Physician Quality Research Articles

Did medical doctors who order abdominal CT scans during on-call hours truly become worse at clinical reasoning? Yes, they did

ObjectiveTo investigate temporal changes in clinical reasoning quality of physicians who requested abdominal CT scans at a tertiary care center during on-call hours within a 15-year period.MethodsThis retrospective study included 531 patients who underwent abdominal CT at a tertiary care center during on-call hours on 36 randomly sampled unique calendar days in each of the years between 2005 and 2019. Clinical reasoning quality was expressed as a percentage (0–100%), taking into account the degree by which the differential diagnoses on the CT request form matched the CT diagnosis. Temporal changes in the quality of clinical reasoning and number of CT scans were assessed using Mann-Kendall tests. Associations between the quality of clinical reasoning with patient age and gender, requesting department, and time of CT scanning were determined with linear regression analyses.ResultsThe median annual clinical reasoning score was 14.7% (interquartile range: 12.2 to 16.0%; range: 7.7 to 34.6%). The quality of clinical reasoning significantly decreased between 2005 and 2019 (Mann-Kendall Tau of −0.390, p = 0.048), while the number of abdominal CT scans significantly increased (Mann-Kendall tau of 0.790, p < 0.001).ConclusionThe clinical reasoning quality of physicians who request abdominal CT scans during on-call hours has deteriorated over time. Clinical reasoning appears to be worse in younger patients.Key Points• In patients with suspected acute abdominal pathology who are scheduled to undergo CT scanning, referring physicians generally have difficulties in making an accurate pretest (differential) diagnosis.• Clinical reasoning quality of physicians who request acute abdominal CT scans has deteriorated over the years, while the number of CT scans has shown a significant increase.• Clinical reasoning quality appears to be worse in younger patients in this setting.

Shared Decision-Making in Pancreatic Surgery.

The objective of this study is to determine the factors influencing pancreatic surgery patients' perceptions of the shared decision-making process (SDM). Decision-making in pancreatic surgery is complicated by the risk of morbidity and mortality and risk of early recurrence of disease. Improvement in SDM has the potential to improve the receipt of goal- and value-concordant care. This cross-sectional survey included patients who underwent pancreatic surgery. The following components were studied in relation to SDM: modified satisfaction with decision scale (SWD), modified decisional regret scale (DRS), quality of physician and patient interaction, and the impact of quality of life (FACT-Hep). Correlations were computed using Pearson's correlation score and a regression model. The survey completion rate was 72.2% (of 40/55) and the majority (72.5%) of patients underwent pancreaticoduodenectomy. There were significant positive relationships between the SDM measure and (DRS, SWD; r = 0.70, P < 0.001) and responses to questions regarding how well the patient's actual recovery matched their expectations before treatment (r = 0.62, P < 0.001). The quality of the physician-patient relationship correlated with how well recovery matched expectations (r = 0.53, P = 0.002). SDM measure scores were significant predictors of the decision evaluation measure (R2(adj) = 0.48, P < 0.001), FACT-Hep (R2(adj) = 0.15, P < 0.001), and recovery expectations measure (R2(adj) = 0.37, P < 0.001). Improved SDM in pancreatic surgery is associated with more realistic recovery expectations, decreased decisional regret, and improved quality of life.

Impact of Faculty Training in Health Systems Science on Scholarly Presentation of Resident Physician and Fellow Quality Improvement Projects.

The objective was to evaluate whether faculty participation in a Health Systems Science training program was associated with increased presentation and publication of quality improvement (QI) projects involving resident physicians and fellows at 1 institution. The authors evaluated annual, department-level counts of QI projects with resident physician or fellow involvement, presented locally or published, according to residency or fellowship program director and faculty participation in Teachers of Quality Academy. Ten clinical departments had 82 presentations and 2 publications. Each additional faculty member's participation in Teachers of Quality Academy increased the annual count of published or presented QI projects by 9% (P < 0.001). At this institution, participation in a Health Systems Science training program among clinical faculty improved engagement of resident physicians and fellows in local presentation of QI projects.

Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance.

Lloyd R, Morgenthaler TI, Donald R, etal. Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance. J Clin Sleep Med. 2022;18(11):2673-2680.

