Physicians In Private Practice Research Articles

Telemedicine Pays: Billing and Coding Update.

Purpose of ReviewTelemedicine is a rapidly growing healthcare sector that can improve access to care for underserved populations and offer flexibility and convenience to patients and clinicians alike. However, uncertainty about insurance coverage and reimbursement policies for telemedicine has historically been a major barrier to adoption, especially among physicians in private practice (the majority of practicing allergists).Recent FindingsThe COVID-19 public health emergency has highlighted the importance of telehealth as a safe and effective healthcare delivery model, with governments and payers rapidly expanding coverage and payment in an effort to ensure public access to healthcare in the midst of an infectious pandemic. This comprehensive review of updated telemedicine coverage and payment policies will include a tabular guide on how to appropriately bill and optimize reimbursement for telemedicine services.SummaryThis review of current trends in telemedicine coverage, billing, and reimbursement will outline the historical and current state of telemedicine payment policies in the USA, with special focus on recent policy changes implemented in light of COVID-19. The authors will also explore the potential future landscape of telehealth coverage and reimbursement beyond the resolution of the public health emergency.

Impact of a three-dose diphtheria outbreak response immunization in East Java, Indonesia, 6 months after completion

ABSTRACT Several outbreaks of diphtheria have occured in the East Java Province of Indonesia since 2011. The last effort to stop the outbreak in the province was a three round outbreak response immunization (ORI) in 2018.The aim of the this study was to evaluate the impact of the 2018 ORI in East Java province – 6 months following the completion of the program. Surveillance data was collected for 6 month period, from January to June 2019. The source of data was the district health offices, hospitals, community health centers, and private physician and paramedic practices. The data included demographic characteristics, involved health facilities, patient immunization history, clinical signs and symptoms, some laboratory test results and other additional examinations. All cases were evaluated by the East Java Provincial Diphtheria Expert Committee and not based on the individual physician decision. During the 6 month period, there were 97 diphtheria cases which approved by the Diphtheria Expert Committee. The reports came from 36 of 38 districts. One patient died, denoting a case fatality rate of 1%. The majority were 19 years of age or less, with uncomplete immunization. Patients above 19 years were 24%. Compared with 2017 (438 cases) and 2018 (310), 2019 saw a significant reduction in the number of reported cases. Only 4 positive culture results were collected (positivity rate 4,13%). Two patients had Mitis subtype and the other two had Gravis subtype. Diphtheria ORI in East Java had a significant impact during the first 6 months of 2019.

Impact of the SARS-CoV-2 epidemic on private ENT consulting practice during the first month of lockdown in Réunion Island in 2020

ObjectiveTo analyze the impact of the first month of lockdown related to the 2020 SARS-Cov-2 epidemic on the consulting activity of private ENT physicians in Réunion Island. Material and methodsA multicenter prospective study analyzed the consulting activity of 12 ENT physicians in full-time private practice. The main endpoints were the number, characteristics and conditions of consultations. Secondary endpoints comprised presenting symptoms, diagnosis, prescriptions, adverse effects, and progression of monthly consulting turnover. ResultsSix hundred and ninety three consultations were performed during the study period (Appendix 1), with 50% emergency consultations. In 57.9% were face-to-face, 28.4% by phone and 13.7% video. In face-to-face consultation, the physician wore gloves in 53.8% of cases and a mask in 92.2%: surgical mask in 71.6% of cases and FFP2 in 28.4%. The three most frequent symptoms (48.5% of cases) were otalgia, hearing impairment, and vertigo. The three most frequent diagnoses (60.6% of cases) were otitis, intra-auricular foreign body (including wax), and pharyngeal infection. The three most frequently prescribed complementary exams (74.3% of cases) were imaging, hearing work-up, and specialist opinion. The three most frequently prescribed treatments (52.7% of cases) were intra-auricular drops, oral antibiotics, and nasal spray. The incidence of adverse effects was 0.001%. None of the physicians or patients seemed to have been infected by Covid-19 during the study period. There was a 47.3-91% (median, 75.6%) drop in monthly consultation turnover. ConclusionThe present study underscored the availability and adaptability of ENT physicians in the Réunion Island in an epidemic context, although economic impact was detrimental.

