Individual Physician Level Research Articles

Neonatology Staffing Practices: An In-Depth Exploration of Leaders’ Perspectives

To describe neonatology leaders' perspectives on ideal staffing practices, including clinical work, nonclinical roles, shift characteristics, and flexibility. Although the current state of neonatology staffing issues is reported in the literature, a description of ideal, recommended staffing practices is lacking. We performed a qualitative study, using purposive sampling to interview 26 neonatology leaders. Semi-structured interviews included open-ended questions on ideal staffing practices in 4 categories: clinical and nonclinical aspects of work, shift characteristics, and flexibility in the work environment. We conducted a directed content qualitative analysis of interview transcripts. Leaders described their perspectives of ideal staffing practices. All clinical hours should count toward total clinical time and clinical full-time equivalent, and many nonclinical efforts should be compensated with time or money. Most stated varying workloads reflective of team structures and patient factors should be considered. Maximum in-house shift length should be≤24hours and weekend assignments should be equitable, irrespective of career track. Most endorsed flexibility at the individual physician level with a clear plan for covering variable staffing acute and chronic needs. Neonatology leaders recognize current staffing challenges and the need to evolve toward more ideal staffing practices. However, competing interests and complexities drive maintenance of the status quo and make change difficult for healthcare organizations and academic departments. Future work needs to create and measure optimal, standardized, and transparent staffing practices with appropriate adjustments for clinical, administrative, teaching, and scholarly obligations.

Explaining Variability in Electronic Health Record Effort in Primary Care Ambulatory Encounters.

Electronic health record (EHR) user interface event logs are fast providing another perspective on the value and efficiency EHR technology brings to health care. Analysis of these detailed usage data has demonstrated their potential to identify EHR and clinical process design factors related to user efficiency, satisfaction, and burnout. This study aimed to analyze the event log data across 26 different health systems to determine the variability of use of a single vendor's EHR based on four event log metrics, at the individual, practice group, and health system levels. We obtained de-identified event log data recorded from June 1, 2018, to May 31, 2019, from 26 health systems' primary care physicians. We estimated the variability in total Active EHR Time, Documentation Time, Chart Review Time, and Ordering Time across health systems, practice groups, and individual physicians. In total, 5,444 physicians (Family Medicine: 3,042 and Internal Medicine: 2,422) provided care in a total of 2,285 different practices nested in 26 health systems. Health systems explain 1.29, 3.55, 3.45, and 3.30% of the total variability in Active Time, Documentation Time, Chart Review Time, and Ordering Time, respectively. Practice-level variability was estimated to be 7.96, 13.52, 8.39, and 5.57%, respectively, and individual physicians explained the largest proportion of the variability for those same outcomes 17.09, 27.49, 17.51, and 19.75%, respectively. The most variable physician EHR usage patterns occurs at the individual physician level and decreases as you move up to the practice and health system levels. This suggests that interventions to improve individual users' EHR usage efficiency may have the most potential impact compared with those directed at health system or practice levels.

Academic productivity correlates with industry earnings in foot and ankle fellowship programs in the United States: A retrospective analysis.

The study investigates the connection between academic productivity and industry earnings in foot and ankle orthopedic surgery fellowships. Utilizing metrics like the H-index and Open Payments Database (OPD) data, it addresses a gap in understanding the relationship between scholarly achievements and financial outcomes, providing a basis for further exploration in this specialized medical field. To elucidate the trends between academic productivity and industry earnings across foot and ankle orthopedic surgery fellowship programs in the United States. This study is a retrospective analysis of the relationship between academic productivity and industry earnings of foot and ankle orthopedic surgery fellowships at an individual faculty and fellowship level. Academic productivity was defined via H-index and recorded from the Scopus website. Industry earnings were recorded from the OPD. Forty-eight foot and ankle orthopedic surgery fellowships (100% of fellowships) in the United States with a combined total of 165 physicians (95.9% of physicians) were included. Mean individual physician (n = 165) total life-time earnings reported on the OPD website was United States Dollar (USD) 451430.30 ± 1851084.89 (range: USD 25.16-21269249.85; median: USD 27839.80). Mean physician (n = 165) H-index as reported on Scopus is 14.24 ± 12.39 (range: 0-63; median: 11). There was a significant but weak correlation between individual physician H-index and individual physician total life-time earnings (P < 0.001; Spearman's rho = 0.334) and a significant and moderate positive correlation between combined fellowship H-index and total life-time earnings per fellowship (P = 0.004, Spearman's rho = 0.409). There is a significant and positive correlation between academic productivity and industry earnings at foot and ankle orthopedic surgery fellowships in the United States. This observation is true on an individual physician level as well as on a fellowship level.

