Physician Factors Research Articles

Inappropriate dosing of direct oral anticoagulants: findings from a clinical vignette study and physician survey

ABSTRACT Objective Direct oral anticoagulants (DOACs) are first-line therapy for stroke prevention for 1.4 million atrial fibrillation (AF) patients in the UK. However, the rates of DOAC dosing below evidence-based recommendations are estimated between 9% and 22%. This study explores specific patient and physician factors associated with prescribing inappropriate DOAC underdoses. Methods DOAC-prescribing physicians within the UK completed both a clinical vignette survey, which contained 12 hypothetical patient profiles designed to replicate DOAC prescribing scenarios, and a physician survey to capture sociodemographic, clinical experience, and prescriber-related beliefs and motivations related to DOAC prescribing. Eight patient factors based on a literature search and an expert consultation process were varied within the vignettes. Associations between the prescribers’ dosing choices and patient factors were explored via multilevel logistic regression. The analysis is focused on the most frequently selected DOACs, apixaban and rivaroxaban, both of which have different dosing guidelines. Results In all, 336 prescribers (69% male; 233/336) completed the survey, mostly general physicians (GPs) (45%) or cardiology specialists (36%) with a mean of 17.9 years’ experience. Most prescribers (73%; 244/336) inappropriately underdosed at least once; rates between GPs and specialists were nearly identical. Patient factors most strongly associated with apixaban inappropriate underdosing included a history of major bleeding and falls. For rivaroxaban, these were major bleeding and severe frailty. Only 32% (106/335) of prescribers reported DOAC dosing guidelines as the sole influence on their prescribing behaviour. Among prescribers who did not inappropriately underdose, greater prescribing confidence was aligned to increased perception of inappropriate underdose risk. Conclusions Overall, patient factors such as major bleeding and severe frailty were found to be associated with inappropriate underdosing of apixaban and rivaroxaban. Furthermore, prescribers who were more confident in DOAC prescribing, and were more worried about the risk of stroke, were significantly less likely to inappropriately underdose. These findings suggest that all prescribers, regardless of speciality, may benefit from education and training to raise awareness of the risks associated with inappropriate DOAC underdosing.

Examining supporting and constraining factors of physicians’ acceptance of telemedical online consultations: a survey study

As healthcare demands exceed outpatient physicians’ capacities, telemedicine holds far-reaching potential for both physicians and patients. It is crucial to holistically analyze physicians’ acceptance of telemedical applications, such as online consultations. This study seeks to identify supporting and constraining factors that influence outpatient physicians’ acceptance of telemedicine.We develop a model based on the unified theory of acceptance and use of technology (UTAUT). To empirically examine our research model, we conducted a survey among German physicians (n = 127) in 2018–2019. We used the partial least squares (PLS) modeling approach to test our model, including a mediation analysis. The results indicate that performance expectancy (β = .397, P < .001), effort expectancy (β = .134, P = .03), and social influence (β = .337, P < .001) strongly impact the intention to conduct online consultations and explain 55% of its variance. Structural conditions regarding data security comprise a key antecedent, associating with performance expectancy (β = .193, P < .001) and effort expectancy (β = .295, P < .001). Regarding potential barriers to usage intentions, we find that IT anxiety predicts performance (β = –.342, P < .001) and effort expectancy (β = –.364, P < .001), while performance expectancy fully mediates (βdirect = .022, P = .71; βindirect = -.138, P < .001) the direct relationship between IT anxiety and the intention to use telemedical applications.This research provides explanations for physicians’ behavioral intention to use online consultations, underlining UTAUT’s applicability in healthcare contexts. To boost acceptance, social influences, such as personal connections and networking are vital, as colleagues can serve as multipliers to reach convergence on online consultations among peers. To overcome physicians’ IT anxiety, training, demonstrations, knowledge sharing, and management incentives are recommended. Furthermore, regulations and standards to build trust in the compliance of online consultations with data protection guidelines need reinforcement from policymakers and hospital management alike.

Improving the diagnosis of endometriosis in Asia-Pacific: Consensus from the Asia-Pacific Endometriosis Expert Panel for Endometriosis.

