Specialty Encounters Research Articles

Features of pharyngoscopic changes in the palatine tonsils

Diseases of the pharynx are a common pathology that doctors of various specialties encounter in everyday practice. Many of these diseases are difficult to diagnose although the pharynx is easily accessible for examination. The article describes the most frequently identified pharyngoscopic symptoms of diseases of the palatine tonsils: plaque, tonsillar detritus accumulation, tonsillar keratin cysts, asymmetry of the palatine tonsils, as well as the most important differential diagnostic signs that facilitate the interpretation of these symptoms in the diagnostic process. In addition, data from morphological studies of pathological elements of the tonsils are presented.

Fertility Preservation Knowledge, Attitudes, and Self-Reported Behaviors of Resident Physicians.

Purpose: Fertility preservation (FP) and family building are important considerations for quality survivorship for young cancer patients. Resident physicians across all specialties encounter reproductive-aged cancer patients. The purpose of this study was to assess resident physicians' attitudes and awareness about FP with the goal to identify specific educational gaps to direct future training. Methods: The Institutional Review Board (IRB)-approved anonymous online survey was sent to resident physicians across specialties at three separate academic-affiliated campuses in one state. The survey consisted of three sections: awareness about FP options and knowledge about referral placement, attitudes and comfort levels discussing FP, and practices regarding FP. Data were collected in Qualtrics and analyzed by resident specialty, age, level of training, and gender. Statistical analyses were conducted with Prism. Results: Obstetrics and gynecology residents and fellows were significantly more aware of FP options in cancer patients than their counterparts in other specialties. Postgraduate year (PGY 3) residents and beyond were more aware of at least one male and one female FP option compared with PGY 1 and 2 residents. Of importance, we found that the majority of resident physicians are aware of FP options and the referral process, but they are uncomfortable discussing these techniques with their patients. Conclusion: To provide better education for patients, focus should be on outpatient educational activities for both the health care provider and the patient to facilitate conversation about FP.

Mental Health Diagnoses, Health Care Utilization, and Placement Stability on Antipsychotic Prescribing Among Foster Care Youth.

This study sought to examine how mental health diagnoses, health care utilization and foster care placement instability affect antipsychotic prescribing and how these factors may contribute to disproportionate antipsychotic prescribing among youth in foster care. This retrospective cohort study utilized EHR data that were linked to administrative child welfare data. Two outcome variables were analyzed: 1) any antipsychotic prescription documented and 2) number of antipsychotic prescriptions documented. Predictor variables included foster care status, number of unique mental health diagnoses, counts of health care encounters over the study period, and counts of foster care placements. Covariates included gender, persons of color, and age in years. Models were estimated using logistic regression for the dichotomous outcome and Poisson regression for the count outcome. Increased antipsychotic prescribing among children in foster care persists even after accounting for mental health diagnoses and health care utilization. However, the number of placements modified the effect of foster care involvement on antipsychotic prescribing such that after 2 placement changes, the odds of being prescribed an antipsychotic surpassed the effect of foster care involvement. More mental health diagnoses, more inpatient and emergency health care encounters, and more foster care placements were associated with an increased odds of being prescribed an antipsychotic and an increased count of antipsychotic prescriptions. Decreased primary care encounters were associated with increased odds of antipsychotic prescriptions, and decreased specialty encounters were associated with higher counts of antipsychotic prescriptions. Placement instability is associated with disproportionate antipsychotic prescribing among youth in foster care.

Surgeons Receiving Information About Patient Language Reflecting Unhelpful Thoughts or Distress About Their Symptoms Identify Such Language More Often Than Those Who Do Not Receive This Information.

