disease observed in patients living in rural areas. The objective of the current study is to determine the association between provider:patient ratios and incidence and stage at diagnosis in patients with cervical cancer. <h3>Methods:</h3> The United States Area Health Resource File was utilized to determine the number of primary obstetric-gynecologists (OBGYN) as well as family practice (FP), and internal medicine (IM) providers in each county. Population estimates by county were obtained from census.gov and provider to resident ratios were calculated. Cervical cancer cases by county were retrieved from the 2015 SEER database. Spearman rank correlations were used to compare the number of providers per 100,000 residents to the overall incidence of cervical cancer as well as the percentage of patients diagnosed at an advanced stage (IIA-IVB). Multivariable logistic regression was performed to assess factors independently associated with advanced stage cervical cancer and county of residence was accounted for through robust sandwich standard error estimation. <h3>Results:</h3> The analysis included 3,505 cases of cervical cancer in 405 counties, with 1422 early stage cancers, 1728 advanced stage cancers, and 355 of unknown stage. The median number of office-based OBGYN providers per county was 5 per 100,000 residents and the median number of OBGYN, FP, and IM providers per county was 40 per 100,000 residents. Spearman correlation demonstrated a significant inverse association between the number of OBGYN providers per 100,000 residents and the incidence of cervical cancer (p<0.0001) as well as the percentage of cases diagnosed at a late stage (p=0.003). When accounting for OBGYN, FP, and IM providers per 100,000 residents there was a significant inverse correlation with the incidence of cervical cancer cases (p<0.0001), but no significant correlation with the percentage of late stage cervical cancer cases (p=0.09). Adjusting for age, race and insurance type, the odds of presenting with advanced disease decreased as the number of OBGYN providers per 100,000 residents increased with an OR of 0.93 (95% CI: 0.77-1.12) for 8-12 providers per 100,000 residents and an OR of 0.78 (95% CI: 0.61-0.99) for >12 providers per 100,000 residents (reference group: <8 providers per 100,000 residents). <h3>Conclusions:</h3> This study demonstrated a significant inverse correlation between the number of OBGYN providers per 100,000 residents and incidence of cervical cancer. Most notably, the proportion of advanced stage disease was significantly lower in counties with >12 OBGYN providers per 100,000 residents. Increasing provider density in these underserved, high-risk areas may improve timely cancer detection. Efforts should be made to examine barriers and incentives to increasing provider density in these areas.

Clinician Variation in Ordering and Completion of Low-Dose Computed Tomography for Lung Cancer Screening in a Safety-Net Medical System

BackgroundLess than 5% of eligible individuals in the United States undergo lung cancer screening. Variation in clinicians’ participation in lung cancer screening has not been determined. Patients and MethodsWe studied medical providers who ordered ≥ 1 low-dose computed tomography (LDCT) for lung cancer screening from February 2017 through February 2019 in an integrated safety-net healthcare system. We analyzed associations between provider characteristics and LDCT orders and completion using chi-square, Fisher exact, and Student t tests, as well as ANOVA and multinomial logistic regression. ResultsAmong an estimated 194 adult primary care physicians, 144 (74%) ordered at least 1 LDCT, as did 39 specialists. These 183 medical providers ordered 1594 LDCT (median, 4; interquartile range, 2-9). In univariate and multivariate models, family practice providers (P < .001) and providers aged ≥ 50 years (P = .03) ordered more LDCT than did other clinicians. Across providers, the median proportion of ordered LDCT that were completed was 67%. The total or preceding number of LDCT ordered by a clinician was not associated with the likelihood of LDCT completion. ConclusionIn an integrated safety-net healthcare system, most adult primary care providers order LDCT. The number of LDCT ordered varies widely among clinicians, and a substantial proportion of ordered LDCT are not completed.

Pediatric Asthma Action Plans: National Cross-Sectional Online Survey of Parents' Perceptions.