Endometriosis should be diagnosed as early as possible in the continuum of care; but substantial delays of approximately 6-8 years between symptom onset and endometriosis diagnosis have been widely reported. With the purpose of improving the prompt diagnosis of endometriosis, the Asia-Pacific Endometriosis Expert Panel (APEX) sought to address the reasons for diagnostic delays across the region, and formulate a multi-pronged approach to overcoming these challenges. In the first instance, clinical diagnosis is preferable to surgical diagnosis, in order to facilitate earlier empirical treatment and minimize the negative sequelae of undiagnosed/untreated disease. There should be a high clinical index of suspicion in women presenting with cyclical symptoms, including those involving extrapelvic organs. Diagnostic delays in Asia-Pacific countries are attributable to a variety of patient, physician, and healthcare factors, including poor awareness, normalization/trivialization of pain, individual/cultural attitudes toward menstruation, default use of symptom-suppressing treatments, misdiagnosis, and a lack of diagnostic resourcing or adequate referral pathways in some areas. Suggested initiatives to reduce diagnostic delays are geared toward improving public awareness, improving clinical diagnostic skills, streamlining multidisciplinary care pathways for timely referral, updating and implementing diagnostic guidelines, lobbying policymakers and insurance companies for endometriosis support, and increasing efforts to bridge data gaps and perform further research in this field. Formulating specific action plans and gathering traction are the responsibility of individual countries within local parameters. The APEX group advocates for any initiatives and policies that support the unmet needs of women with endometriosis, to improve patient experience and outcomes.

Comparison of trans-gastric vs trans-enteric (trans-duodenal or trans-jejunal) endoscopic ultrasound guided gallbladder drainage using lumen apposing metal stents.

Endoscopic ultrasound guided gallbladder drainage (EUS-GBD) is being increasingly used in practice (either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patients). Stents are used to create a conduit between the lumen of the gallbladder (GB) and the intestinal lumen through the gastric or enteric routes. Among the various types of stents used, cautery-enhanced lumen apposing metallic stents (LAMS) may be associated with fewer adverse events (AEs). To compare the clinical success, technical success, and rate of AEs between transgastric (TG) and trans-enteric [transduodenal (TD)/transjejunal (TJ)] approach to GB drainage. Further, we analyzed whether using cautery enhanced stents during EUS-GBD impacts the above parameters. Study was registered in PROSPERO (CRD42022319019) and comprehensive literature review was conducted. Manuscripts were reviewed for the data collection: Rate of AEs, clinical success, and technical success. Random effects model was utilized for the analysis. No statistically significant difference in clinical and technical success between the TD/TJ and TG approaches (P > 0.05) were noted. There was no statistically significant difference in the rate of AEs when comparing two-arm studies only. However, when all studies were included in the analysis difference was almost significant favoring the TD/TJ approach. When comparing cautery-enhanced LAMS with non-cautery enhanced LAMS, a statistically significant difference in the rate of AEs was observed when all the studies were included, with the rate being higher in non-cautery enhanced stents (14.0% vs 37.8%; P < 0.01). As per our study results, TD/TJ approach appears to be associated with lower rate of adverse events and comparable efficacy when compared to the TG approach for the EUS-GBD. Additionally, use of cautery-enhanced LAMS for EUS-GBD is associated with a more favorable adverse event profile compared to cold LAMS. Though the approach chosen depends on several patient and physician factors, the above findings could help in deciding the ideal drainage route when both TG and TD/TJ approaches are feasible.

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

Clinical guidelines recommend that older patients (65+) with mild cognitive impairment (MCI) and early-stage dementia receive similar guideline-concordant care after cardiovascular disease (CVD) events as those with normal cognition (NC). However, older patients with MCI and dementia receive less care for CVD and other conditions than those with NC. Whether physician recommendations for guideline-concordant treatments after two common CVD events, acute myocardial infarction (AMI) and acute ischemic stroke (stroke), differ between older patients with NC, MCI, and early-stage dementia is unknown. To test the influence of patient cognitive status (NC, MCI, early-stage dementia) on physicians' recommendations for guideline-concordant treatments for AMI and stroke. We conducted two parallel, randomized survey studies for AMI and stroke in the US using clinical vignettes where the hypothetical patient's cognitive status was randomized between physicians. The study included cardiologists, neurologists, and generalists who care for most patients hospitalized for AMI and stroke. The primary outcome was a composite quality score representing the number of five guideline-concordant treatments physicians recommended for a hypothetical patient after AMI or stroke. 1,031 physicians completed the study (58.5% response rate). Of 1,031 respondents, 980 physicians had complete information. After adjusting for physician factors, physicians recommended similar treatments after AMI and stroke in hypothetical patients with pre-existing MCI (adjusted ratio of expected composite quality score, 0.98 [95% CI, 0.94, 1.02]; P = 0.36) as hypothetical patients with NC. Physicians recommended fewer treatments to hypothetical patients with pre-existing early-stage dementia than to hypothetical patients with NC (adjusted ratio of expected composite quality score, 0.90 [0.86, 0.94]; P < 0.001). In these randomized survey studies, physicians recommended fewer guideline-concordant AMI and stroke treatments to hypothetical patients with early-stage dementia than those with NC. We did not find evidence that physicians recommend fewer treatments to hypothetical patients with MCI than those with NC.