Surgical and Clinical Reactivation for Elective Procedures during the COVID-19 Era: A Global Perspective

Surgical and Clinical Reactivation for Elective Procedures during the COVID-19 Era: A Global Perspective

La gouvernance de la télémédecine face à l’organisation libérale des soins

Cet article propose d’expliquer le faible développement de la télémédecine en médecine de ville à partir d’une enquête réalisée auprès de médecins libéraux. L’enquête dégage un résultat paradoxal : l’institutionnalisation de la télémédecine, supposée lever les freins à la pratique, semble responsable de son non-développement en médecine libérale. Les raisons fréquemment évoquées dans les débats publics au sujet du manque d’appétence des médecins pour l’outil technologique et des difficultés d’appropriation liées ne sont pas celles données par les médecins interrogés. En adoptant une démarche institutionnaliste, nous questionnons ainsi la pertinence du modèle organisationnel proposé par les instances de gouvernance de la télémédecine.

MON-501 Physician-Reported Misuse of Thyroid Ultrasound

BACKGROUND: Over the past four decades, there has been a substantial increase in the incidence of thyroid cancer with studies suggesting that greater use of thyroid ultrasound contributes to the rise in incidence. However, little is known about physician reported practice patterns on ultrasound use. Methods: Patients diagnosed with differentiated thyroid cancer in 2014–15 from the Surveillance, Epidemiology and End Results registries of Georgia and Los Angeles were surveyed and asked to identify the surgeon who performed their thyroid surgery, and the endocrinologist and other doctors most involved in their thyroid cancer treatment decision making. We surveyed all physicians identified by more than one patient, and a random sample of physicians identified by one surveyed patient (N=610; 65% response rate). Surveyed physicians were asked to identify the clinical scenarios in which they would schedule a thyroid or neck ultrasound. We generated descriptive statistics for all categorical variables and used multivariable logistic regression to identify factors associated with thyroid ultrasound misuse. Results: The cohort consisted of primary care physicians (PCPs; N=162), endocrinologists (N=176), otolaryngologists (N=130), and general surgeons (N=134). In addition to physicians reporting ultrasound use for accepted reasons such as palpable nodule on exam (98%), large goiter (92%), and nodule seen on other imaging test (88%), a substantial number of physicians endorsed ultrasound use for clinically unsupported reasons: patient request (33%); abnormal thyroid function tests (28%); and positive thyroid antibodies (22%). In multivariable analysis, compared to PCPs, endocrinologists, otolaryngologists, and general surgeons were significantly more likely to schedule an ultrasound in response to patient request (odds ratio (OR) 2.52, 95% confidence interval (CI) 1.27–5.11; OR 2.98, 95% CI 1.57–5.79; OR 2.14, 95% CI 1.17–3.97, respectively). Physicians in private practice were more likely to schedule an ultrasound for abnormal thyroid function tests (OR 2.44, 95% CI 1.33–4.73) and positive thyroid antibodies (OR 2.47, 95% CI 1.27–5.21) compared to those in academic medical centers. Physicians who managed ten patients or less, compared to more than 50 patients, with thyroid nodules in the past 12 months were less likely to schedule an ultrasound for positive thyroid antibodies (OR 0.43, 95% CI 0.19–0.95). Conclusion: Physicians report scheduling thyroid ultrasound for reasons not supported by clinical guidelines and in conflict with the Choosing Wisely recommendations. Understanding why physicians use thyroid ultrasound and factors that correlate with clinically unsupported reasons is essential to creating targeted educational interventions to improve physician adherence to guidelines, reduce unnecessary imaging, and curb the overdiagnosis of low-risk thyroid cancer.

Proposal of the French Society of Vascular Medicine for the prevention, diagnosis and treatment of venous thromboembolic disease in outpatients with COVID-19.