Trends in Ophthalmology Practice Consolidation: 2015–2022

To quantify trends in ophthalmology practice consolidation in the United States. A retrospective cross-sectional study. Providers in the Centers for Medicare and Medicaid Services (CMS) National Downloadable File with a primary specialty designation of ophthalmology. We used the CMS database to determine national practice consolidation trends in ophthalmology on individual physician and group practice levels and analyzed by region, sex, and years spent in practice. We used the Cochran-Armitage test to determine the statistical significance of practice size differences between 2015 and2022. Temporal practice size trends for physicians and practices in ophthalmology and regional, sex-specific, and age-related trends. Between 2015 and 2022, the number of ophthalmologists decreased from 17 656 to 17 615 (-0.2%), whereas the number of practices decreased from 7149 to 5890 (-18%). The percentage of ophthalmologists in practices of 1 to 2 members decreased from 35% to 28%, whereas those in groups of 50 or more increased from 7% to 11%. The percentage of practices with 1 to 2 members decreased from 75% to 71%, and those with 50 or more increased from 0.2% to 0.4%. Consolidation trends were significant on individual ophthalmologist (P < 0.001) and group practice (P < 0.001) levels. All regions, sexes, and subgroups of years spent in practice demonstrated consolidation (P < 0.001). The Northeast showed the greatest increase in groups of 50 or more physicians (+7%) between 2015 and 2022. Proportionally fewer female than male ophthalmologists were associated with practice sizes of 1 to 2 members in 2015 (29% and 36%, respectively) and 2022 (23% and 30%, respectively). Proportionally fewer ophthalmologists with 0 to 10 years of experience in practice were associated with practice sizes of 1 to 2 members than those with more than 30 years in practice in 2015 (18% and 48%, respectively) and 2022 (14% and 40%, respectively). Ophthalmology has undergone practice consolidation from 2015 to 2022. A decrease in the proportion of physicians affiliated with smaller practice sizes seems to have occurred. Proprietary or commercial disclosure may be found after the references.

Dermatology residents as educators: a qualitative study of identity formation

BackgroundOne of the many identities a physician comes to form during their career is their identity as an educator. Exploring formation of this identity may enrich our understanding of how physicians make decisions related to their roles as educators, their behaviors, and how this ultimately influences the educational environment. It is the aim of this study to investigate educator identity formation of dermatology residents while early in their careers.MethodsDrawing on a social constructionist paradigm, we conducted a qualitative study, utilizing an interpretative approach. We examined longitudinal data over a 12-month period using dermatology residents’ written reflections from their professional portfolios and semi-structured interviews. We collected this data as we progressed through and beyond a 4-month professional development program designed to encourage residents’ growth as educators. Sixty residents in their second, third, or final year of residency programs located in Riyadh, Saudi Arabia were invited to take part in this study. Twenty residents participated with sixty written reflections and 20 semi-structured interviews. Qualitative data were analyzed using a thematic analysis approach.ResultsSixty written reflections and 20 semi-structured interviews were analyzed. Data was categorized according to themes corresponding to the original research questions. For the first research question regarding identity formation, themes included definitions of education, the process of education, and identity development. For the second research question, 1 theme entitled professional development program included, the following sub-themes: individual act, interpersonal activity, and an organizational undertaking, with many believing that residency programs should prepare residents for their educator roles. Participants also described newfound leadership ambitions of creating new dermatology fellowship programs as a result of taking part in the Resident-as-Educator program.ConclusionsOur study provides insights on the dynamic formation of educator identities amongst dermatology residents. Investment in developing residents as educators through professional development programs may instigate transformational change on the individual physician level and profession’s level.