Initial experience with AI Pathway Companion: Evaluation of dashboard-enhanced clinical decision making in prostate cancer screening.

PurposeRising complexity of patients and the consideration of heterogeneous information from various IT systems challenge the decision-making process of urological oncologists. Siemens AI Pathway Companion is a decision support tool that provides physicians with comprehensive patient information from various systems. In the present study, we examined the impact of providing organized patient information in comprehensive dashboards on information quality, effectiveness, and satisfaction of physicians in the clinical decision-making process.MethodsTen urologists in our department performed the entire diagnostic workup to treatment decision for 10 patients in the prostate cancer screening setting. Expenditure of time, information quality, and user satisfaction during the decision-making process with AI Pathway Companion were recorded and compared to the current workflow.ResultsA significant reduction in the physician’s expenditure of time for the decision-making process by -59.9% (p < 0,001) was found using the software. System usage showed a high positive effect on evaluated information quality parameters completeness (Cohen’s d of 2.36), format (6.15), understandability (2.64), as well as user satisfaction (4.94).ConclusionThe software demonstrated that comprehensive organization of information improves physician’s effectiveness and satisfaction in the clinical decision-making process. Further development is needed to map more complex patient pathways, such as the follow-up treatment of prostate cancer.

Patient-physician language concordance and quality and safety outcomes among frail home care recipients admitted to hospital in Ontario, Canada.

Background:When patients and physicians speak the same language, it may improve the quality and safety of care delivered. We sought to determine whether patient–physician language concordance is associated with in-hospital and postdischarge outcomes among home care recipients who were admitted to hospital.Methods:We conducted a population-based study of a retrospective cohort of 189 690 home care recipients who were admitted to hospital in Ontario, Canada, between 2010 and 2018. We defined patient language (obtained from home care assessments) as English (Anglophone), French (Francophone) or other (allophone). We obtained physician language from the College of Physicians and Surgeons of Ontario. We defined hospital admissions as language concordant when patients received more than 50% of their care from physicians who spoke the patients’ primary language. We identified in-hospital (adverse events, length of stay, death) and post-discharge outcomes (emergency department visits, readmissions, death within 30 days of discharge). We used regression analyses to estimate the adjusted rate of mean and the adjusted odds ratio (OR) of each outcome, stratified by patient language, to assess the impact of language-concordant care within each linguistic group.Results:Allophone patients who received language-concordant care had lower risk of adverse events (adjusted OR 0.25, 95% confidence interval [CI] 0.15–0.43) and in-hospital death (adjusted OR 0.44, 95% CI 0.29–0.66), as well as shorter stays in hospital (adjusted rate of mean 0.74, 95% CI 0.66–0.83) than allophone patients who received language-discordant care. Results were similar for Francophone patients, although the magnitude of the effect was smaller than for allophone patients. Language concordance or discordance of the hospital admission was not associated with significant differences in postdischarge outcomes.Interpretation:Patients who received most of their care from physicians who spoke the patients’ primary language had better in-hospital outcomes, suggesting that disparities across linguistic groups could be mitigated by providing patients with language-concordant care.

Family Physician Quality Improvement Plans: A Realist Inquiry Into What Works, for Whom, Under What Circumstances.

Evaluation of quality improvement programs shows variable impact on physician performance often neglecting to examine how implementation varies across contexts and mechanisms that affect uptake. Realist evaluation enables the generation, refinement, and testing theories of change by unpacking what works for whom under what circumstances and why. This study used realist methods to explore relationships between outcomes, mechanisms (resources and reasoning), and context factors of a national multisource feedback (MSF) program. Linked data for 50 physicians were examined to determine relationships between action plan completion status (outcomes), MSF ratings, MSF comments and prescribing data (resource mechanisms), a report summarizing the conversation between a facilitator and physician (reasoning mechanism), and practice risk factors (context). Working backward from outcomes enabled exploration of similarities and differences in mechanisms and context. The derived model showed that the completion status of plans was influenced by interaction of resource and reasoning mechanisms with context mediating the relationships. Two patterns were emerged. Physicians who implemented all their plans within six months received feedback with consistent messaging, reviewed data ahead of facilitation, coconstructed plan(s) with the facilitator, and had fewer risks to competence (dyscompetence). Physicians who were unable to implement any plans had data with fewer repeated messages and did not incorporate these into plans, had difficult plans, or needed to involve others and were physician-led, and were at higher risk for dyscompetence. Evaluation of quality improvement initiatives should examine program outcomes taking into consideration the interplay of resources, reasoning, and risk factors for dyscompetence.

