Physicians In Florida Research Articles

When Laws Collide With Responsible Patient Care

When Laws Collide With Responsible Patient Care

Clinical Decision Making by Medical Marijuana Physicians in Florida: A Qualitative Assessment

Medical marijuana (MMJ) was legalized in November 2016 with the passing of Amendment 2 in the state of Florida. Since the legalization, many studies have been conducted to understand the direct effect medical marijuana has on specific medical conditions. Unlike most allopathic drugs, medical marijuana does not target single ailments or specific conditions and does not follow precise recommending guidelines. There is scarce knowledge on how patient characteristics, including medical conditions, affect a physician’s direct recommendations and registry limits. To obtain insight on the effect patient characteristics have on the clinical decision-making process, we conducted ten qualitative interviews of medical marijuana physicians who are certified to order medical marijuana for patients in Florida. Interview topics ranged from typical daily practice to specific recommendations for patient histories. Each interview was transcribed and thematically analyzed. Five major patient characteristics that influence a physician’s recommendation emerged from the interviews: patient medical history, co-medications, lifestyle, marijuana experience level and counter-indications. Each category was analyzed further to understand how the characteristics influenced the practice of recommending and ordering product. Physicians emphasized the equivalent importance of reviewing a patient’s medical history, lifestyle, and past marijuana experiences while also expressing the need to look holistically at the individual patient. Instead of the characteristics determining what the physician recommends for the patient and orders through the registry, the characteristics dictate the education given to the patient so that the patient may lead and determine their own individual care.

Priorities for Medical Marijuana Research from the Perspective of Physicians, Dispensary Owners/Staff, and Patients: A Survey Study

Objective: More patients are turning to medical marijuana as an alternative treatment, yet there are apparent knowledge gaps on the risk benefit of medical marijuana for a variety of indications. This study aimed to determine the priorities for medical marijuana research from the perspective of multiple stakeholders including patients, clinicians, and industry representatives. Methods: An anonymous survey was administered to attendees of the 2019 American Medical Marijuana Physicians Association annual meeting in Orlando, Florida. Respondents completed the survey on paper or smartphone via Qualtrics. The survey included questions on demographics and medical marijuana research priorities under the following broad categories: clinical conditions, safety issues, marijuana types, populations, and others. Results: Forty-six participants (56.5% female, mean age = 51.6 ± 14.1) responded to the survey. A majority were medical marijuana qualified physicians in Florida (56.5%), 30.5% other physicians or clinicians, and 21.7% medical marijuana patients (multiple choices allowed). The top conditions prioritized for research by this group were chronic pain, cancer, and anxiety, and the top priority safety issues were dosing/product choice, complications from smoking/vaping, and drug interactions. Regarding marijuana types, the group prioritized research on THC/CBD ratios, different modes of consumption, and terpenes. Conclusions: Findings from this survey indicate that medical marijuana stakeholders perceived a broad range of research topics as priorities. More research is needed to advance the evidence in these areas and provide guidance to patients, physicians, and the medical marijuana industry.

How Do Physicians Respond to Malpractice Allegations? Evidence from Florida Emergency Departments

A substantial literature has studied the influence of malpractice pressure on physician behavior. However, these studies generally focus on malpractice pressure stemming from state laws that govern liability exposure, which may be unknown or not salient to physicians. We test how physicians respond to malpractice allegations made directly against them. Our sample is Emergency Department physicians in Florida, where we have the universe of data on patients and how they are treated along with a census of malpractice complaints. We find that physicians oversee 9% fewer discharges after malpractice allegations and treat each discharge 4% more expensively after an allegation. These effects are true for both allegations that result in money paid and allegations which are dropped. Further, the increase in treatment is generalized, i.e., not limited to patients with conditions similar to what the physician is reported for. The results suggest significant, if modest, impacts of malpractice claims on medical practice. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Practice Patterns and Training Needs Among Physicians Certifying Patients for Medical Marijuana in Florida.