The proposal is intended to help physicians treating patients with COVID-19 for the diagnosis, treatment and prevention of venous thromboembolic disease either when leaving the hospital or treated as outpatients. This document is a synthesis of opinions of a working group from the French Society of Vascular Medicine (SFMV) composed of private practice and hospital-based physicians. This proposal is based on a limited level of evidence. This proposal is likely to evolve with the knowledge of the disease.

The "practice track" - How can teaching content related to outpatient healthcare be integrated into medical studies? Learning objectives, conception and implementation of a specialized voluntary program.

The “practice track” (PAT) at Goethe University Frankfurt provides students with the opportunity to focus on outpatient care during their medical studies. The aim of this article is to describe the objectives, conception and implementation of the program.At the Institute of General Practice, a new teaching concept has been developed in cooperation with the Dean’s Office of the Faculty of Medicine at Goethe University and further partners. Medical students generally receive their training in highly specialized hospitals. However, the new concept will allow them to gain a practical insight into the outpatient care provided by physicians in private practice during their medical studies. Every year, 15 interested students will be able to participate in the longitudinal program, which includes internships, seminars and mentoring sessions. In the three current PAT cohorts, all 45 places have been taken up, and the first cohort has now completed the program. In addition to practical skills in the disciplines of family medicine, internal medicine, surgery, gynecology and pediatrics, it has been possible to show students the full scope of ambulatory health care. However, legal limitations to the implementation of the program in registered medical practices have meant that some parts of it could only be carried out voluntarily. Against the background of the current and future situation in health care, it makes sense that registered physicians in private practice should teach medical students about outpatient care during their medical studies. In order to establish such programs and permit their complete integration into the medical curriculum, it is essential that the necessary changes are made to medical licensing regulations.

Cancer patients in cardiology: how to communicate with patients with special psychological needs and manage their cardiac problems in daily clinical practice.

: Cancer patients are increasingly referred for cardiology evaluations. These patients differ from those routinely seen in cardiology clinics because of their psychological burden and because the therapies and cancer itself can cause cardiac symptoms. A humane approach is critical to managing these patients. Cardiologists may see patients who are newly diagnosed with cancer or are in various phases of treatment; these patients may or may not have preexisting cardiac disease, and may develop cardiotoxicity from chemoimmunotherapy or radiotherapy. Each of these situations presents unique communication challenges for cardiologists. Although some oncology centers provide training in communication skills for their personnel, including cardiologists, this training is not widely available to physicians in general hospitals or private practice. This article examines the psychological aspects of cardio-oncology. It offers practical suggestions on how to best communicate with cancer patients in different phases of oncology care, and discusses when professional psychological help is needed.

Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis.

Lyme borreliosis is the most common tick-borne infectious disease in Europe. A neurological manifestation occurs in 3–15% of infections and can manifest as polyradiculitis, meningitis and (rarely) encephalomyelitis.This S3 guideline is directed at physicians in private practices and clinics who treat Lyme neuroborreliosis in children and adults.Twenty AWMF member societies, the Robert Koch Institute, the German Borreliosis Society and three patient organisations participated in its development. A systematic review and assessment of the literature was conducted by the German Cochrane Centre, Freiburg (Cochrane Germany).The main objectives of this guideline are to define the disease and to give recommendations for the confirmation of a clinically suspected diagnosis by laboratory testing, antibiotic therapy, differential diagnostic testing and prevention.

Physicians in private practice and the “Work Style Reform” of physicians

Physicians in private practice and the “Work Style Reform” of physicians

Heterogeneity in The drivers of health expenditures financed by health insurance in a fragmented health system: The case of Switzerland