BackgroundAsthma Action Plans (AAPs) are recommended for pediatric patients to help improve asthma control. Studies have shown variable results for unscheduled doctor and emergency room visits. AAPs may have an impact on parental self-efficacy for asthma management as well as on other daily living factors that are valuable for patients and families, such as the number of missed school days and parental workdays, and on school and caregiver management.ObjectiveThe purpose of this study is to understand parent perceptions of AAPs. The goals of this analysis were threefold, including examining (1) the association between pediatric AAPs and parental self-efficacy, (2) parent perceptions of the helpfulness of an AAP for daily living factors, and (3) associations with the type of provider who gave the AAP (a primary care provider or an asthma specialist).MethodsA national cross-sectional online survey was completed in October 2018 by parents of children with asthma aged 0-17 years. Survey questions included the presence or absence of a pediatric AAP, the Bursch Parental Self-efficacy for Asthma scale, parental perceptions of the AAP's helpfulness with regard to daily living factors ranked on a 5-point Likert scale, and the provider type who gave the AAP. Survey responses were summarized in terms of percentages or means and standard deviations. A 2-sample t test and analysis of covariance were used to compare self-efficacy for asthma and parental-perception-of-helpfulness scores between subjects with an AAP versus subjects without an AAP. All reported P values were 2-sided.ResultsA total of 704 parents with a child with asthma completed the survey. The parents had a mean age of 37.5 years (SD 10.9), and 82% (577/704) were women and 18% (127/704) were men. Most (564/704, 80%) parents had an AAP for their child; 65% (367/564) were written, 51% (286/564) were online, and 84% (474/564) were available at school. The Bursch Self-efficacy scale was significantly higher for parents with an AAP (mean 57.7, SD 8.6) versus no AAP (mean 55.1, SD 9.9; P<.001). Parents reported that they agreed/strongly agreed that an AAP was helpful for daily living factors, including managing asthma (446/544, 82%), decreased parental missed workdays (367/544, 68%), decreased child missed-school days (396/542, 73%), and for when a child is at school (422/541 78%), with other caregivers (434/543, 80%), doing normal activities (421/540 78%), and leading a normal life (437/540 81%). Parents agreed/strongly agreed that an AAP was helpful from all provider types: a pediatric provider (583/704, 82.8%), a family practice provider (556/704, 79%), and an asthma specialist (594/704, 84.4%). There was no significant difference (P=.53) between the type of provider who gave the AAP.ConclusionsParents who had pediatric AAPs for their children reported increased parental self-efficacy compared to those who did not have AAPs. Parents found AAPs helpful for decreasing missed time from work and school, and for asthma management when at home, school, and with other caregivers. Significant AAP helpfulness was seen regardless of the provider who gave the AAP, the parent's education, and income level. Findings support the usefulness of pediatric AAPs for families and the development of easily sharable electronic AAPs for children.

Effects of Implementing a Comprehensive Opioid Reduction Protocol on Overall Opioid Prescribing Among Patients with Chronic, Non-Cancer Pain in a Rural Family Medicine Clinic: A Controlled Cross-over Trial.

The opioid crisis presents many challenges for family practice providers in rural communities who treat patients with chronic non-cancer pain (CNCP). Unfortunately, evidence for effective opioid reduction strategies is sparse. We evaluated the effects of implementing a comprehensive opioid reduction protocol on overall opioid prescribing among patients with chronic non-cancer pain in our rural family medicine clinics. We compared mean daily milligrams morphine equivalent (MME) prescribed to patients with CNCP in our rural family medicine clinic (n = 93) with another matched clinic (n =93) after implementation of our comprehensive protocol. We also compared mean daily MME prescribed to our patients with CNCP before and after implementation of the protocol. In a subsequent cross over phase, we examined the effects of the protocol when applied to the original control group patients. Mean daily MME in the intervention clinic (29.77) was significantly lower than the control clinic (93.2) after the intervention (t = 6.03; P < .00). Mean daily MME in the intervention group was significantly lower after implementation of the protocol (29.77) than before the protocol (MME 80.34) (t = 5.889; P < .00). After crossover, the mean daily MME was significantly lower (14.34) in the original control group than prior to the cross over intervention (85.68); (t = 8.19; P = .00). Our comprehensive opioid reduction protocol led to significant reductions in opioid prescribing in our rural family medicine clinics. Future studies should include important qualitative outcome measures such as patient function.