Protecting Family Physicians from Burnout: Meaningful Patient-Physician Relationships Are "More than Just Medicine".

Meaning in work has been identified as an important factor promoting physician resilience against burnout. However, research has only minimally explored meaningful patient-physician relationships in relation to physician burnout, and has largely focused on patient perspectives. To address this knowledge gap, this study explored the elements of relationships with patients that physicians find meaningful, as well as physicians' perceptions of how those relationships influence experiences of burnout. In this qualitative study, 20 family medicine physicians recruited via convenience and snowball sampling participated in semistructured interviews. The research team then engaged in an iterative process of thematic analysis. 5 main themes emerged in participants' descriptions of meaningful relationships with their patients: Patient-centered care, continuity, effective care, trust, and purpose and mission. Participants described meaningful relationships as situated within a professional mission to connect with patients and make a difference in their lives. Meaning in these relationships centered around a trusting therapeutic relationship formed through continuity, person-centered care, and effective care. Participants strongly felt that meaningful relationships with patients are protective against burnout. Though many burnout interventions have targeted change at the individual (physician) level, a growing amount of evidence points to the need for change at the health system level. The findings of this study suggest that system-level interventions aimed at enhancing and prioritizing physicians' experiences of continuity and connection with their patients may be particularly impactful in efforts to reduce and prevent burnout.

COVID-19 Pandemic and Physician Burnout: Ramifications for Healthcare Workforce in the United States.

Across the United States, physician burnout is progressively escalating, with accompanying negative sequelae for myriad stakeholders in healthcare, including communities, patients, physicians, and Healthcare Organizations (HCOs) with essential manpower implications. This ubiquitous trend is due to complex and multifactorial elements, including individual physician-related influences, generational perspectives, sociocultural communal effects, HCOs, and more recently the mounting challenges accompanying the COVID-19 pandemic. To achieve the overarching goals of US healthcare provision (ie, safe, effective, patient-centered, timely, efficient, and equitable patient care), proposed solutions should focus on longitudinal actionable data acquisition to meet workforce needs preemptively, resource allocation for wellness programs geared towards enhancing recruitment and retention, and shared responsibility at the level of individual physician and HCO. This descriptive literature-based treatise expounds on the underlying causality for physician burnout, its consequences for the healthcare workforce in the US, and provides individual- and institution-based solutions for its mitigation.

Hospital-cardiologist integration often occurs without a practice acquisition.

To describe how much of the recent increase in hospital-cardiologist integration has come from acquisitions of physician practices compared to individual employment decisions. While the role of physician practice acquisitions has received considerable attention in the news, integration may also be driven by individual physicians accepting employment at hospital-based practices. American Medical Association Physician Masterfile and Medicare data. Analysis of changes in hospital-cardiologist integration from 2011 to 2018. We measured increases in integration and changes in the number of independent and hospital-owned practices. Not applicable. In 2011, 18% of cardiologists were integrated, rising to 25% in 2016. Of this rise, 48% occurred with no acquisitions. Physicians who had completed residencies in the past 5 years (early career physicians) had higher rates of integration that also increased over time: the percentage of early career physicians joining hospital systems rose from 25% to 32%, indicating rapid growth in the number of physicians who began their careers working in hospital-based sites. A large and growing portion of hospital-cardiologist integration came from hospital employment at the individual physician level. Future policies focused on preserving competition and affordability may benefit from better understanding this form of consolidation.

Opioid Prescribing Practices and Quality Improvements Within an Outpatient Orthopedic Practice.