Background:Little is known about the clinical training or practice experiences among physicians who certify patients for medical marijuana. The objective of this study was to determine information sources, factors influencing recommendations, clinical practices in patient assessment, communications, and recommendations, and priority areas for additional training among physicians who certify patients for medical marijuana.Methods:A cross-sectional state-wide anonymous survey of registered medical marijuana physicians in Florida between June and October 2020 was administered. Numerical responses were quantified using counts and percentages. The frequencies for “often” and “always” responses were aggregated when appropriate.Results:Among 116 respondents, the mean (standard deviation) age was 57 (12) years old, and 70% were male. The most frequently used information sources were research articles (n = 102, 95%), followed by online sources (n = 99, 93%), and discussions with other providers and dispensary staff (n = 84, 90%). Safety concerns were most influential in patient recommendations (n = 39, 39%), followed by specific conditions (n = 30, 30%) and patient preferences (n = 26, 30%). Ninety-three physicians (92%) reported they “often” or “always” perform a patient physical exam. Eighty-four (77%) physicians provided specific administration route recommendations. Half (n = 56) “often” or “always” provided specific recommendations for Δ-9-tetrahydrocannabinol: cannabidiol ratios, while 69 (62%) “often” or “always” provided specific dose recommendations. Online learning/training modules were the most preferred future training mode, with 88 (84%) physicians “likely” or “very likely” to participate. The top 3 desired topics for future training were marijuana-drug interactions (n = 84, 72%), management of specific medical conditions or symptoms (n = 83, 72%), and strategies to reduce opioids or other drugs use (n = 78, 67%).Conclusions:This survey of over 100 medical marijuana physicians indicates that their clinical practices rely on a blend of research and anecdotal information sources. While physicians report clinical factors as influential during patient recommendation, patient assessment practices and treatment regimen recommendations vary substantially and rely on experimental approaches. More research is needed to inform evidence-based practice and training, especially considering details on drug interactions, risk-benefit of treatment for specific clinical conditions, and strategies to reduce opioid use.

Defining and estimating the reliability of physician quality measures in hierarchical logistic regression models

In healthcare provider profiling, the reliability of a performance measure indicates whether observed differences in patient outcomes can be attributed to genuine differences in quality across providers. While reliability is easy to define, estimate, and interpret when the outcome of interest is continuous and a hierarchical linear model can be assumed, several different definitions and estimators of reliability are in use for performance measures based on binary outcomes. We compare these candidate definitions and estimators when a hierarchical logistic regression model is assumed for the binary outcome. Our simulations revealed important differences across reliability estimators, particularly when the number of patients per provider is low, as expected for physician quality measures. Using claims data on Medicare fee-for-service beneficiaries treated by physicians in Florida, we illustrate the practical implications by examining two process-of-care measures collected by the Centers for Medicare and Medicaid Services in the U.S. for physician quality reporting.

Transitioning to Value-Based Diabetes Care: A Call for Action Derived from Primary Care Providers in South Florida.

In Florida, 2.4 million people have diabetes and 5.8 million are pre-diabetic. Not only has the prevalence of diabetes doubled over the past 20 years from 5.2 in 1992 to 11.2 in 2014, but the Centers for Disease Control and Prevention expects 1 out of every 3 adults will have diabetes by the year 2050. In addition, in every year since 1996, Florida well exceeds the national levels in terms of prevalence of diabetes, and the gap is getting wider. A study was conducted to gather information from key physician stakeholders as to how to address unmet needs of patients at risk for, or whom already have, diabetes in a tri-county region of South Florida where the prevalence of diabetes is very high. The goal was to catalyze innovation and generate solutions for high quality and affordable diabetes care by convening community physicians in South Florida and querying them about solutions for delivering value-based care. A physician-led task force of community physicians was convened to uncover unmet needs in the diabetes care continuum, identify areas of improvement for coordinating care across the continuum and effectively accessing specialty care. Focus groups were convened with 30 participants to capture qualitative data relative to unmet needs, utilizing the Rapid Ideation Technique. A survey instrument was designed and administered to the twenty-one community clinicians on the task force to augment the qualitative data with quantitative data. The first part of the survey captured characteristics of the participating clinicians, their practices, their diabetes services and management approaches. The second part of the survey captured individual ratings of the importance and merit of needs and/or potential solutions generated. The focus groups generated a wealth of information regarding challenges, issues, areas of opportunities, and potential solutions that could be organized within eight main themes: care coordination and integration; patient engagement, education and behavioral change; physician and practice support; EMR and data issues; telehealth solutions; health informatics and data analytics; and access to care. The surveys culminated in the formation of a Call-For-Action Agenda for immediate work. The ultimate goal of the taskforce was to catalyze innovation and generate solutions for high quality and affordable care. This article reports the findings and provides a roadmap for the future.