Switzerland is the world’s second largest spender on health care, both per capita and as a share of the Gross Domestic Product (GDP). The Swiss health care system is a federation of 26 cantonal systems with highly fragmented provision and financing of care, leading to important geographical disparities in expenditures. We propose a simple conceptual framework to guide the decomposition of health care expenditures into five core components (i.e. demography, propensity to use health services, substitution between domains of care, quantity of services delivered, and unit price of these services), with the objective of better understanding the drivers of geographic variation. We illustrate this framework using aggregated insurance data from 85 % of the 2006 insured population and measure cross-cantonal variation disaggregated into these five components. Results obtained indicated a West-East gradient of controllable costs after adjusting for demography and propensity to use health services. Moreover, we found specific explanations for cost overruns: visits to physicians in private practice in some cantons, and, e.g., outpatient hospital care or variations in drug related expenses in others. This shows that the simple proposed approach provides interesting insights into the drivers of cost differences between regions, specifically in terms of substitution among health services, quantity of delivered services, and their prices.

Genesis of Antibiotic Resistance (AR) XLVII: “Dream Team of Antibiotic Stewardship (DTAS)”

Antibiotic Stewardship Programs (“ASP”) have been created to promote optimal use of antibiotics in the acute and chronic infectious disease by effective monitoring and implementation of defined daily dose (DDD), days of therapy (DOT), route of administration, and infection clearance rate. An extensive review of “ASP” policies across the globe exhibit lack of continuity in the chain of command and inadequate elements for a successful “ASP”. We have identified that impediments in the current implementation of “ASP” lacks a clear and coherent chain of communication in terms: a. data availability to the “ASP” team (Emergency Room‐Clinical data on AntiBio gram‐ pharmacy director‐charge nurse‐infection control personal ‐intensive care unit ‐ family involvement‐county‐state‐CDC&P epidemiologist); b. Implementation of isolation protocol for patients with infections lasting more than 7days to limit the spread of infection; c. Implementation of effective informed decision making based on mandatory continuing education on “ASP” in home health care, hospice care, dentistry, nurse practitioners, physician assistants, urgent care, and urgent care /emergency (STAT) dispensaries, and physicians in private practice, education on FDA Adverse Event Reporting System(FAERS); d. Patient education on auto medication, poly pharmacy, drug‐drug reaction, sharing of antibiotics, prevailing trends in infection in the community; e. monitor and rule out the cause of the infection by determining Infection vs. contamination vs. colonization‐ false positive, duration antibiotic therapy (7 days/10 days); f. institution need based specific “ASP” review committee/expertise; g. correlation of meat (Red / White) consumption and clearance of infection by an expert dietician/nutritionist are missing elements. Based on our review here with we propose a “DTAS” constituting the following members: pharmacy director, charge nurse, director of nursing (DON), Clinical Infectious Diseases Director (an MD with expertise in interventions strategies on the infectious diseases expertise across the modality as per the health care setting (Ex: Surgery, Transplant medicine, Oncology, and ICU), director of nutrition/dietician, director of clinical laboratory, director of housekeeping operation, local representative of state health and human services, local representative USDA, hospital epidemiologist, local representative of state and national epidemiology and/or local representative of CDC&P, with an expertise on morbidity and mortality rate of infectious disease and vital statistics data, and community liaison with an expertise in patient education with resource supplemented via health district administration (“Bubble Map”). Taken together, implementation of the DTAS to break the Chain of Infection for Mitigation of Antibiotic Resistance Pandemic (ARP) across the globe in both acute and long term care (Hospice, rehabilitation, dialysis centers, outpatient clinics in the developing countries, physicians in private practice), while plausible “ASP” code enforcement just as the law enforcement agencies would be the pivotal first step to mitigate ARP.Support or Funding InformationSupported by Professional Development Funds provided by SWTJC to Subburaj KannanThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Promoting Leadership by Women in Gastroenterology—Lessons Learned and Future Directions

Promoting Leadership by Women in Gastroenterology—Lessons Learned and Future Directions

Disease Patterns among rural residents—An Explorative Qualitative Study with Physicians in Private Practice of a Village in Western Maharashtra, India

Disease Patterns among rural residents—An Explorative Qualitative Study with Physicians in Private Practice of a Village in Western Maharashtra, India

Determinants of Abnormal Cervical Cancer Screening Follow-Up And Invasive Cervical Cancer Among Uninsured and Underinsured Women in New Jersey.