\u201cI had no other choice but to catch it too\u201d: the roles of family history and experiences with diabetes in illness representations

BackgroundA family history of diabetes and family members’ experiences with diabetes may influence individuals’ beliefs and expectations about their own diabetes. No qualitative studies have explored the relationship between family history and experiences and individuals’ diabetes illness representations.MethodsSecondary data analysis of 89 exploratory, semi-structured interviews with adults with type 1 or type 2 diabetes seeking care in an urban health system. Participants had a recent diabetes-related ED visit/hospitalization or hemoglobin A1c > 7.5%. Interviews were conducted until thematic saturation was achieved. Demographic data were collected via self-report and electronic medical record review. Interviews were audio-recorded, transcribed, and coded using a conventional content analysis approach. References to family history and family members’ experiences with diabetes were analyzed using selected domains of Leventhal’s Common Sense Model of Self-Regulation.ResultsParticipants cited both genetic and behavioral family history as a major cause of their diabetes. Stories of relatives’ diabetes complications and death figured prominently in their discussion of consequences; however, participants felt controllability over diabetes through diet, physical activity, and other self-care behaviors.ConclusionsFindings supported an important role of family diabetes history and experience in development of diabetes illness representations. Further research is needed to expand our understanding of the relationships between these perceptions, self-management behaviors, and outcomes. Family practice providers, diabetes educators and other team members should consider expanding assessment of current family structure and support to also include an exploration of family history with diabetes, including which family members had diabetes, their self-care behaviors, and their outcomes, and how this history fits into the patient’s illness representations.

Primary Care for Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) Patients

The lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community is a vulnerable populace that accounts for 4.5% of the United States population. Unfortunately, this group of individuals faces discrimination. They need access to quality, prejudice-free health care. This article initiates the discussion of how nurse practitioners, primary care, and family practice providers can provide inclusive, unbiased, quality care to this community that is evidence based. Information is provided about common barriers preventing this population from receiving equitable care. Evidence-based methods are outlined for screening this population for common health conditions, paying particular attention to an established HIV risk assessment and its application in clinical settings to identify candidates for pre-exposure prophylaxis. Finally, pharmacologic information about preexposure prophylaxis and transgender hormone therapy is presented. The information presented prepares nurse practitioners to begin caring for this population.

Does the MCHAT-R Detect Similar Children at Risk for Developmental-Behavioral/Mental Health Problems as Broad-Band Screens like PEDS?

Category/Date Emerging Knowledge for Clinical Practice Podium Presentations focusing on the Research Agenda Priority of Pediatric Research: Professional Role & Health Promotion and Disease Prevention, Presented at NAPNAP's 40th National Conference on Pediatric Health Care, March 8, 2019, New Orleans, LA. Purpose A recent American Academy of Pediatrics (AAP) survey revealed that more than 80% of clinicians use a screen for autism spectrum disorders (ASD), with 74%, using the Modified Checklist of Autism in Toddlers (MCHAT)/MCHAT-Revised (MCHAT-R). The AAP recommends administering both broad-band (e.g., Parents’ Evaluation of Developmental Status (PEDS) & narrow-band (e.g., MCHAT-R) screens focused on detecting children at-risk for mental health, behavior, & developmental disorder/delay. Yet, use of broad-band mental health, behavior, & developmental disorder/delay screens is less common: only 50% of pediatric providers and fewer family practice providers report use of validated, accurate broad-band screens. Methods Sites were 197 primary care clinics using PEDS Online, a web-based service focused on identifying mental health, behavior, & developmental disorder/delay in children 0 to 8 years of age via: a) two broad-band validated mental health, behavior, & developmental disorder/delay screens– PEDS & PEDS: Developmental Milestones (PEDS:DM); and b) a narrow-band mental health, behavior, & developmental disorder/delay screen focused on ASD – either MCHAT or MCHAT-R. From the 231,789 encounters in 2014 through 2016, we selected only the 16% (N = 37,608) in which children were administered both broad- and narrow-band screens. We defined children at-risk for mental health, behavior, & developmental disorder/delay as children with at-risk screen results on one or more broad-band screens and/or on a narrow-band ASD screen. Results In 197 clinics representing 24 US States, 66% (N=24,992) of screening occurred in pediatric clinics and 34% (N=12,616) in family practices (including public health/community clinics). Compared to US Census Bureau data, the sample resided more in Southern and Northeast States (86% vs 55% nationally) and parents were less likely to be high school graduates (76% vs 87% nationally). Mean age of children was 24 months (SD = 6.02). Of the 37,608 encounters, 12% (N=4572) of children were identified at-risk for mental health, behavior, & developmental disorder/delay. Of the 4572 with probable mental health, behavior, & developmental disorder/delay, broad-band screens identified 73% (N=3332/4572). The MCHAT/MCHAT-R uniquely identified 27% (N= 1240/4572). There was agreement among broad- and narrow-band measures of 22% (N=984/4572). ASD screens, if used alone, identified only 49% of those with probable mental health, behavior, & developmental disorder/delay (N = 2224/4572). Although ASD screens contribute uniquely to early identification, such tools do not seem to adequately detect most children at-risk for mental health, behavior, & developmental disorder/delays. Conclusions Use of an ASD screen alone would miss about 51% of children at-risk for mental health, behavior, & developmental disorder/delay. Mental health, behavior, & developmental disorder/delay screening should embrace both broad-band and narrow-band measures to best identify children at-risk.