Use of Biomarker Testing in Lung Cancer Among Puerto Rico and Florida Physicians: Results of a Comparative Study

Lung cancer biomarker-driven therapies are the gold standard of treatment and recent studies suggest a higher prevalence of specific targetable biomarkers among Hispanic/Latinos (H/L) than Non-Hispanic Whites (NHW). The study aimed (1) to identify Florida (FL) and Puerto Rico (PR) physicians' knowledge and perceived value of newer genomic data regarding race/ethnicity in relation to optimal lung cancer treatment and survival; and (2) to identify modifiable practice barriers both across and within each location regarding biomarker testing in lung cancer.A 25-item survey was administered to a stratified random sample of physicians in FL and PR (medical oncologists, radiation oncologists, pulmonologists, and pathologists). Questions targeted domains of biomarker knowledge, attitudes toward testing, barriers, and practice behaviors regarding lung cancer biomarker testing.The response rate was 45%. Participants identified guiding treatment decisions (82%) and personalizing treatments for patients (78%) as key benefits to mutation testing. PR physicians were more likely (p=0.022) to believe H/L had an elevated incidence of targetable epidermal growth factor receptor (EGFR) mutations compared to NHW. They also perceived lack of appropriate testing resources as a primary barrier compared to FL physicians (43.6% vs. 20.6%, p<0.001), whereas FL physicians identified mutation tests not conducted routinely as part of patient diagnosis as a primary barrier (43.1% vs 24.2%, p= 0.008).Practice behaviors differed by specialty and between locations, and differences were noted concerning physician's preferences for ordering mutation testing, indicating a clear need for education among physicians in both locations.Educating physicians regarding biomarker testing is imperative to improve patient care.

Florida physicians' reported use of AFIX-based strategies for human papillomavirus vaccination

HPV vaccination rates in Florida are low. To increase rates, the CDC recommends clinics adhere to components of their evidence-based quality improvement program, AFIX (Assessment, Feedback, Incentives, and eXchange of information). We explored factors associated with engaging in HPV-specific AFIX-related activities. In 2016, we conducted a cross-sectional survey of a representative sample of 770 pediatric and family medicine physicians in Florida and assessed vaccination practices, clinic characteristics, and HPV-related knowledge. Data were analyzed in 2017. The primary outcome was whether physicians' clinics engaged in ≥1 AFIX activity. We stratified by physician specialty and developed multivariable models using a backward selection approach. Of the participants in the analytic sample (n = 340), 52% were male, 60% were White of any ethnicity, and 55% were non-Hispanic. Pediatricians and family medicine physicians differed on: years practicing medicine (p < 0.001), HPV-related knowledge (p < 0.001), and VFC provider status (p < 0.001), among others. Only 39% of physicians reported engaging in ≥1 AFIX activity. In the stratified multivariable model for pediatricians, AFIX activity was significantly associated with HPV-related knowledge (aOR = 1.33;95%CI = 1.08–1.63) and provider use of vaccine reminder prompts (aOR = 3.61;95%CI = 1.02–12.77). For family medicine physicians, HPV-related knowledge was significant (aOR = 1.57;95%CI = 1.20–2.05) as was majority race of patient population (non-Hispanic White vs. Other: aOR = 3.02;95%CI = 1.08–8.43), daily patient load (<20 vs. 20–24: aOR = 9.05;95%CI = 2.72–30.10), and vaccine administration to male patients (aOR = 2.98;95%CI = 1.11–8.02). Fewer than half of Florida pediatric and family medicine physicians engaged in any AFIX activities. Future interventions to increase AFIX engagement should focus on implementing and evaluating AFIX activities in groups identified as having low engagement in AFIX activities.