Standardized acute care doctors training on the emerging pandemic of coronavirus pneumonia

The novel corona virus pneumonia epidemic poses a serious challenge to the medical and health systems of all nations in the world, especially discovering the severe shortage of intensive care medical professionals. Although our country’s intensive care medicine physicians have played a primary part in the combat against the epidemic, some problems have been debunked in the training of intensive care medicine personnel; equally there is inadequacy of standardized intensive care medicine training platform, and the lack of integrated training content and training format.&#x0D; Relatively single, insufficient preparations for responding to public health emergencies etc, Based on the actual experience of epidemic prevention and control and the treatment of critically ill patients, this article recommend that standardized training of resident physicians for critical care medicine should be carried out, the training content should be standardized, the combination of theory and clinical practice should be enhanced, the comprehensive quality of resident physicians should be improved, and the training methods should be expanded and strengthened. "Construction of a demand and capacity model for intensive care and hospital". These measures can make the critical care team become a professional team with a feel of social importance, which is of great acceptation for the long-term progress of critical care medicine, for the Nepalese medical system to easily respond to public health emergencies, and improve the comprehensive diagnosis and treatment capabilities of emergency and critical diseases. Excess deaths associated with COVID-19 are a direct result of the inadequate capacity of intensive care units and hospital beds.

Reducing inpatient mortality in patients with cancer through multidisciplinary review and targeted interventions.

1524 Background: Excess inpatient mortality is a marker of poor quality in cancer care. We developed a multidisciplinary mortality review committee to review each inpatient death to determine key drivers of mortality and develop targeted interventions to reduce our inpatient mortality index. Methods: Through retrospective review, inpatient deaths were identified at Stanford Health Care for patients with an ICD10 cancer diagnosis regardless of inpatient service. Details of each hospitalization were reviewed by a quality consultant and subsequently reviewed by a physician quality team member to identify opportunities for improvement. Most cases were then discussed in a monthly multidisciplinary committee meeting. The committee analyzed key drivers of inpatient mortality, communicated suggestions to the patient’s outpatient and inpatient attending physicians, and/or identified opportunities for systemic change. The resulting targeted interventions were tracked using the observed versus expected mortality ratio for inpatient deaths over time. Results: From May 2017 through August 2021 we reviewed 528 inpatient oncology deaths. Patients’ median age was 65 years, and the median length of stay was 8 days. 73% of patients had metastatic cancer, and 28% received chemotherapy within 14 days of death. 25% of patients had a prior ED visit, and 35% had a prior hospitalization within 30 days of admission. Only 26% of patients had an advanced directive on record at time of death. Opportunities for improvement were identified for 60% of cases (Table). Interventions have aimed to increase advance care planning conversations and documentation, develop predictive models for cancer-related readmissions and mortality, expand outpatient services for urgent symptoms, and expedite transitions to hospice. Conclusions: Understanding key drivers for preventable inpatient mortality through a multidisciplinary review process identified targeted interventions that have successfully contributed to reduction of the inpatient cancer mortality index.[Table: see text]

Endogenous quality investments in the U.S. hospital market

High and increasing hospital prices could reflect market imperfections, including provider concentration. Yet high prices could also reflect increased willingness to pay by privately insured consumers for clinical and non-clinical quality. In this paper, we explore strategic quality choices where hospitals make quality investments to increase private revenue. We then measure the relationship between potential prices and numerous quality measures including patient satisfaction, hospital processes, risk-adjusted mortality, the revealed preferences of current Medicare patients, technology adoption, physician quality, and ED wait times. We show that across a range of measures quality is correlated with the profitability of the payer mix: hospitals with more potential privately insured patients are of higher quality.

Physician wound certification: a much-needed reality too long denied.