Increasing Human Papillomavirus Vaccination Rates Among Adolescents: Overcoming Vaccine Hesitancy and Using Practice Improvements

The human papillomavirus (HPV) is responsible for thousands of cases of cancer annually, including cancers of the cervix, oropharynx, and anogenital areas. Since 2006, a vaccine for HPV has been available that offers the hope of dramatically reducing rates of HPV-related cancers. Rates of vaccination for HPV are much lower than rates of other recommended childhood vaccinations, because of difficulties reaching teenage patients and hesitancy toward the vaccine. This article provides recommendations to help pediatric and family practice providers increase rates of uptake of the HPV vaccine among adolescent patients, including communication strategies, and practice improvements that encourage vaccination.

1240. Antibiotic Prescribing in US Nursing Homes Using National Pharmacy Transaction Data

BackgroundAntibiotics are frequently prescribed inappropriately in nursing homes (NHs); however, national estimates of NH antibiotic use are limited. We aimed to describe antibiotic prescribing in US NHs to identify potential targets for antibiotic stewardship.MethodsA descriptive analysis was conducted using the 2014 proprietary IQVIA long-term care (LTC) Xponent database, which captures oral and intravenous antibiotic prescription transactions from sampled LTC pharmacies representing 70–85% of the LTC market. The data are projected to 100% of the US LTC market. Denominators for rate calculations were captured from the 2014 Minimum Data Set as the number of residents with at least one resident day in an NH in 2014. Antibiotic transaction counts and rates were calculated by resident gender, age, US census region, route of administration, antibiotic class and agent, and total transaction counts were summarized by provider type. Prescribing patterns for antibiotic classes and agents stratified by resident age were also calculated.ResultsIn 2014, there were over 14 million antibiotic transactions in LTC pharmacies, for a rate of 3,302 per 1,000 residents. Female residents accounted for 62% of antibiotic transactions at a rate of 3,305 transactions per 1,000 residents compared with 3,240 per 1,000 male residents. Antibiotic prescribing was highest in the South at 3,752 transactions per 1,000 residents (vs. 2,601 per 1,000 residents in the West). Oral antibiotics accounted for 85% of transactions. Fluoroquinolones were the most frequently prescribed antibiotic class (22%; 723 transactions per 1,000 residents) and the most common agents were levofloxacin, ciprofloxacin, and sulfamethoxazole–trimethoprim. Stratified by age, the percent change in prescribing rates among residents aged <85 to residents aged ≥85 was largest for fluoroquinolones (645 vs. 883) and urinary anti-infectives (210 vs. 319). Internal medicine and family practice providers accounted for 37% and 32% of all antibiotic transactions, respectively.ConclusionA potential antibiotic stewardship target in NHs is fluoroquinolone prescribing. Targeting states in the South for interventions may have the largest impact. Figure. Antibiotic prescribing rates in long-term care by U.S. census regionsDisclosures All authors: No reported disclosures.