Understanding temporal change of spatial accessibility to healthcare: An analytic framework for local factor impacts

Population demand, health service supply, and the linkages between them (e.g., transport infrastructure) are important factors that determine spatial accessibility to healthcare at a place. These three factors vary differently over time and location, leading to temporal changes and spatial disparities in access to healthcare. Few analytic methods have been developed to measure local impacts of these factors on healthcare accessibility over time, which are essential to alleviating health disparities and evaluating intervention programs. We propose a spatially explicit analytic framework to measure local factor impacts over time by adopting a chain substitution method from economics. The analysis is illustrated by a case study of spatial accessibility to physicians in Florida, USA, from 1990 to 2010. For each census block group, the results show the impact of local population change, physician relocation, and road-network expansion on the loss and gain of healthcare accessibility over time. The leading impact factor are identified for each census block group through comparison, and spatial clusters of factor impacts are discovered. To the literature of healthcare accessibility, this article presents a promising start of factor impact analysis and offers new perspectives in exploring spatial processes underlying people's access to healthcare.

Physicians’ current use and preferences for male HPV vaccine-related patient education materials

Understanding physician preferences for educational materials to support male HPV vaccination is critical to improving vaccine uptake. Pediatric (Peds) and Family Medicine (FM) physicians in Florida completed a survey from May-August 2014 assessing current use of male-specific HPV vaccination patient education materials, and preferences for materials to increase HPV vaccination uptake. Peds and FM responses were compared with chi-squared or nonparametric tests. Most participants were FM (53.2%), White (66.6%), non-Hispanic (74.1%), and provided male patients/parents with HPV educational materials (59.1%). More than half (55.5%) provided a CDC factsheet for parents. Peds were more likely to indicate they provide educational materials (p<0.0001) than FM. The preferred source was the CDC (77.8%). Peds preferred using a factsheet as the medium of information more often than FM (85.6% vs. 68.0%; p<0.0001). When asked about preferences for targeted materials, 74.8% of providers indicated they would prefer materials targeted towards patients, 63.2% preferred information targeted towards parents, and 20.7% indicated they prefer non-targeted materials. Future research should focus on the development and testing of new HPV vaccine-specific materials and communication strategies for Peds and FM physicians.

Missing the Target for Routine Human Papillomavirus Vaccination: Consistent and Strong Physician Recommendations Are Lacking for 11- to 12-Year-Old Males

Rates of routine human papillomavirus (HPV) vaccination of adolescent males in the United States are low. Leading health organizations advocate consistent and strong physician recommendations to improve HPV vaccine dissemination. This study describes the prevalence and correlates of consistent and strong physician recommendations for HPV vaccination of adolescent males. We surveyed pediatric and family medicine physicians in Florida about their HPV vaccine recommendations for male vaccine-eligible age groups (11-12, 13-17, 18-21 years). Descriptive statistics compared consistency and strength of HPV recommendations across age groups. Multivariable logistic regression examined factors associated with consistent and strong recommendations for 11- to 12-year-olds. We received 367 completed surveys (51% response rate). Physicians most often consistently and strongly recommended HPV vaccine to males ages 13 to 17 (39%) compared with ages 11 to 12 (31%) and 18 to 21 (31%). Consistent and strong recommendation for 11- to 12-year-old males was more likely to be delivered by Vaccine for Children providers and less likely among physicians who reported more personal barriers to vaccination, particularly concerns about vaccine safety, concerns about adding vaccines to the vaccine schedule, and difficulty in remembering to discuss HPV vaccination. Physicians' current consistency and strength of HPV vaccine recommendations do not align with national recommendations. Interventions to improve HPV vaccine recommendations must also consider the influence of physicians' personal barriers to HPV vaccine delivery. As one of the first studies to examine both consistency and strength of physicians' HPV vaccine recommendations for males, our findings can inform future interventions focused on facilitating physicians' recommendations. Cancer Epidemiol Biomarkers Prev; 25(10); 1435-46. ©2016 AACR.

The content and context of physicians' communication with males about human papillomavirus vaccination