To identify determinants of follow-up care and diagnosis of invasive cervical cancer among uninsured/underinsured women screened for cervical cancer. We examined the associations between health care facility, area-level, and individual-level factors on the outcomes of interest in retrospective cohort of women from the New Jersey Cancer Education and Early Detection Program (2000-2015). Women screened at department of health clinics (aOR:3.11, 95% CI: 2.30-4.20) and health care system-affiliated clinics (aOR:1.71, 95% CI: 1.11-2.64) had higher odds of lacking follow-up care compared with women in private physician practices. Similarly, women residing in areas with the highest unemployment had higher odds of lacking follow-up (aOR:1.48, 95% CI: 1.07-2.06). Delays in follow-up care were higher for women born in Central/South American countries compared with U.S.-born women (aOR: 1.46, 95% CI: 1.12-1.92). Improved outreach efforts and multilevel strategies are needed to address the persistent barriers to appropriate follow-up care for underserved women.

'If We Are to Believe the Psychologists …': Medicine, Psychoanalysis and Breastfeeding in Britain, 1900-55.

In 1942, the British Minister of Health commissioned a report from the newly established Advisory Committee on Mothers and Young Children into 'What can be done to intensify the effort to secure more breast feeding of infants?'. To make their case, the members of the sub-committee put in charge of the report sought expert testimony on the benefits of breastfeeding. They consulted medical officers of health, maternity and child-welfare officers, health visitors, midwives, obstetricians, paediatricians and a physician in private practice. They also consulted five 'psychologists' (a contemporary umbrella term for psychologists, psychoanalysts and psychiatrists). It is not surprising that the committee turned to medical professionals, as infant feeding had long been an area of their expertise. However, seeking the views of 'psychologists' when establishing the benefits of breastfeeding marked a more innovative development, one which suggested that a shift in conceptualising the significance of breastfeeding was gathering pace. In the interwar period, psychoanalysts and psychoanalytically oriented psychiatrists showed growing interest in early infancy. It led to an extensive psychoanalytic engagement with contemporary feeding advice disseminated by the medical profession. This article will explore the divergences and intersections of medical and psychoanalytic theories on breastfeeding in the first half of the twentieth century, concluding with a consideration of how medical ideas on breastfeeding had absorbed some of the contentions of 'psy'-approaches to infant feeding by the post-war period.

496. Secondary Prophylaxis for Clostridium difficile Infection: A Physician Practice Assessment

BackgroundRecurrent Clostridium difficile infection (CDI) is associated with significant morbidity, mortality and healthcare related costs. Up to 30% of CDI cases recur, resulting in 83,000 cases of recurrent CDI per year. Although agents for primary and secondary prophylaxis for CDI including the use of probiotics, antibiotics, fecal microbiota transplantations, and newer therapies such as bezlotoxumab have been reported, there is no consensus guidelines regarding their use. The purpose of this study was to assess physician practices regarding secondary prophylaxis for CDI.MethodsThis cross-sectional study using Qualtrics electronic survey (24 questions) assessed physician practice preferences. The survey was distributed through institutional emails and through the Infectious Disease Society of America “IDea Exchange” forum. Responses were collected and analyzed using descriptive statistics.ResultsA total of 246 surveys were completed. Physicians were surveyed from greater than 100 locations (see Figure 1). Most (229, 93%) of the physicians practiced in an inpatient setting. Respondent specialties were primarily infectious diseases (138, 56%) followed by internal medicine (72, 29%). Most physicians (173, 71%) use secondary prophylaxis for CDI prevention (see Figure 2). Vancomycin (121, 70%) and probiotics (114, 66%) were most commonly used for CDI secondary prophylaxis, (see Figure 3). Of 164 physicians who used secondary prophylaxis half of them (89, 54.2%), used prophylaxis only for patients with a history of recurrent CDI receiving antibiotics and about a third, (49, 29.9%) utilized it for patients with a history of CDI who were receiving antibiotics. ID physicians were more likely to prescribe secondary prophylaxis as compared with non-ID physicians (85% of 127 respondents vs. 75% of 85 respondents, P = 0.052). The use of secondary prophylaxis was similar among private practice and academic physicians (84% of 39 vs. 80% of 157 respondents, P = 0.591).ConclusionThe majority of the physicians who responded to this survey use secondary prophylaxis to prevent recurrent CDI, hence future CDI guidelines need to address the role of secondary prophylaxis in clinical practice. Disclosures All authors: No reported disclosures.