Unhelpful thoughts and feelings of distress regarding symptoms account for a large proportion of variation in a patient's symptom intensity and magnitude of capability. Clinicians vary in their awareness of this association, their ability to identify unhelpful thoughts or feelings of distress regarding symptoms, and the skills to help address them. These nontechnical skills are important because they can improve treatment outcomes, increase patient agency, and foster self-efficacy without diminishing patient experience. In this survey-based study, we asked: (1) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the total number of identified instances of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? (2) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the interobserver reliability of a surgeon's identification of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? Surgeons from an international collaborative consisting of mostly academic surgeons (Science of Variation Group) were invited to participate in a survey-based experiment. Among approximately 200 surgeons who participate in at least one experiment per year, 127 surgeons reviewed portions of transcripts of actual new musculoskeletal specialty encounters with English-speaking patients (who reported pain and paresthesia as primary symptoms) and were asked to identify language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. The included transcripts were selected based on the rated presence of language reflecting unhelpful thinking as assessed by four independent researchers and confirmed by the senior author. We did not study accuracy because there is no reference standard for language reflecting unhelpful thoughts or feelings of distress regarding symptoms. Observers were randomized 1:1 to receive supportive information or not regarding definitions and examples of unhelpful thoughts or feelings of distress regarding symptoms (referred to herein as "priming") once at the beginning of the survey, and were not aware that this randomization was occurring. By priming, we mean the paragraph was intended to increase awareness of and attunement to these aspects of human illness behavior immediately before participation in the experiment. Most of the participants practiced in the United States (primed: 48% [29 of 60] versus not primed: 46% [31 of 67]) or Europe (33% [20 of 60] versus 36% [24 of 67]) and specialized in hand and wrist surgery (40% [24 of 60] versus 37% [25 of 67]) or fracture surgery (35% [21 of 60] versus 28% [19 of 67]). A multivariable negative binomial regression model was constructed to seek factors associated with the total number of identified instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. To determine the interobserver agreement, Fleiss kappa was calculated with bootstrapped 95% confidence intervals (resamples = 1000) and standard errors. After controlling for potential confounding factors such as location of practice, years of experience, and subspecialty, we found surgeons who were primed with supportive information and surgeons who had 11 to 20 years of experience (compared with 0 to 5 years) identified slightly more instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms (regression coefficient 0.15 [95% CI 0.020 to 0.28]; p = 0.02 and regression coefficient 0.19 [95% CI 0.017 to 0.37]; p = 0.03). Fracture surgeons identified slightly fewer instances than hand and wrist surgeons did (regression coefficient -0.19 [95% CI -0.35 to -0.017]; p = 0.03). There was limited agreement among surgeons in their ratings of language as indicating unhelpful thoughts or feelings of distress regarding symptoms, and priming surgeons with supportive information had no influence on reliability (kappa primed: 0.25 versus not primed: 0.22; categorically fair agreement). The observation that surgeons with brief exposure to supportive information about language associated with unhelpful thoughts and feelings of distress regarding symptoms identified slightly more instances of such language demonstrates the potential of training and practice to increase attunement to these important aspects of musculoskeletal health. The finding that supportive information did not improve reliability underlines the complexity, relative subjectivity, and imprecision of these mental health concepts. Level I, therapeutic study.

Implementation of Suicide Risk Estimation Analytics to Support Mental Health Care for Quality Improvement

This quality improvement study describes use of estimation analytics to augment existing suicide prevention practices during routine mental health specialty encounters at a large US health care system.

Assessment of the Attitudes and Knowledge of Musculoskeletal Medicine Among Medical Students at King Faisal University: A Cross-Sectional Study