Patient perspectives on barriers to obtaining surgery for primary hyperparathyroidism: A qualitative review

BackgroundThe purpose of this study was to qualitatively explore patient-reported barriers to surgery for primary hyperparathyroidism (PHPT) and identify actionable interventions to improve access to surgical care. MethodsWe recruited forty-nine patients in an endocrine surgery clinic at a large, academic medical to participate in an 11- question phone interview. All interviewees underwent parathyroidectomy for primary hyperparathyroidism. Responses were recorded and a codebook of qualitative themes, blinded to patient race and sex, was created by 3 independent reviewers. Comments were subsequently sorted into the codebook with patient demographic information. ResultsPatients that experienced delays in parathyroidectomy most commonly cited “issues with the referral process” and “missed diagnosis” as the cause. Patients were asked to identify the most challenging part about the surgery process. Commonly evoked themes among patients of both races and sexes included “transportation” and “financial” with subthemes of “no ride,” “distance from surgeon,” “insurance,” and “difficulty taking time off work.” Patients were asked to name actionable interventions to improve access to surgical care. The most commonly evoked theme involved “support systems,” with subthemes of “transportation assistance,” “financial,” and “patient advocacy.” Physician factors were also commonly evoked among patients of both races with subthemes of “knowledge”, “communication,” and “listening.” ConclusionPHPT patients cited multiple barriers to undergoing surgery. Future work can focus on examining these questions with a larger patient cohort and examining delays at the referral and diagnosis stage, which was most commonly cited by our respondents.

Public and Physicians Perception of Oculoplastic Surgery Subspecialty in Saudi Arabia.

Oculoplastic surgery is a highly specialized subspecialty that studies pathologies of the orbit, lacrimal system, and eyelids. Although it is an independent ophthalmological subspecialty, many procedures fall within the shared scope and anatomical area of oculoplastic surgery, otorhinolaryngology, and plastic and reconstructive surgery, which tend to confuse physicians and patients seeking medical advice. In this study, our goal is to evaluate the perception of oculoplastic surgery among the public and physicians. A cross-sectional study in which data were collected from an online questionnaire formulated by the authors. The questionnaire included 18 questions divided into two categories: demographics and targeted questions that serve the objective of the study. Each answer option to targeted questions was encoded with either one or zero points, and each participant's response was scored accordingly, with the maximum score being 22 points, reflecting the highest perception rate according to the questionnaire. Data were collected from 1029 questionnaire responses, with 202 of the respondents belonging to physicians. The highest number of responses was from females which consisted 82% of our sample. Perception scores were higher among physicians with a mean of 12.3 ± 2.9 points compared to a mean score of 11.2 ± 2.9 among the public. Age played a statistically significant factor in both physicians and the public as younger participants' scores were higher. Insufficient knowledge of oculoplastic surgery subspecialty was observed among the public and physicians. Moreover, core aspects of oculoplastic field such as lacrimal system pathology and orbit pathology were less recognized by participants of our study, which highlights the importance of raising awareness of oculoplastic surgery and the diversity of the field, to enhance referral patterns among physicians and improve medical advice seeking among the public resulting in better health care.

Self-rated health and its related influencing factors among emergency department physicians: a national cross-sectional study.