ABSTRACTA physician's recommendation for human papillomavirus (HPV) vaccine is a key predictor of vaccine uptake; however, little is known about how physicians communicate about HPV vaccine with male patients. We sought to describe physicians' HPV vaccine communication practices with males who are of vaccine-eligible age (9-26 years). We surveyed representative samples of pediatric and family medicine physicians in Florida, and assessed whether physicians present HPV vaccine as optional or routine, and as a vaccine that prevents cancer. We also assessed the type of visit during which physicians discuss HPV vaccine with adolescent males and whether other healthcare providers in the practice discuss HPV vaccine or make the initial recommendation. We received 367 completed surveys (50.7% response rate). Few physicians (29.9%) reported they typically present HPV vaccine as routine to males ages 11-12 years, who constitute the target group for routine vaccination. When discussing HPV vaccination, many physicians reported somewhat or strongly emphasizing cancer prevention (80.0%). Physicians most often discussed HPV vaccine when they saw patients for well-child visits (93.0%) and least often at acute care visits (15.3%). Over half reported that at least one other healthcare professional in their practice discusses (56.1%) or makes the initial recommendation for (54.9%) HPV vaccination. Many physicians in our sample are presenting HPV vaccine as optional rather than routine and are missing opportunities to communicate with males about the vaccine. Our findings identify areas for future interventions to improve physicians' HPV vaccine communication and, ultimately, increase the use of this cancer-preventing vaccine.

A76 Inequalities in the distribution of primary care providers: Comparing healthcare disparity among urban and rural Floridian

Abstract Background Many economics, sociology, and urban planning researchers have assessed regional inequalities, especially for those populations affected by socioeconomic factors such as low income and unemployment status. Inequalities regarding health and its providers have been documented in the last few decades. In 2010, the Department of Human and Health Service (DHHS) launched the Healthy People 2020 movement with goals to eliminate health inequality/disparity and to encourage healthy development. According to the DHHS, health disparity is defined as “a particular type of health difference that is closely linked with physical distance to service, social, economic, and/or environmental disadvantage”. Health disparity that results from the limited access to healthcare facilities is believed to be associated with the unequal distribution of resources and opportunities such as healthcare service, physical activity facilities, and healthy food. However, empirical studies are insufficient for understanding the extent and magnitude of health disparities in the United States. This study seeks to use the inequality of distribution of healthcare providers as a measure for spatial health disparities in urban and rural areas (AIM1) while also monitoring socioeconomic characteristics of the populations in said areas (AIM2). Methods For the first aim, this study will calculate the population per physician ratio for each urban and rural census tract boundary in Florida. The Gini coefficient and Lorenz curve are used to measure the sufficiency or the insufficiency of physician distribution for each urban and rural Florida. These measures are designed to analyze inequality of income or wealth, but they also have been used to study the distribution of health resources such as physician distribution. Second, this study will use Hot Spot Analysis in Geographic Information System (GIS) to calculate the Getis-Ord GI statistic to identify patterns of disadvantaged socioeconomic populations. Cluster areas with high or low densities of certain socioeconomic characteristics, hot spots, will be determined. Results Preliminary results present that primary care physicians in both urban and rural areas of Florida were unevenly distributed. The Gini coefficient for the distribution of primary care physicians in urban Florida was 0.49 (SD=0.0001), while that of the rural Florida was 0.38 (SD=0.01). Conclusions The inequality in the distribution of primary care physicians was higher in urban areas compared with that of the rural Florida. For this purpose, the availability (number) of physicians could be adjusted depending on socioeconomic factors.

Effect of Training Pediatricians and Family Physicians in Early Childhood Caries Prevention

To analyze the effect of postresidency early childhood caries prevention training on physicians' oral health knowledge, confidence, and practice patterns and to identify variations by type of training. We conducted pre- and post-training surveys of pediatricians and family physicians in Florida. Paired t test and repeated-measures ANOVA analyses were used to compare physicians with no oral health training, those with applied in-office training, and those with another type of training on 5 composite measures: fluoride knowledge, nonfluoride oral health knowledge, confidence in advising parents, confidence in conducting oral health screening and caries risk assessment, and frequency in performing recommended oral health practices. The final sample included 229 physicians (162 pediatricians and 67 family physicians). The interaction in the repeated-measures ANOVA between group (training category) and time (pre- and post-training) was significant for the nonfluoride knowledge [F(2, 225) = 4.1, P = .02] and confidence in screening [F(2, 224) = 4.1, P = .02] composite measures, lending support for a positive treatment effect of training on these domains. Greater gains were observed among physicians with in-office training compared with those who received another type of training. A statistically significant treatment effect on oral health practices was not detected. Efforts to engage physicians in oral health training and to incorporate applied components in training curricula may improve physicians' oral health knowledge and increase their confidence in conducting oral health screenings and caries risk assessments. Additional research is needed to evaluate the relative costs and benefits of different training modalities on specific oral health practices.