Background: Musculoskeletal conditions are a frequent reason for seeking medical attention. In the United States and Canada, orthopedic injuries constitute about 15-30% of primary care visits. Physicians from various specialties encounter musculoskeletal conditions and manage both, acute and chronic problems, on a daily basis. Considering this, mastery of the fundamentals of musculoskeletal medicine is required for all medical school graduates. In this study, we aim to evaluate the attitudes and knowledge of musculoskeletal medicine among medical students at King Faisal University. Methodology: A cross-sectional study with one-stage sampling technique was conducted among medical students at King Faisal University from February 2021 to May 2021. Results: Our study demonstrated that students possess a lower level of clinical confidence in their ability to perform musculoskeletal clinical examinations compared to pulmonary clinical examinations. Further, they displayed a lower level of clinical confidence in their ability to make musculoskeletal differential diagnoses compared to pulmonary differential diagnoses. Also, their average scores on the basic competency exam did not reach 73.1. Conclusion: The current study evaluated the attitudes and knowledge of musculoskeletal medicine among medical students at King Faisal University. The findings in our study are consistent with the results of other research that indicate medical students are not getting sufficient education in musculoskeletal medicine.

54. Self-Perception of Risk for HIV Acquisition and Calculated Risk for HIV Acquisition Among Active Duty Air Force Members with Newly Diagnosed HIV Infection

BackgroundPersons may underestimate their risk of HIV infection despite presence of risk factors. Accurate appraisal of HIV risk may assist both patients and providers in preventing HIV acquisition. We evaluated self-perceived risk (SPR) versus calculated risk (CR) of HIV infection in active duty US Air Force (USAF) members with incident HIV infection.MethodsUSAF members with new HIV diagnosis evaluated at a specialty care military medical center between January 2015-March 2020 with available case report forms were included (n=142). Chart reviews were performed and demographic, social, and clinical characteristics were collected from initial Infectious Disease specialty encounters and case report forms. SPR was characterized as Low or High and compared to CR derived by the Denver HIV Risk Score (DHRS) by points based on patient demographic and risk exposure characteristics.ResultsOverall, patients were predominantly male (98%), with a median age of 26 years (IQR 22-30), and the majority (85%) reported same-sex partners (Table 1). Patients more commonly characterized themselves as Low SPR (n=78; 55%) than High SPR (n=64; 45%). Demographic characteristics were similar except a higher proportion of Low SPR patients (29%) were married or partnered compared to High SPR patients (14%; p=0.04). There was no difference in self-reported condom use (≥50% of the time) between Low (63%) and High (72%) SPR patients (p=0.28) and documented history of sexually transmitted infections was similarly high in both groups ( >70%; p=0.85). Previous HIV pre-exposure prophylaxis (PrEP) use was uncommon in both Low SPR (8%) and High SPR (6%) groups. For the evaluation of CR by DHRS (Table 2), both Low and High SPR groups had median scores in the very high risk category (≥50 points) with similar results by test component. ConclusionUSAF members with incident HIV infection more commonly identified with low SPR despite similar risk behaviors and CRs as high SPR patients. The development of patient education programs and promotion of HIV prevention services including PrEP are needed to reduce incident HIV cases in the USAF. Validated HIV risk calculators like the DHRS may also assist medical providers in identifying candidates for HIV prevention services.Disclosures All Authors: No reported disclosures

COVID-19 Pandemic–Related Reductions in Pediatric Asthma Exacerbations Corresponded with an Overall Decrease in Respiratory Viral Infections

BackgroundRespiratory viruses, air pollutants, and aeroallergens are all implicated in worsening pediatric asthma symptoms, but their relative contributions to asthma exacerbations are poorly understood. A significant decrease in asthma exacerbations has been observed during the coronavirus disease 2019 pandemic, providing a unique opportunity to study how major asthma triggers correlate with asthma activity.ObjectiveTo determine whether changes in respiratory viruses, air pollutants, and/or aeroallergens during the coronavirus disease 2019 pandemic were concomitant with decreased asthma exacerbations.MethodsHealth care utilization and respiratory viral testing data between January 1, 2015, and December 31, 2020, were extracted from the Children’s Hospital of Philadelphia Care Network’s electronic health record. Air pollution and allergen data were extracted from US Environmental Protection Agency public databases and a National Allergy Bureau–certified station, respectively. Pandemic data (2020) were compared with historical data.ResultsRecovery of in-person asthma encounters during phased reopening (June 6 to November 15, 2020) was uneven: primary care well and specialty encounters reached 94% and 74% of prepandemic levels, respectively, whereas primary care sick and hospital encounters reached 21% and 40% of prepandemic levels, respectively. During the pandemic, influenza A and influenza B decreased to negligible frequency when compared with prepandemic cases, whereas respiratory syncytial virus and rhinovirus infections decreased to low (though nonnegligible) prepandemic levels, as well. No changes in air pollution or aeroallergen levels relative to historical observations were noted.ConclusionsOur results suggest that viral respiratory infections are a primary driver of pediatric asthma exacerbations. These findings have broad relevance to both clinical practice and the development of health policies aimed at reducing asthma morbidity.