Protecting and improving the personal health of healthcare workers is critical to improving the efficiency and quality of care. To effectively meet the needs of the emergency service system, emergency physicians need to be in a good state of health. However, due to the special characteristics of work in the emergency department, emergency physicians have to face various psychosocial pressures, which may bring them physical and mental distress. Therefore, this study aims to explore the emergency physicians' self-rated health status and its related factors, to provide an empirical study for the improvement of emergency physicians' self-rated health status. A cross-sectional survey of emergency physicians was conducted in China between July and August 2018. The questionnaires contained items on demographic characteristics, behavioral lifestyle and job-related factors, as well as self-rated health. The generalized ordinal logistic model was used to identify related factors of emergency physicians' self-rated health status. Only 14.4% of Chinese emergency physicians considered themselves in good health status. Results showed that emergency physicians who never exercised (β = 0.76, p < 0.001) and exercised <2 times per week (β = 0.34, p < 0.001) were more likely to report poor health status. In addition, emergency physicians with good sleep quality (β = -3.84, p < 0.001), fewer night work shifts (β = -0.47, p < 0.001), less frequency of visiting patients (β = -0.33, p < 0.001), never suffered the workplace violence (β = -0.47, p < 0.001) and never perceived effort-reward imbalance (β = -0.68, p < 0.001) were more likely to report good self-rated health. Chinese emergency physicians' self-rated health status was not optimistic. Self-rated health is associated with multiple domains of work-related factors and personal lifestyle. Feasible measures should be taken to improve the working environment of emergency physicians, develop acceptable shift schedules for employees, monitor and maintain the health status of emergency department physicians.

Understanding Discordant Perceptions of Disease Severity Between Physicians and Patients With Eczema and Psoriasis Using Structural Equation Modeling

Patients and physicians often have differing opinions on the patient's disease severity. This phenomenon, termed discordant severity grading (DSG), hinders the patient-physician relationship and is a source of frustration. To test and validate a model explaining the cognitive, behavioral, and disease factors associated with DSG. A qualitative study was first performed to derive a theoretical model. In this subsequent prospective cross-sectional quantitative study, the qualitatively derived theoretical model was validated using structural equation modeling (SEM). Recruitment was conducted between October 2021 and September 2022. This was a multicenter study in 3 Singapore outpatient tertiary dermatological centers. Dermatology patients and their attending physicians were recruited by convenience sampling. Patients were aged 18 to 99 years with psoriasis or eczema of at least 3 months' duration and recruited only once. The data were analyzed between October 2022 to May 2023. The outcome was the difference between global disease severity (0-10 numerical rating scale with a higher score indicating greater severity) as independently scored by the patient and the dermatologist. Positive discordance was defined as patient-graded severity more than 2 points higher (graded more severely) than physicians, and negative discordance if more than 2 points lower than physicians. Confirmatory factor analysis followed by SEM was used to assess the associations between preidentified patient, physician, and disease factors with the difference in severity grading. Of the 1053 patients (mean [SD] age, 43.5 [17.5] years), a total of 579 (55.0%) patients were male, 802 (76.2%) had eczema, and 251 (23.8%) had psoriasis. Of 44 physicians recruited, 20 (45.5%) were male, 24 (54.5%) were aged between 31 and 40 years, 20 were senior residents or fellows, and 14 were consultants or attending physicians. The median (IQR) number of patients recruited per physician was 5 (2-18) patients. Of 1053 patient-physician pairs, 487 pairs (46.3%) demonstrated discordance (positive, 447 [42.4%]; negative, 40 [3.8%]). Agreement between patient and physician rating was poor (intraclass correlation, 0.27). The SEM analyses showed that positive discordance was associated with higher symptom expression (standardized coefficient B = 0.12; P = .02) and greater quality-of-life impairment (B = 0.31; P < .001), but not patient or physician demographics. A higher quality-of-life impairment was in turn associated with lower resilience and stability (B = -0.23; P < .001), increased negative social comparisons (B = 0.45; P < .001), lower self-efficacy (B = -0.11; P = .02), increased disease cyclicity (B = 0.47; P < .001), and greater expectation of chronicity (B = 0.18; P < .001). The model was well-fitted (Tucker-Lewis: 0.94; Root Mean Square Error of Approximation: 0.034). This cross-sectional study identified various modifiable contributory factors to DSG, increased understanding of the phenomenon, and set a framework for targeted interventions to bridge this discordance.

Far from the truth: Real-world treatment patterns among newly diagnosed metastatic prostate cancer in the era of treatment intensification.