Perianesthetic and Anesthesia-Related Mortality in a Southeastern United States Population: A Longitudinal Review of a Prospectively Collected Quality Assurance Data Base.

Perianesthetic mortality (death occurring within 48 hours of an anesthetic) continues to vary widely depending on the study population examined. The authors study in a private practice physician group that covers multiple anesthetizing locations in the Southeastern United States. This group has in place a robust quality assurance (QA) database to follow all patients undergoing anesthesia. With this study, we estimate the incidence of anesthesia-related and perianesthetic mortality in this QA database. Following institutional review board approval, data from 2011 to 2016 were obtained from the QA database of a large, community-based anesthesiology group practice. The physician practice covers 233 anesthetizing locations across 20 facilities in 2 US states. All detected cases of perianesthetic death were extracted from the database and compared to the patients' electronic medical record. These cases were further examined by a committee of 3 anesthesiologists to determine whether the death was anesthesia related (a perioperative death solely attributable to either the anesthesia provider or anesthetic technique), anesthetic contributory (a perioperative death in which anesthesia role could not be entirely excluded), or not due to anesthesia. A total of 785,467 anesthesia procedures were examined from the study period. A total of 592 cases of perianesthetic deaths were detected, giving an overall death rate of 75.37 in 100,000 cases (95% CI, 69.5-81.7). Mortality judged to be anesthesia related was found in 4 cases, giving a mortality rate of 0.509 in 100,000 (95% CI, 0.198-1.31). Mortality judged to be anesthesia contributory were found in 18 cases, giving a mortality of 2.29 in 100,000 patients (95% CI, 1.45-3.7). A total of 570 cases were judged to be nonanesthesia related, giving an incidence of 72.6 per 100,000 anesthetics (95% CI, 69.3-75.7). In a large, comprehensive database representing the full range of anesthesia practices and locations in the Southeastern United States, the rate of perianesthestic death was 0.509 in 100,000 (95% CI, 0.198-1.31). Future in-depth analysis of the epidemiology of perianesthetic deaths will be reported in later studies.

Health, risk behaviour and consumption of addictive substances among physicians\xa0- results of an online survey

BackgroundPrevious studies were able to show that hazardous alcohol and substance abuse among physicians is not rare. Currently no recent data to detect risk groups are available either on the prevalence of hazardous drinking disorders and risky health behaviour among physicians or on influencing factors (age, gender, role, institution, specialization, working hours).MethodsA 42-item online questionnaire was distributed to 38 university hospitals, 296 teaching hospitals and 1290 physicians in private practice. The questionnaire addressed health behaviour and alcohol/substance consumption as well as demographic and work-related properties.ResultsOut of 1338 a total of 920 questionnaires could be evaluated. 90% of physicians estimate their health status as satisfying. 23% of doctors consume hazard quantities of ethanol, 5% are nicotine addicted, and 8% suffer from obesity. Childlessness (p = 0,004; OR = 1,67; KI = 1,17-2,37) for both genders and the role of a resident for females (p = 0,046, OR = 3,10, KI = 1,02-9,40) poses a risk factor for hazardous alcohol consumption. Weekly working hours of more than 50 h (p = 0,009; OR = 1,56; KI = 1,12-2,18) and a surgical profession (p < 0,001; OR = 2,03; KI = 1,47-2,81) may also be a risk factor towards hazardous and risky health behaviour.ConclusionA more structured and frequently repeated education on help offerings and specific institutions for addicted and risk groups seems essential.