BackgroundDuring the last several decades, the opioid epidemic throughout the United States has been recognized as an increasing problem. The aim of this study was to identify and implement processes throughout a single private orthopedic practice and managed ambulatory surgery centers to reduce opioid prescription pill quantity and strength, while also reducing consumption.MethodologyA baseline assessment along with the development of four separate phases was implemented. Data collection included type, dosage, and quantity of opioids prescribed after elective outpatient procedures as well as patient interviews/surveys within two weeks after surgery. Quality improvement implementation included: (a) presentations on opioid prescribing at an individual physician level, (b) internal prescription guidelines, (c) required Prescription Monitoring Program registration, and (d) patient narcotic education pamphlets after surgery. The average opioids prescribed and consumed were compared between different time points.ResultsAnalysis revealed a highly statistically significant decrease in both pills and morphine equivalent units (MEUs) prescribed (p < 0.001, p < 0.001) between the baseline assessment and four subsequent phases, as well as consumed (p < 0.001, p < 0.001) between phases one through four. Even though patients were consuming less pills and MEUs than they were prescribed on average across all phases, overall pain levels increased between phases one through four (p < 0.001), and overall satisfaction of pain control decreased between phases two through four (p < 0.001).ConclusionsOver a 24-month time frame, a single private orthopedic practice set a goal of reducing prescribing habits and with successful implementation of various measures, a significant reduction in opioids prescribed and consumed was accomplished. Interestingly, pain level and satisfaction of pain control worsened even though patients were continuing to be prescribed more opioids on average than they were consuming. Therefore, it may be normal to see these results when attempting to set the expectation for some level of pain and reduced consumption of opioid medications post-operatively. Overall, these results can be useful to healthcare administrators and surgeons looking for ways to combat the opioid epidemic.

Utilization of serum D-dimer assays prior to computed tomography pulmonary angiography scans in the diagnosis of pulmonary embolism among emergency department physicians: a retrospective observational study

BackgroundA variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients.ObjectiveTo describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA).MethodsData was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Secondary analysis was done to examine the impact of D-Dimer testing prior to CTPA on individual physician diagnostic yield or utilization rate.ResultsA total of 2811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer, and 343 (18.7%) underwent a CTPA despite a negative D-Dimer. Those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those ordered without a D-Dimer (9.9% versus 11.3%, p = 0.26). At the individual physician level, no statistically significant relationship was found between D-Dimer utilization and CTPA utilization rate or diagnostic yield.ConclusionThis study provides evidence of suboptimal adherence to guidelines in terms of D-Dimer screening prior to CTPA, and forgoing CTPAs in patients with negative D-Dimers. However, the lack of a positive impact of D-Dimer testing on either CTPA diagnostic yield or utilization rate is indicative of issues relating to the high false-positive rates associated with D-Dimer screening.

Disaggregating the Differential Impact of Healthcare IT in Complex Care Delivery: Insights from Field Research in Chronic Care

This study focuses on the impact of digitizing medical information on the efficiency and perceived quality of chronic care delivery at the individual physician level. This study extends the theory of task technology fit to activity systems consisting of highly interdependent tasks. We find that the outcomes of efficiency and quality gains are driven by the structure of interdependencies between tasks that physicians perform. While structured information plays a key role in enabling both decision-making and task execution, we find that physician-created semistructured information is also an important predictor of both efficiency and quality gains. We show that the structure of activity systems (task interdependencies) has a strong moderating influence on the factors that drive efficiency and quality gains. We find that digitization enables physicians to preprocess patients’ records prior to their visit which in turn drives gains in both the efficiency and the perceived quality of care delivered.

Comparative Marketing Communication: The Case of Drug Detailing

Comparative marketing communication has emerged as an important area of managerial and scholarly inquiry. In the pharmaceutical industry, it has been practiced in detailing, the personal selling to physicians. With physician-level panel data of detailing and prescriptions, we examine the effectiveness of comparative detailing versus noncomparative detailing. In particular, we investigate whether a brand’s comparative detailing directly damages competing brands or provides them free exposure to physicians. The Bayesian hierarchical probit model with reduced-form detailing policy functions allows us to examine comparative detailing at both aggregate level and individual physician level, while controlling for possible simultaneity issues in noncomparative detailing and comparative detailing. We find that (1) comparative detailing is less or equally effective than noncomparative detailing at the aggregate level, but there is strong heterogeneity across individual physicians; (2) some brands strategically focus their comparative detailing efforts on physicians who are less responsive to noncomparative detailing but more responsive to comparative detailing than others; (3) the market leader faces a denigrating loss if underdog brands compare against it in their detailing visits, but a generic brand enjoys a free-exposure benefit when other brands in the category compare against it in their detailing visits. Our estimates provide rich managerial implications by identifying physicians who are more profitable for comparative detailing. Finally, our policy simulation shows that a ban of comparative detailing can reduce the market share of generic drugs by 1.76% in statin market.