AcademyHealth Annual Research Meeting (ARM): A Selection of Abstracts Accepted for Oral Presentation, 2021.

Research ObjectiveTo investigate the extent to which telehealth visits mitigated COVID‐19 pandemic‐related impacts on in‐person outpatient visits among Medicare beneficiaries, including those who are high‐cost high‐need. High‐cost high‐need patients were defined as those 65 years or older and with 2 or higher Hierarchical Condition Categories (HCC) scores.Study DesignA difference‐in‐difference design was used to estimate the change in outpatient in‐person and telehealth utilization for the COVID‐19 pandemic cohort compared to the control cohort in the prior year.Population StudiedMedicare patients from an Accountable Care Organization (ACO) were used as the study sample. The pandemic cohort was defined as those enrolled in the ACO in 2019–2020 (N = 21,361). The control cohort was defined as those enrolled in the ACO in 2018–2019 (N = 20,028). The study period was defined as April–September 2020 for the pandemic cohort and the same months in 2019 for the control cohort, with the preceding 12 months used as the baseline periods, respectively. Over 740,000 patient‐month records were analyzed using logistic and negative binomial regressions. The models were adjusted for patient‐level characteristics, including HCC scores, which reflect the complexity of patient health conditions and risk for future healthcare costs.Principal FindingsThe total number of outpatient encounters (in‐person and telehealth) in both primary and specialty care decreased by 41.5% in April 2020 compared to the pre‐pandemic period. Telehealth comprised 78% of all outpatient encounters in April 2020 but declined to 22% by the end of September 2020. Only about 40% of all patients had at least one telehealth encounter between April–September 2020. Compared to the control cohort, the pandemic cohort experienced a monthly average of 113 fewer primary care encounters per 1000 patients (OR: 0.75, 95% CI: [0.73, 0.77]) and 49 fewer specialty care encounters (OR: 0.82, 95% CI: [0.80, 0.85]) over the six‐month study period. This represented a decline of 25.6% and 17.3% in primary care and specialty encounters, respectively, among high‐cost high‐need patients. High‐cost high‐need patients or those with disabilities were more likely to use telehealth and experienced a lesser reduction in outpatient care utilization than other Medicare beneficiaries (OR: 1.20 and 1.06). Medicare beneficiaries with dual Medicaid coverage, those of non‐white race/ethnic groups, and those living in rural/suburban areas were less likely to use telehealth and experienced a greater reduction in total outpatient care (OR: 0.86, 0.96 and 0.90).ConclusionsWhile there was a substantial significant increase in telehealth use in April 2020, utilization declined significantly during the six‐month study period, and did not fully mitigate the decline in in‐person outpatient visits resulting from the COVID‐19 pandemic. While high‐cost high‐need Medicare patients and those with disabilities were more likely to use telehealth, disparities in telehealth usage and reductions in outpatient care remain among low‐income, non‐white, and rural Medicare beneficiaries.Implications for Policy or PracticeOlder patients insured by Medicare, including those with high‐cost high‐need or disabilities were able to make use of telehealth services for outpatient visits during the COVID‐19 pandemic. Health policies and interventions should target improving telehealth access and delivery for advancing sustainability and equity among Medicare beneficiaries.Primary Funding SourcePatient‐Centered Outcomes Research Institute.