Ichthyosis Vulgaris

Ichthyosis Vulgaris

Development and implementation of a centralized comprehensive refill authorization program in an academic health system.

The development and implementation of a centralized, comprehensive, refill authorization (CCRA) program within an academic health system are described. In order to improve continuity of care for our medically complicated patients, ambulatory pharmacy services developed and implemented a highly coordinated CCRA program for multiple community clinics within the system. To implement the CCRA program, we centralized the refill-request intake process to the Pharmacy Ambulatory Clinical Care Center (PAC3). PAC3 technicians were incorporated into the refill authorization process, and the collaborative practice agreement was updated to standardize the pharmacist refill approval process at the PAC3. We successfully standardized and centralized the medication refill process from 10 community clinics with 95 family practice and internal medicine providers and 26 medical residents. We handled an average of 12,000 refill requests each month, and pharmacists documented any interventions performed with each refill request. The cost savings associated with the CCRA program were attributed to the increased efficiency of the staff reviewing refill requests. The CCRA program increased the refill approval up to 10% compared with the previous decentralized refill authorization model. With the increased approval rate, the CCRA program saved 510 hours of our providers' time annually, which created time for an additional 1,530 clinic visits. We demonstrated a faster average turnaround time for refill authorization, from an average of 72 hours before implementation to about 1 business day. Implementation of an integrated refill authorization service standardized the method by which patients' refill requests were addressed, increased refill efficiency, and improved refill authorization turnaround time.

Physician Burnout: The Hidden Health Care Crisis

Physician burnout is an under-recognized and under-reported problem. Characterized by a state of mental exhaustion, depersonalization, and a decreased sense of personal accomplishment, burnout may affect more than 60% of family practice providers and at least one third of gastroenterologists. Some studies have shown that younger physicians, physicians performing high-risk procedures, and physicians experiencing work-life conflicts are at greatest risk. If unrecognized, the costs to the physician and to the health care system can be enormous because physician burnout is associated with increased rates of depression, alcohol and drug abuse, divorce, suicide, medical errors, difficult relationships with coworkers, and patient dissatisfaction, as well as physician attrition. If properly recognized, appropriate treatments are available. This article presents a case study of a physician suffering from burnout, reviews how burnout is defined, identifies those providers at greatest risk, discusses root causes, and outlines a treatment program.

Abdominal imaging ordering patterns by referring provider specialty.

Prior work has demonstrated marked growth in the volume of abdominal imaging performed by radiologists. However, decisions to pursue imaging are largely driven by referring providers. In this study, we take the novel approach of investigating abdominal imaging utilization patterns by referring provider specialty. Data on imaging services were obtained from the 2014 DocGraph Medicare Referring Provider Utilization for Procedures (MrPUP) public use file. MrPUP contains aggregated transaction data for combinations of unique referring provider and service code. Imaging services were classified by modality and body region using the Neiman Institute Types of Service (NITOS). Each referring provider's specialty was determined using Medicare Physician Compare. Abdominal imaging ordering patterns were summarized by referring specialty. The final dataset included 5,824,754 abdominal imaging transactions. The most common ordering specialties of abdominal imaging were as follows: (1) internal medicine; (2) urology; (3) emergency medicine; (4) family practice; and (5) gastroenterology. The most common ordering specialties by abdominal imaging modality were emergency medicine for CT; gastroenterology for MRI and nuclear medicine; and internal medicine for ultrasound and radiography. While numerous specialties commonly ordered abdominal radiography and CT, urologists also commonly ordered retroperitoneal ultrasound and retrograde urography, and gastroenterologists also commonly ordered abdominal ultrasound, abdominal MRI, and esophagrams. Internal medicine, family practice, and emergency medicine providers ordered a much broader mix of imaging, including many non-abdominal imaging examinations. Referring specialty abdominal imaging ordering patterns are varied but distinct. Awareness of these patterns may facilitate focused educational and policy initiatives to improve abdominal imaging appropriateness and utilization.