Abstract ES7-2: The toll on health care providers

Abstract The Toll on Health Care Providers Challenging conversation between health care provider and patients and their families can contribute to provider’s burnout. A challenging interaction for a medical professional already overstretched by the healthcare system may increase levels of stress, anxiety and anger, which in turn will affect performance and communication. Burnout is a well-known work-related stress syndrome characterized by exhaustion, cynicism, and inefficiency. It is established that at least 50% of US physicians experience professional burnout with consequent negative impact on quality care, patient satisfaction, and overall institutional success. Cancer care professionals have experienced a drastically increase in the incidence of burnout over the past decade due to the emotionally demanding nature of their work and the ever-growing burden of administrative work. A recent Medscape report describes a burnout rate of 55% among female oncologist and 45% among male oncologist. Both individual physician level factors and organizational level factors contribute to oncologist burnout. We will discuss common driver factors and strategies to prevent and mitigate this public health problem. Many gaps in our knowledge on physician burnout remain, but effective individual and organizational interventions are crucial for the prevention and improvement of clinician well-being and need to be incorporated into oncology care. Citation Format: SH Giordano. The toll on health care providers [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr ES7-2.

The Association between Industry Payments and Brand-Name Prescriptions in Otolaryngologists.

To associate pharmaceutical industry payments to brand-name prescriptions by otolaryngologists. Retrospective cross-sectional analysis. Open Payments Database and the Medicare Part D Participant User File 2013-2016. We identified otolaryngologists receiving nonresearch industry payments and prescribing to Medicare Part D recipients. Records were linked by physician name and state. The value of industry payments and the percentage of brand-name drugs prescribed per hospital referral region (HRR) were characterized as medians. Industry payments were correlated to the rate of brand-name prescription by Kendall's τ correlation. This was repeated at the individual physician level and stratified by payment type. In total, 8167 otolaryngologists received a median of $434 (interquartile range, $138-$1278) in industry compensation over 11 (3-26) payments. Brand-name drugs made up a median of 12.9% (8.6%-18-4%) of each physician's drug claims. The number (τ = 0.05, P < .001) and dollar amount (τ = 0.04, P < .001) of industry payments were correlated with the rate of brand-name drug prescription at the individual physician level. The number of industry payments was also associated with the rate of brand-name prescription by HRR (τ = 0.14, P < .001), but the dollar amount was not. By HRR, food and beverage payments received by physicians were associated with the rate of brand-name drug prescription (τ = 0.04, P < .001), but travel and lodging payments were not. Industry financial transactions are associated with brand-name drug prescriptions in otolaryngologists, and these associations are stronger at the regional level than at the individual physician level. These correlations are of modest strength and should be interpreted cautiously by readers.

Epidemiology and Implementation of Cancer Prevention in Disparate Populations and Settings.

Successful cancer prevention strategies must be tailored to support usability. In this article, we will focus on cancer prevention strategies in populations that differ by race and ethnicity, place and location, sexual orientation and gender identity, and age by providing examples of effective approaches. An individual may belong to none of these categories, to all of these categories, or to some. This intersectionality of belonging characterizes individuals and shapes their experiences. Even within a category, broad diversity exists. Effective cancer prevention strategies comprehensively engage the community at multiple levels of influence and may effectively include lay health workers and faith-based cancer education interventions. Health system efforts that integrate cancer health with other health promotion activities show promise. At the individual physician level, culturally literate approaches have demonstrated success. For example, when discussing cancer screening tests with older adults, clinicians should indicate whether any data suggest that the screening test improves quality or quantity of life and the lag time to benefit from the screening test. This will allow older adults to make an informed cancer screening decision based on a realistic understanding of the potential benefits and risks and their values and preferences. Addressing individual and health system bias remains a challenge. Quality improvement strategies can address gaps in quality of care with respect to timeliness of care, coordination of care, and patient experience. The time is ripe for research on effective and interdisciplinary prevention strategies that harness expertise from preventive medicine, behavioral medicine, implementation science, e-health, telemedicine, and other diverse fields of health promotion.