Appropriateness of Computed Tomography Scanning in the Diagnosis of Craniosynostosis.

Although physicians from a variety of specialties encounter infants with possible craniosynostosis, judicious use of computed tomography (CT) imaging is important to avoid unnecessary radiation exposure and healthcare expense. The present study seeks to determine whether differences in specialty of ordering physician affects frequency of resulting diagnostic confirmations requiring operative intervention. Radiology databases from 2 institutions were queried for CT reports or indications that included "craniosynostosis" or "plagiocephaly." Patient demographics, specialty of ordering physician, confirmed diagnosis, and operative interventions were recorded. Cost analysis was performed using the fixed unit cost for a head CT to calculate the expense before 1 study led to operative intervention. Three hundred eighty-two patients were included. 184 (48.2%) CT scans were ordered by craniofacial surgeons, 71 (18.6%) were ordered by neurosurgeons, and 127 (33.3%) were ordered by pediatricians. One hundred four (27.2%) patients received a diagnosis of craniosynostosis requiring operative intervention. Craniofacial surgeons and neurosurgeons were more likely than pediatricians to order CT scans that resulted in a diagnosis of craniosynostosis requiring operative intervention (P < 0.001), with no difference between craniofacial surgeons and neurosurgeons (P = 1.0). The estimated cost of obtaining an impact CT scan when ordered by neurosurgeons or craniofacial surgeons as compared to pediatricians was $2369.69 versus $13,493.75. Clinicians who more frequently encounter craniosynostosis (craniofacial and neurosurgeons) had a higher likelihood of ordering CT images that resulted in a diagnosis of craniosynostosis requiring operative intervention. This study should prompt multi-disciplinary interventions aimed at improving evaluation of pretest probability before CT imaging.

Standard procedure for the pharmacotherapy of pain in childhood

Physicians of all specialties encounter patients in pain. The basis of the philosophy of caring children is not to question the existence of pain but to predict, prevent, and adequately treat it. Acute pain services implement preventive and multimodal analgesic treatment to increase the analgesic effect at the lowest possible doses to minimize undesirable effects of individual drugs. However, this service cannot be provided in all hospitals 24 hours a day. This study provides a clear, color-coded recommendation for pain relief in children, which provides a quick, rational, and safe choice of analgesics or their safe and effective combinations and dosage for each age group.

Validation of the RAISE (Readiness Assessment of Independence for Specialty Encounters) Tool: Provider-Based Transition Evaluation

PurposeThe aim of this study was to establish content validity of a developmentally based assessment tool of readiness for medical independence for specialty providers. Design and methodsThe validation process used expert panel evaluation to assess the items believed to measure the desired content in the nine age-based scales within the RAISE (Readiness Assessment of Independence for Specialty Encounters) tool. Experts in child development and transition rated items on relevance, clarity and developmental appropriateness via electronic survey. Statistical analyses included calculation of interrater agreement (IRA), content validity indices (CVIs), and factorial validity indices (FVI). ResultsA total of 135 items were rated by 36 experts. Mean I-CVIs for 123 items across nine developmental scales met criteria for retention, ranging from 0.76 (threshold) to 1.00 (excellent). Mean I-CVIs for all 25 items across the five psychosocial stressor scales met criteria for retention, ranging from 0.92 to 1.00 (excellent). ConclusionsFindings from the current content validation study suggest that items on the revised RAISE tool are relevant, clear, and developmentally-appropriate as rated by experts in the fields of child development and transition. The tool, consisting of age based scales (ages birth-2, 3–4, 5–6, 7–8, 9–11, 12–13, 14–15, 16–17, 18–21), is shown to have content validity of the retained items meeting criteria. Practice implicationsWith content validity of the RAISE tool established by experts, this developmentally based assessment tool can be integrated into practice to assist providers in educating patients around skills of medical independence which could improve transition outcomes.