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Underrepresented minorities in academic medicine: is Florida better off?

The state of Florida has experienced challenges recruiting and retaining underrepresented minority faculty in academic medicine, as well as maintaining a population-like balance of minority physicians practicing in the state. We sought to quantify the percentage of practicing minority physicians as compared to the general population of Florida and focus specifically on black, Hispanic, and Asian/Pacific Islander physicians in academic medicine. We hypothesized that because of the diversity of the state, the number of underrepresented minority academic physicians in Florida would be higher than the national average. Data were derived and analyzed from a biennial survey initiated in 2007 that all physicians renewing licenses in Florida are required to complete. Fifty percent of the licensing cohort completes the survey annually. We focused on physician practice demographics and academic employment. Blacks make up 15.4% of the state population, 6.4% of practicing physicians, but only 3.9% of academic physicians. Hispanics are 22.8% of the state population, 19.2% of practicing physicians, but only 12.5% of academic physicians. Asians are 2.5% of the state population, 14.4% of practicing physicians, and 12.6% of academic physicians. Whites are 58% of the state population, 52% of practicing physicians, and 65% of academic physicians. There is disparity in clinical practice and academic medicine for blacks and Hispanics. Despite the diversity of the state, the disparity of blacks in academic medicine in Florida only marginally exceeds the national average. Asians and Hispanics make up the same percentage of academic physicians, but there are 10 times more Hispanics in the state. More research and programming are needed to further define and arrive at solutions to this problem.

Preparedness of Rural Physicians for Bioterrorist Events in Florida

Human-induced public health emergencies such as the anthrax bioterrorism event and the terrorism events of September 11, 2001 in the United States have increased awareness of the nation's vulnerability to large-scale emergencies. Scant attention has been given to preparing physicians in sparsely populated areas for public health emergencies. This study introduces a conceptual model developed from participants' responses that can be used to improve our understanding of rural physicians' preparedness regarding public health emergencies such as a bioterrorism event. The conceptual model is valuable because it illustrates some areas of question, concern, and future inquiry regarding bioterrorism preparedness. This study used a qualitative research approach and grounded theory methods for data analysis. Semistructured interviews were conducted among six rural physicians in Florida. Florida was considered a particularly appropriate location given that the state was an initial site of the 2001 anthrax attacks. In addition, approximately half of Florida's counties are considered rural. The findings of this study suggest that not all rural physicians in Florida believe that they are adequately prepared for a bioterrorism event. The conceptual model elements--cognitive, clinical, expectation, and simulation--emerged from an analysis of participant responses. According to participant responses and the formulation of the conceptual model it may be postulated that preparedness may be effectively achieved if physicians are aware of the possibility of bioterrorism through education and seminars, able to suspect and recognize an event when it occurs, and institute appropriate medical management.

Preventive Oral Health Care in Early Childhood: Knowledge, Confidence, and Practices of Pediatricians and Family Physicians in Florida

Preventive Oral Health Care in Early Childhood: Knowledge, Confidence, and Practices of Pediatricians and Family Physicians in Florida

Preventive Oral Health Care in Early Childhood: Knowledge, Confidence, and Practices of Pediatricians and Family Physicians in Florida

To examine the relationships among pediatricians' and family physicians' oral health training, knowledge, confidence, and practice patterns. A survey of physicians identified through the membership databases of the Florida Academy of Family Physicians and the Florida Pediatric Society was conducted in 2008. Responses of pediatricians and family physicians were compared through bivariate and multivariate analyses. Although training was not directly associated with performing recommended practices, there were positive associations between training and confidence and between confidence and performing recommended practices (P <.05). Pediatricians were more likely than family physicians to answer fluoride-related knowledge questions correctly and reported greater confidence (P <.05). Less than 20% of the respondents reported counseling parents about bringing their child to the dentist before age 1 year or inquiring about the parents' dental health. Oral health training appears to promote confidence in performing recommended oral health practices. Differences in fluoride knowledge by provider type suggest that fluoride guidance has been disseminated more effectively among pediatricians than among family physicians. Educational content of oral health training programs should place increased emphasis on current fluoride guidance, early dental visits, and assessing parents' oral health. Instructional methods should address physicians' confidence, particularly among family physicians.