Real-world uptake of treatment intensification (TI) with novel hormonal agents (NHA) or chemotherapy as treatment of metastatic prostate cancer remains low outside of trial settings. We aim to report the prescription patterns and treatment outcomes of de novo metastatic hormone-sensitive prostate cancer (mHSPC) in a tertiary institution. This is a retrospective cohort study using real-world data from a prospectively maintained prostate cancer registry. We selected patients newly diagnosed with mHSPC from January 2016 to December 2020. Clinicopathological parameters were recorded to determine their impact on prescription patterns. In total, 585 patients with metastatic prostate cancer were identified. Prescription of NHA increased from 10.5% (2016) to 50.4% (2020), but that of chemotherapy declined. Factors associated with TI were (1) baseline health status: Charlson Comorbidity Index 0-2, ECOG 0-1, age ≤ 65, (2) disease burden: PSA (>400, CHAARTED high volume disease, p = 0.004), development of systemic complications and (3) physician factor: primary physician being uro-oncologist and medical oncologist versus general urologist. Patients with TI had a longer mean time to castration-resistant prostate cancer (45.0 vs. 32.5 months, HR 0.567, 95% CI: 0.441-0.730, p < 0.001) and overall survival (55.3 vs. 46.8 months, HR 0.612, 95% CI, 0.447-0.837, p = 0.001). This study demonstrated the trend of treatment prescription of mHSPC and factors contributing to the use of TI. TI improved mean time to CRPC and OS.

Association between physician characteristics and practice-level uptake of paediatric virtual mental healthcare: a population-based study

ObjectiveTo examine physician factors associated with practice-level uptake of virtual mental healthcare for children and adolescents.Design, setting and participantsA population-based data linkage study of a cohort of all physicians (n=12...

Factors associated with potentially inappropriate prescribing among older persons in primary care settings: Systematic review

Background Potentially inappropriate prescribing (PIP) is common in primary care and is associated with adverse outcomes. Knowledge of the risk factors of PIP can be critical in designing PIP interventions, especially in guiding our understanding on how PIP occurs in primary care. Objective This systematic review examined factors associated with PIP, specific to primary care. Methods We searched PubMed, Embase, CINAHL, Web of Science, Scopus and PsycINFO for studies related to ‘older persons’, ‘primary care’ and ‘inappropriate prescribing’. Two reviewers conducted study selection, data extraction and quality appraisal. Factors associated with PIP were narratively synthesized. Results Of the 1017 articles identified, we included 25 articles and a total of 2,893,925 participants, with average age of 70.4–84.0 years. Risk factors of PIP could be classified into patient, physician and system factors. Patient factors were related to patient demographics (advanced age, lower education level and lower socioeconomic status), medical comorbidities (polypharmacy and multimorbidity) and lifestyle factors (unhealthy habits and use of over-the-counter medications). Physician and system factors included older, male, solo general practitioner (GP), higher number of visits of pharmaceutical sales representatives to GP, centrally located GP practice, and smaller number of older patients following up with GP, and medication source from public health system. Conclusions The findings provide contextual information to guide our understanding of PIP in primary care. Factors identified in this review can inform the design of complex interventions for PIP, as well as be used to develop risk prediction tools to identify high-risk groups who may require further interventions related to PIP.

Regional differences in physicians' behavior and factors influencing the intensity of PCSK9 inhibitor therapy with alirocumab: a subanalysis of the ODYSSEY APPRISE study.

Despite better accessibility of the effective lipid-lowering therapies, only about 20% of patients at very high cardiovascular risk achieve the low-density lipoprotein cholesterol (LDL-C) goals. There is a large disparity between European countries with worse results observed for the Central and Eastern Europe (CEE) patients. One of the main reasons for this ineffectiveness is therapeutic inertia related to the limited access to appropriate therapy and suitable dosage intensity. Thus, we aimed to compare the differences in physicians' therapeutic decisions on alirocumab dose selection, and factors affecting these in CEE countries vs. other countries included in the ODYSSEY APPRISE study. ODYSSEY APPRISE was a prospective, single-arm, phase 3b open-label (≥12 weeks to ≤30 months) study with alirocumab. Patients received 75 or 150 mg of alirocumab every 2 weeks, with dose adjustment during the study based on physician's judgment. The CEE group in the study included Czechia, Greece, Hungary, Poland, Romania, Slovakia, and Slovenia, which we compared with the other nine European countries (Austria, Belgium, Denmark, Finland, France, Germany, Italy, Spain, and Switzerland) plus Canada. A total of 921 patients on alirocumab were involved [modified intention-to-treat (mITT) analysis], including 114 (12.4%) subjects from CEE countries. Therapy in CEE vs. other countries was numerically more frequently started with lower alirocumab dose (75 mg) at the first visit (74.6 vs. 68%, p = 0.16). Since week 36, the higher dose was predominantly used in CEE patients (150 mg dose in 51.6% patients), which was maintained by the end of the study. Altogether, alirocumab dose was significantly more often increased by CEE physicians (54.1 vs. 39.9%, p = 0.013). Therefore, more patients achieved LDL-C goal at the end of the study (<55 mg/dl/1.4 mmol/L and 50% reduction of LDL-C: 32.5% vs. 28.8%). The only factor significantly influencing the decision on dose of alirocumab was LDL-C level for both countries' groups (CEE: 199.2 vs. 175.3 mg/dl; p = 0.019; other: 205.9 vs. 171.6 mg/dl; p < 0.001, for 150 and 75 mg of alirocumab, respectively) which was also confirmed in multivariable analysis (OR = 1.10; 95% CI: 1.07-1.13). Despite larger unmet needs and regional disparities in LDL-C targets achievement in CEE countries, more physicians in this region tend to use the higher dose of alirocumab, they are more prone to increase the dose, which is associated with a higher proportion of patients reaching LDL-C goals. The only factor that significantly influences decision whether to increase or decrease the dose of alirocumab is LDL-C level.