Over the past 20 years, the number of physicians who focus their practice on wounds and wound care has grown slowly but significantly. It is estimated that there are >13,000 physicians who practice wound care but who have no 'home' to nurture their discipline and ensure, through standards and best practices, quality in the care they deliver. Unlike most others, these physicians pursue patient care without a certifying medical board to confirm the quality of their care and the scope of their practice. Because organised medicine correctly insists on quality in the care physicians deliver, it is time to establish a subspecialty in wound care. However, establishing a new subspecialty is a very challenging task. It raises questions of overlapping jurisdiction with other medical boards, about the multiplicity of subspecialties and the challenge of ensuring that enough physicians will seek certification to cover the costs of examinations, etc. All of these issues can be met with satisfactory responses. The time for action is now.

Association Between the Physician Quality Score in the Merit-Based Incentive Payment System and Hospital Performance in Hospital Compare in the First Year of the Program

(Abstracted from JAMA Network Open 2021;4(8):e2118449) In an effort to deliver better patient outcomes at a lower cost, the Centers for Medicare &amp; Medicaid Services (CMS) mandates eligible clinicians to participate in either the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models. Physicians or physician groups being evaluated through MIPS can receive a maximum of 60 points for quality, composed of 6 measurement categories that they may select.

The future of value-based emergency care: Development of an emergency medicine MIPS value pathway framework.

The Centers for Medicare & Medicaid Services (CMS) implemented the Merit‐based Incentive Payment System (MIPS) to accelerate the transition of physician payment toward value‐based care models and away from traditional fee‐for‐service payment programs. In recent years, CMS has sought to modify the program by developing a MIPS Value Pathway (MVP) framework intended to use existing and future physician quality and cost measures to reward value‐based care delivery. This article describes the multi‐step process of the MVP Task Force, convened by the American College of Emergency Physicians (ACEP) to develop an emergency medicine‐specific MVP proposal informed by diverse stakeholder perceptions regarding: (1) which existing quality measures reflect high quality emergency care, and (2) the degree to which emergency clinicians can impact clinical outcomes and cost for the care domains captured by existing quality measures. The MVP Task Force synthesized stakeholder feedback and underwent a consensus‐building approach to develop the “Adopting Best Practices and Promoting Patient Safety within Emergency Medicine” MVP, recently reviewed and approved by CMS for national implementation starting in 2023. Our process and findings have broad implications for clinicians, administrators, and policymakers navigating the continued transition to value‐based care in conjunction with CMS's implementation of the MVP framework.

Donor Recognizes the Unique Benefits of Giving to the Foundation for PALTC

Donor Recognizes the Unique Benefits of Giving to the Foundation for PALTC

The Final Rule for 2022: What's New and How Changes in the Medicare Physician Fee Schedule and Quality Payment Program Affect Dermatologists.

The Centers for Medicare & Medicaid Services (CMS) 2022 final rule, which went into effect on January 1, 2022, contains updates affecting the practice of dermatology. This article reviews many of the changes to the Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) and their impact on clinical practice.

Abstract TMP46: Physician Quality Of Communication And Shared Decision Making After Stroke In A Bi-ethnic Community: The Oasis Project

Objective: To explore ethnic differences in stroke patient surrogate decision makers’ (e.g. family) impressions of physician quality of communication (QOC) and shared decision making (SDM) in Mexican Americans (MAs) and non-Hispanic Whites (NHWs). Methods: Surrogate decision makers who discussed life-sustaining treatments for severe stroke patients (ischemic or intracerebral hemorrhage) from the Brain Attack Surveillance in Corpus Christi (BASIC) project completed validated measures of physician QOC (QOC-overall, QOC-general, and QOC-end-of-life) and SDM (collaboRATE). Regression models with Generalized Estimating Equations were used to investigate ethnic differences in outcome adjusted for pre-specified demographics, severity, mortality, and identified confounders. Results: From 4/2016 to 9/2020, 320 surrogates for 257 stroke cases were enrolled. Patient characteristics: median age 75 (IQR 64-87), female 52%, Race-ethnicity (MA 61%, NHW 33%, Other 5%), ICH 25%, median NIHSS 12 (IQR 5-20), deceased 45%. Surrogates had a median age of 57 (IQR 46-66) and were mostly female (77%). Compared to NHW surrogates, MA surrogates were more often women, had lower education, and less use of advance directives, but had more trust in physicians and were more likely to pray daily. Regression results for QOC are shown in the table. MA surrogates reported higher unadjusted scores for QOC-overall and QOC-end-of-life. These associations were stronger after adjustment for demographics, severity, and patient survival, though were no longer significant in the final fully adjusted models. A generally similar pattern was seen for SDM. Conclusions: MA surrogates tended to report better physician communication and more SDM than NHWs, though no difference was seen after adjustment for factors such as trust, daily prayer, or advance care planning. Further study of contributions to positive outcomes among diverse populations of stroke surrogates are warranted.