Effectiveness of educational outreach visits compared with usual guideline dissemination to improve family physician prescribing\u2014an 18-month open cluster-randomized trial

BackgroundEducational outreach visits are meant to improve the practice of health professionals by promoting face-to-face visits to deliver educational contents. They have been shown to change prescription behavior, but long-term effects are still uncertain. This trial aimed to determine if they improve family physician prescribing compared with passive guideline dissemination.MethodsParallel, open, superiority, and cluster-randomized trial. National Health Service primary care practices (clusters) were recruited in the Lisbon region—Portugal between March 2013 and January 2014. They could enter if they had at least four family physicians willing to participate and not planning to retire in the follow-up period. Three national guidelines were chosen for dissemination: acid secretion modifiers, non-steroidal anti-inflammatory drugs, and antiplatelets. Physicians in the intervention group received one 15 to 20 min educational outreach visit at their workplace for each guideline. Physicians in the control group had access to guidelines through the Directorate-General for Health’s website (passive dissemination). Primary outcomes were the proportion of COX-2 inhibitors prescribed within the NSAID class and the proportion of omeprazole within the PPI class at 18 months after the intervention. A cost-benefit analysis was performed. Practices were randomized by minimization. Data analyses were done at individual physician level using generalized mixed-effects regression models. Participants could not be blinded.ResultsThirty-eight practices with 239 physicians were randomized (120 to intervention and 119 to control). Of 360 planned visits, 322 were delivered. No differences were found between physicians in the intervention and control groups regarding the proportion of omeprazole prescribed among PPIs 18 months after the visit (46.28 vs 47.15%, p = 0.971) or the proportion of COX-2 inhibitors among NSAIDs (12.07 vs 13.08%, p = 0.085). All secondary outcome comparisons showed no effect. There was no difference in cumulative drug costs at 18 months (3223.50€/1000 patients in the intervention group and 3143.92€/1000 patients in the control group, p = 0.848).ConclusionsEducational outreach visits were unsuccessful in improving compliance with guideline recommendations among Portuguese family physicians. No effects were observed at 1, 6, and 18 months after the intervention, and there were no associated cost savings.Trial registrationClinicalTrials.gov NCT01984034. Registered 7 November 2013.

Reliability of Physician-Level Measures of Patient Experience in Primary Care.

Patient experience measures are widely used to compare performance at the individual physician level. To assess the impact of unmeasured patient characteristics on visit-level patient experience measures and the sample sizes required to reliably measure patient experience at the primary care physician (PCP) level. Repeated cross-sectional design. Academic family medicine practice in California. One thousand one hundred forty-one adult patients attending 1319 visits with 56 PCPs (including 45 resident and 11 faculty physicians). Post-visit patient experience surveys including patient measures used for standard adjustment as recommend by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Consortium and additional patient characteristics used for expanded adjustment (including attitudes toward healthcare, global life satisfaction, patient personality, current symptom bother, and marital status). The amount of variance in patient experience explained doubled with expanded adjustment for patient characteristics compared with standard adjustment (R2 = 20.0% vs. 9.6%, respectively). With expanded adjustment, the amount of variance attributable to the PCP dropped from 6.1% to 3.4% and the required sample size to achieve a reliability of 0.90 in the physician-level patient experience measure increased from 138 to 255 patients per physician. After ranking of the 56 PCPs by average patient experience, 8 were reclassified into or out of the top or bottom quartiles of average experience with expanded as compared to standard adjustment [14.3% (95% CI: 7.0-25.2%)]. Widely used methods for measuring PCP-level patient experience may not account sufficiently for influential patient characteristics. If methods were adapted to account for these characteristics, patient sample sizes for reliable between-physician comparisons may be too large for most practices to obtain.

Physician Variability in Management of Emergency Department Patients with Chest Pain.