Exploring decisional control preferences in older patients with cancer and their caregivers.

12042 Background: Shared decision making is preferred by many patients but it is often viewed from the lens of the patient and physician dyad only. Caregivers often support cancer decision-making, although their decision control preferences are not typically considered. We explored decisional control preferences of older patients with cancer and their caregivers, and examined concordance in preferences of the dyad, as well as patient, caregiver, physician factors associated with concordance. Methods: We utilized data from a national geriatric assessment (GA) cluster-randomized trial (NCT 02054741; PI: Mohile; funding NCI UG1CA189961) that recruited patients aged ≥70 with incurable cancer, their caregivers, and oncologists. Controlled Preferences Scale (CPS) was used to assess shared decision making preferences. Both patients and caregivers were asked about the role of patients (Patient-role CPS) and caregiver (Caregiver-role CPS) in the decision making process. Patient-role CPS options were 1) doctor makes the decisions, 2) doctor makes the decisions with patient’s input, 3) equally shared decision, 4) patient makes the decisions with doctor’s input, 5) patient makes the decisions. Caregiver-role CPS options were 1) doctor makes the decisions, 2) patient makes the decision with doctor, 3) patient and caregiver make the decisions with doctor, 4) caregiver makes the decisions with doctor. Matching responses of the dyads for each CPS question were considered concordant. We used descriptive statistics to summarize CPS for patients and caregivers and the concordance between them. We utilized logistic regression to assess dyads' sociodemographic information, patients' GA and physicians’ practice characteristics associated with patient-caregiver CPS concordance. Results: Enrolled dyads with completed CPS were included (N=332); mean age (SD) of patients and caregivers was 76.6 (5.3) and 66.6 (12.2). Women constituted 39% of patients and 76% of caregivers. Patient-role CPS for patients’ (and caregivers’) were 11% (6%) for doctor makes the decisions, 33% (28%) for doctor makes the decisions with patient’s input, 45% (49%) for equally shared, 9% (14%) for patient makes the decisions with doctor’s input, 2% (3%) for patient makes the decision. Patients’ (and caregivers’) answers on caregiver-role CPS were 20% (19%) for doctor makes the decisions, 18% (28%) for patient makes the decisions with doctor, 61% (52%) for patient and caregiver make the decisions with doctor and 1% (1%) for caregiver makes the decisions with doctor. Dyads concordance occurred in 46% of patient-role CPS and 54% of caregiver-role CPS, indicating moderate concordance. No baseline factors were associated in dyad concordance for either the patient-role or caregiver-role CPS. Conclusions: Clinicians should inquire about decisional control preferences of patients and caregivers in order to optimally support shared decision making. Clinical trial information: NCT02054741 .