Assessment of Resident Burnout After Formalization of Wellness Program.

Burnout has reached epidemic levels among resident physicians. Characterized by emotional exhaustion (EE), depersonalization, and feelings of inefficacy, burnout negatively affects patient outcomes, increases costs, and decreases physician quality of life. These negative outcomes catalyze leaders in graduate medical education to address burnout and reverse its trends. The primary aim of this project is to design a residency Wellness Program utilizing the facets of physician wellness, assess levels of burnout among resident physicians, and determine the program's effects on burnout. A Wellness Program was formalized at a Midwestern, military-civilian Obstetrics and Gynecology residency program for the 2019-2020 academic year. Resident wellness and perceptions were assessed at three time points (0, 6, and 12 months) through surveys consisting of free response, yes-no questions, and the Maslach Burnout Inventory Scales. On average, 17 of 24 residents completed all three survey assessments. Perception of the residency program prioritization of wellness increased significantly from 52.9% to 94.4% (P = .007). Residents consistently demonstrated burnout throughout the year with low levels of EE, high levels of depersonalization, and moderate levels of personal achievement. Residents were consistently satisfied with their personal wellness (80%-92.9%) during the program. Residents wanted to see physical activity incorporated into the program. This study assessed burnout during a formalization of a Wellness Program and insight on resident perceptions and wellness requests. Military medicine, graduate medical education, and other residency programs can utilize this research to better develop and study the implementation of wellness initiatives aimed at reducing burn out.

Qualities of Physician in Light of Charaka Samhita-A Literary Study

In Ayurveda, among the four limbs of healthcare system, physician is considered as the most important and principal among others. A successful health care service is primarily dependent on the proficiency of a physician having all the necessary qualities as mentioned in the ancient compendiums. Charaka Samhita being the most important text among all the resources of Ayurveda has given much emphasis on the various aspects of a Bhishaka or Vaidya(physician) -right from his basic qualities, advanced qualities, ideal role in healthcare service, his character and so many other things. Along with these aspects, this compendium also has elaborate description about various categories of physician -both ideal ones and the counterfeits. Along with health care system, as an essential tool for medical education, Charaka Samhita has also discussed the various aspects of an ideal teacher -his qualities, character and duties -which are essential for making a person a competent physician. All this ancient knowledgewill help us to understand better about the ideal character of a physician as it should be in today’s society.

Understanding Patient Perceptions Towards Direct Primary Care: A Focus Group Study.

Direct primary care (DPC) is a growing model of care that is suggested as an alternative to traditional fee-for-service healthcare. Patient-reported experiences of DPC can provide unique insight into the impact of joining the model and inform quality improvement. The purpose of this study was to investigate patient perceptions of DPC. Thirty-one participants were initially recruited for the study and completed a survey assessing patient demographics. Of the 31 participants, 10 went on to complete the focus group interviews. Qualitative analysis of focus group transcripts identified common themes and subthemes. Focus group findings were stratified into 4 themes including quality of care, access to care, affordability, physician qualities, and reasons for choosing DPC. The top positive subthemes were good communication, joining DPC due to poor past healthcare experiences, and physician personability. The most common negative subthemes were difficulty referring to specialists outside the practice, poor communication, and poor access to medications. All findings were presented and discussed with the investigated clinic to facilitate improvements in healthcare delivery.

Vaidya Saadhana: Professionalism in health care – Qualities of an ideal physician

Vaidya Saadhana: Professionalism in health care – Qualities of an ideal physician