Quantifying the impact of the COVID-19 pandemic on gastrointestinal cancer care delivery.

30 Background: Changes in healthcare utilization and delivery during the first months of the COVID-19 pandemic have altered the presentation, treatment, and management of patients with gastrointestinal (GI) malignancies. We hypothesize this has contributed to diagnostic and treatment delays that will increase disease morbidity and mortality. Methods: We performed a retrospective cohort study comparing healthcare utilization of patients with diagnosed GI malignancy (ICD10:C15-C26) during and prior to the COVID-19 pandemic within our health system. Deidentified patient encounter parameters were collected for the first 20 weeks of both 2019 and 2020, including the number of: new patient visits (NPVs), hospital admissions, and specialty encounters. Difference-in-difference analyses adjusted for week-specific and year-specific effects quantified the impact of the COVID-19 pandemic on care delivery, with week 11 of 2020 marking the start of the pandemic period. Results: The 2019 and 2020 cohorts of patients had similar demographic compositions on the basis of sex and ethnicity (2019: n = 23,536, 56.8% M, 70.4/16.3/1.9% White/Black/Hispanic; 2020: n = 25,773, 57.0% M, 70.3/16.3/2.0% White/Black/Hispanic). Across all GI malignancies, the COVID-19 pandemic period was associated with a significant decrease in NPVs (-50.0/week, -45% from 2019, p &lt; 1e-3). Colorectal cancer (CRC) had the largest decrease in NPVs among GI malignancies (-25.3/week, -53% from 2019, p &lt; 1e-4). Of note, there was a parallel decrease in colonoscopies during this time (-682/week, -91% from 2019, p &lt; 1e-11). For patients with diagnosed GI malignancies, the COVID-19 pandemic was associated with statistically significant declines in hospital admissions (-31.7/week, -37% from 2019, p &lt; 1e-5), radiology encounters (-177/week, -38% from 2019, p &lt; 1e-6), radiation oncology encounters (-18.2/week, -12% from 2019, p &lt; 0.01), chemotherapy infusion visits (-62.2/week, -17% from 2019, p &lt; 1e-4), and surgery encounters (-71.1/week, -15.7% from 2019, p &lt; 0.01). Subgroup analyses revealed these reductions were most significant in patients with CRC (radiology encounters, surgery encounters, hospital admissions), anal cancer (radiation oncology encounters), and pancreatic cancer (chemotherapy infusion visits). Conclusions: These data demonstrate that the COVID-19 pandemic is associated with significant disruptions to care delivery. While these effects were appreciated broadly across GI malignancies, CRC—diagnosed and managed by periodic screening—has been affected most acutely. The precipitous drop in screening colonoscopies likely contributed to the decline in NPVs, specialty encounters and hospital admissions. These findings underscore the importance of reinstating regular GI cancer screening and management. Future work will assess the impact of these and other changes to cancer care delivery on long term morbidity and mortality.

Translation into Russian of the Classification of inborn errors of immunity in humans updated by experts from a Committee on Congenital Immunity Errors of International Union of Immunological Societies (Russian version 2019)

We present to Russian-speaking audience a translation and commentary on the classification of inborn errors of immunity presented at the end of 2019 by the Committee on Congenital Immunity Errors at the International Union of Immunological Societies (IUIS). Inborn errors of immunity, or, as they were called earlier, primary immunodeficiencies, is a rapidly expanding class of diseases that includes the most diverse congenital pathologies which can manifest at any age by heterogenous symptomes. Clinical masks characterize these diseases, hence the time from the onset of clinical disorder to the final diagnosis may take many years. A doctor of any specialty encounters these patients, and the molecular mechanisms of pathology concern different organs and systems of the patients. The classification consists of ten tables covering more than 400 syndromes and their corresponding genes, or associated chromosomal abnormalities. This is a tool, which allows navigating a wide variety of different primary immunodeficiencies, autoimmune and autoinflammatory syndromes, complement defects, and bone marrow failure syndromes. We hope that, due to translation, current knowledge about these various diseases will become more close and available to the Russian-speaking audience.