Diagnostic delay in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a progressive, fatal neurodegenerative disease, and the time from symptom onset to diagnosis remains long. With the advent of disease-modifying treatments, the need to identify and diagnose ALS in a timely fashion has never been greater. We reviewed the literature to define the severity of ALS diagnostic delay, the various factors that contribute to this delay (including patient and physician factors), and the role that site of symptom onset plays in a patient's diagnostic journey. Diagnostic delay is influenced by a general practitioner's lack of recognition of ALS due to disease rarity and heterogenous presentations. As a result, patients are referred to non-neurologists, have unnecessary diagnostic testing, and may ultimately be misdiagnosed. Patient factors include their illness behavior-which impacts diagnostic delay-and their site of symptom onset. Limb-onset patients have the greatest diagnostic delay because they are frequently misdiagnosed with degenerative spine disease or peripheral neuropathy. Prompt ALS diagnosis results in more effective clinical management, with earlier access to disease-modifying therapies, multidisciplinary care, and, if desired, clinical trial involvement. Due to lack of commercially available ALS biomarkers, alternative strategies to identify and triage patients likely suffering from ALS must be employed. Several diagnostic tools have been developed to encourage general practitioners to consider ALS and make an urgent referral to ALS specialists, bypassing unnecessary referrals to non-neurologists and unnecessary diagnostic workup.

Surgeons’ Perspectives on Changing the Default Number of Doses for Opioid Prescriptions in Electronic Health Record Systems

An intervention in 2021 at a tertiary medical center found that the implementation of evidence-based default dosing settings for opioid prescriptions written in electronic health record systems was associated with reduced opioid prescribing to adolescents and young adults aged 12 to 25 years undergoing tonsillectomy. It is unclear whether surgeons were aware of this intervention, whether they thought the intervention was acceptable, or whether they believed similar interventions were feasible to implement in other surgical populations and institutions. To assess surgeons' experiences and perspectives regarding an intervention that changed the default number of doses for opioid prescriptions to an evidence-based level. This qualitative study was conducted at a tertiary medical center during October 2021, 1 year after implementation of the intervention, in which the default number of doses for opioid prescriptions written through an electronic health record system to adolescents and young adults undergoing tonsillectomy was lowered to an evidence-based level. Semistructured interviews were conducted with otolaryngology attending and resident physicians who had cared for the adolescents and young adults undergoing tonsillectomy after implementation of the intervention. Factors that play a role in opioid prescribing decisions after surgery and participants' awareness of and views on the intervention were assessed. The interviews were coded inductively and a thematic analysis was performed. Analyses were conducted from March to December 2022. Change in the default dosing settings for opioid prescriptions written in an electronic health record system to adolescents and young adults undergoing tonsillectomy. Surgeons' experiences and perspectives regarding the intervention. The 16 otolaryngologists interviewed included 11 residents (68.8%), 5 attending physicians (31.2%), and 8 women (50.0%). No participant reported noticing the change in the default settings, including those who wrote opioid prescriptions with the new default number of opioid doses. From the interviews, 4 themes regarding surgeons' perceptions and experiences of the intervention emerged: (1) opioid prescribing decisions are influenced by patient, procedure, physician, and health system factors; (2) defaults may substantially influence prescribing behavior; (3) support for the default dosing setting intervention depended on whether it was evidence-based and had unintended consequences; and (4) changing the default dosing settings is potentially feasible in other surgical populations and institutions. These findings suggest that interventions to change the default dosing settings for opioid prescriptions may be feasible to implement in a variety of surgical populations, particularly if the new settings are evidence-based and if unintended consequences are carefully monitored.

Diagnostic Errors in Japanese Community Hospitals and Related Factors: A Retrospective Cohort Study.

Diagnostic error has recently become a crucial clinical problem and an area of intense research. However, the reality of diagnostic errors in regional hospitals remains unknown. This study aimed to clarify the reality of diagnostic errors in regional hospitals in Japan. A 10-month retrospective cohort study was conducted from January to October 2021 at the emergency room of Oda Municipal Hospital in central Shimane Prefecture, Japan. Participants were divided into groups with or without diagnostic errors, and independent variables of patient, physician, and environmental factors were analyzed using Fisher's exact test, univariate (Student's t-test and Welch's t-test), and logistic regression analyses. Diagnostic errors accounted for 13.1% of all eligible cases. Remarkably, the proportion of patients treated without oxygen support and the proportion of male patients were significantly higher in the group with diagnostic errors. Sex bias was present. Additionally, cognitive bias, a major factor in diagnostic errors, may have occurred in patients who did not require oxygen support. Numerous factors contribute to diagnostic errors; however, it is important to understand the trends in the setting of each healthcare facility and plan and implement individualized countermeasures.

Reprint of: Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia

ObjectiveDespite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. MethodsWe evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. ResultsA total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). ConclusionsEarly PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.

Prevalence and Predictors of Physician-Patient Discordance in Prognostic Perceptions in Advanced Cancer.