IntroductionChest pain is a common emergency department (ED) presentation accounting for 8–10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level.MethodsWe conducted a single-institution retrospective observational study of ED patients with a diagnosis of chest pain as determined by diagnostic code from our hospital administrative database. We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram (ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into two groups: “admission” (this included observation and inpatients) and “discharged.” We stratified physicians by age, gender, residency location, and years since medical school. We controlled for patient- and hospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values.ResultsOf 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to the hospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) were discharged. Median number of patients per physician was 132 (interquartile range 89–172). Average admission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) were to observation. There was significant variation in the admission rate at the individual physician level with adjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians’ characteristics, years elapsed since finishing medical school demonstrated a trend towards association with a higher admission probability.ConclusionThere is substantial variation among physicians in the management of patients presenting with chest pain, with physician experience playing a role.

Policies to Optimize Physician Billing Data in Academic Alternative Relationship Payment Plans: Practices and Perspectives

ABSTRACT&#x0D; ObjectivesChanges in physician reimbursement policies may hinder the collection of billing claims in administrative databases. Various provincial academic alternative payment programs (APPs) use incentive- or punitive-based tools to motivate physicians to submit billing claims called shadow billings; however, these incentives are not well documented in the literature. We conducted a nation-wide survey and semi-structured face-to-face interviews in Alberta, Canada to determine existing policies and guidelines for incentivizing and promoting physician billing practices.&#x0D; ApproachMail and online surveys were sent out to academic department head physicians in the following provinces: British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Prince Edward Island and Newfoundland and Labrador. Face-to-face interviews were conducted in the province of Alberta with managers, government stakeholders, and physicians/administrators from academic APPs and Fee-for-Service plans. Face-to-face interviews and responses by mail and email submission were summarized using content analysis grouped by question type.&#x0D; ResultsIn total, there were 46 respondents (15 interviews, 26 mail/online). Content analysis revealed three primary perspectives, grouped at the level of individual physician, academic, and government. Across all of these unique perspectives, three primary themes emerged: 1) governance; 2) accountability; and 3) funding. Within these themes, findings were categorized as either (a) instruments or tools to promote physician billing in AAPPs; (b) enabling factors to support physician billing in AAPPs; and, (c) constraining factors impeding physician billing in AAPPs.&#x0D; ConclusionAccording to the majority of our respondents, financial disincentives (i.e. income at risk, financial clawbacks) appear to be most effective as a mechanism to motivate physicians within an academic APP to submit their billings. However, key barriers to successful implementation and delivery of academic APPs include a lack of alignment between government stakeholders, academic leadership and APP physician members and differences in the organizational and accountability structures of APP plans between academic facilities. It is necessary in moving forward to achieve commonly defined standards and frameworks between the various APP models across provinces and academic institutions.

Attitudes and Opinions of Canadian Nephrologists Toward Continuous Quality Improvement Options.

Background and objectives:A shift to holding individual physicians accountable for patient outcomes, rather than facilities, is intuitively attractive to policy makers and to the public. We were interested in nephrologists’ attitudes to, and awareness of, quality metrics and how nephrologists would view a potential switch from the current model of facility-based quality measurement and reporting to publically available reports at the individual physician level.Design, setting, participants, and measurements:The study was conducted using a web-based survey instrument (Online Appendix 1). The survey was initially pilot tested on a group of 8 nephrologists from across Canada. The survey was then finalized and e-mailed to 330 nephrologists through the Canadian Society of Nephrology (CSN) e-mail distribution list. The 127 respondents were 80% university based, and 33% were medical/dialysis directors.Results:The response rate was 43%. Results demonstrate that 89% of Canadian nephrologists are engaged in efforts to improve the quality of patient care. A minority of those surveyed (29%) had training in quality improvement. They feel accountable for this and would welcome the inclusion of patient-centered metrics of care quality. Support for public reporting as an effective strategy on an individual nephrologist level was 30%.Conclusions:Support for public reporting of individual nephrologist performance was low. The care of nephrology patients will be best served by the continued development of a critical mass of physicians trained in patient safety and quality improvement, by focusing on patient-centered metrics of care delivery, and by validating that all proposed new methods are shown to improve patient care and outcomes.