Discordance between physicians' and patients' prognostic perceptions in advanced cancer care threatens informed medical decision-making and end-of-life preparation, yet this phenomenon is poorly understood. We sought to: (1) describe the extent and direction of prognostic discordance, patients' prognostic information preferences in cases of prognostic discordance, and physicians' awareness of prognostic discordance; and (2) examine which patient, physician, and caregiver factors predict prognostic discordance. Oncologists and advanced cancer patients (median survival ≤12 months; n = 515) from 7 Dutch hospitals completed structured surveys in a cross-sectional study. Prognostic discordance was operationalized by comparing physicians' and patients' perceptions of the likelihood of cure, 2-year mortality risk, and 1-year mortality risk. Prognostic discordance occurred in 20% (likelihood of cure), 24%, and 35% (2-year and 1-year mortality risk) of physician-patient dyads, most often involving patients with more optimistic perceptions than their physician. Among patients demonstrating prognostic discordance, the proportion who preferred not knowing prognosis varied from 7% (likelihood of cure) to 37% (1-year mortality risk), and 45% (2-year mortality risk). Agreement between physician-perceived and observed prognostic discordance or concordance was poor (kappa = 0.186). Prognostic discordance was associated with several patient factors (stronger fighting spirit, self-reported absence of prognostic discussions, an information source other than the healthcare provider), and greater physician-reported uncertainty about prognosis. Up to one-third of the patients perceive prognosis discordantly from their physician, among whom a substantial proportion prefers not knowing prognosis. Most physicians lack awareness of prognostic discordance, raising the need to explore patients' prognostic information preferences and perceptions, and to tailor prognostic communication.

Association of Patient, Physician, and Practice-Level Factors with Uptake of Payer-Led Oncology Clinical Pathways

Payers use oncology clinical pathways programs to increase evidence-based drug prescribing and control drug spending. However, compliance with these programs has been low, which may decrease their efficacy, and factors associated with pathway compliance are unknown. To determine extent of pathway compliance and identify factors associated with pathway compliance using characteristics of patients, practices, and the companies that develop cancer treatment pathways. This cohort study comprised patients with claims and administrative data from a national insurer and a pathways health care professional between July 1, 2018, and October 31, 2021. Adult patients with metastatic breast, lung, colorectal, pancreatic, melanoma, kidney, bladder, gastric, and uterine cancer being treated in the first line were included. Six months of continuous insurance coverage prior to the date of treatment initiation was required for determination of baseline characteristics. Stepwise logistic regression was used to identify factors associated with pathway compliance. Use of a pathway program-endorsed treatment regimen in the first-line setting for metastatic cancer. Among 17 293 patients (mean [SD] age, 60.7 [11.2] years; 9183 [53.1%] women; mean [SD] Black patients per census block, 0.10 [0.20]), 11 071 patients (64.0%) were on-pathway, and 6222 (36.0%) were off-pathway. Factors associated with increased pathway compliance were higher health care utilization during the 6-month baseline period (measured in inpatient visits and emergency department visits) (5220 on-pathway inpatient visits [47.2%] vs 2797 off-pathway [45.0%]; emergency department visits, 3304 [27.1%] vs 1503 [24.2%]; adjusted odds ratio [aOR] for inpatient visits, 1.32; 95% CI, 1.22-1.43; P < .001), volume of patients with this insurance provider per physician (mean [SD] visits: on-pathway, 128.0 [258.3] vs off-pathway, 121.8 [161.4]; aOR, 1.12; 95% CI, 1.04-1.20; P = .002), and practice participation in the Oncology Care Model (on-pathway participation, 2601 [23.5%] vs 1305 [21.0%]; aOR, 1.13; 95% CI, 1.04-1.23; P = .004). Higher total medical cost during the 6-month baseline period were associated with decreased pathway compliance (mean [SD] costs: on-pathway, $55 990 [$69 706] vs $65 955 [$74 678]; aOR, 0.86; 95% CI, 0.83-0.88; P < .001). There was heterogeneity in odds of pathway compliance between different malignancies. Pathway compliance rates trended down from the reference year of 2018. In this cohort study, despite generous financial incentives, compliance with payer-led pathways remained at historically reported low rates. Factors such as increasing exposure to the program due to the number of patients impacted and participation in other value-based payment programs, such as the Oncology Care Model, were positively associated with compliance; factors such as the type of cancer and patient complexity may have played a role, but the directionality of potential effects was unclear.