Complications: Second Victim.

Physicians and surgeons in all specialties encounter and manage complications throughout their careers. Little attention has been given to a surgeon's emotional experience and reaction to the stresses of managing complications. The author has reviewed relevant literature and added observations from 4 decades of experience with a pediatric orthopedic faculty. The author also reviewed the types of complications and principles of successful management of surgical complications. A small number of published articles dealing with the issues of physician and surgeon responses to stressful occurrences were found. Proper management of complications will markedly reduce the stress upon the surgeon. Analysis of the complications with colleagues is essential to the reduction of feelings of guilt, and are useful in preventing future events. Discussions of the accompanying stress between the surgeon and colleagues, family, and occasionally counselors are helpful in achieving resolution and emotional healing. Greater attention to emotional stress issues affecting caregivers, and especially surgeons, is needed. This should happen at all levels of education from medical school through postgraduate training, and in the everyday practice of surgery. Research to clarify the effectiveness of various interventions is needed.

The prevalence of cardiovascular disease and antidiabetes treatment characteristics among a large type 2 diabetes population in the United States.

ObjectivesThe purpose of this study was to assess atherosclerotic cardiovascular disease (ASCVD) prevalence, antidiabetes medication usage and physician specialty encounters among individuals with type 2 diabetes mellitus (T2DM) in the United States during 2015.DesignRetrospective, cross‐sectional analysis.PatientsAdults with T2DM in a large US administrative claims database. Patients were divided into ASCVD and non‐ASCVD groups. Subgroup analyses were conducted for three age groups (18‐44, 45‐64 and 65+ years).ResultsOf 1 202 596 patients with T2DM, 45.2% had established ASCVD. About 40% of T2DM patients with ASCVD had visited a cardiologist during 2015, compared to 11% in the non‐ASCVD group. The use of glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) and sodium‐glucose co‐transporter 2 inhibitors (SGLT‐2is) was low overall (<12%), and even lower in the ASCVD group (<9%). The prevalence of ASCVD was 15%, 36% and 71% in the 18‐44, 45‐64 and 65+ year age groups, respectively. GLP‐1RA and SGLT‐2i use was ≤5% in the 65+ subgroup, regardless of ASCVD status.ConclusionsThese real‐world data showed a high prevalence of ASCVD among T2DM patients, and confirmed, as a baseline assessment, low use of GLP‐1RAs and SGLT‐2is in these at‐risk patients prior to the 2017 American Diabetes Association guidelines recommending use of agents with proven cardiovascular benefits.

Perceptions of Infection Risk With Immunomodulatory Medications.

Physicians of many specialties encounter patients treated with immunomodulatory medications and must weigh the risk of infection when making medical decisions. We explored how physician perceptions of the infection risk of immunomodulatory medications differ by specialty and level of experience. A survey was distributed to physicians from the internal medicine, family medicine, emergency medicine, rheumatology, dermatology, and infectious disease departments at 1 tertiary care institution. Physicians scored their level of concern for the risk of infection of 15 commonly used immunomodulatory medications hypothetically taken for 1 year. The survey was distributed to 634 people; 197 physicians completed the survey. Opinion of the risk of infection differed significantly by specialty for 8 of 15 medications. Experienced providers rated risk of infection differently from less experienced providers for prednisone 10 to 20 mg (P = 0.046), hydroxychloroquine (P = 0.013), dapsone (P = 0.029), and anti-tumor necrosis factor (TNF) therapy (P = 0.027). Most experienced physicians regarded dapsone (95%) and hydroxychloroquine (93%) as low risk, whereas many less experienced physicians scored them as medium- or high-risk medications. In contrast, experienced physicians were more likely to rate prednisone 10 to 20 mg as medium or high risk. Most less experienced physicians (55%) identified anti-TNF therapy as high risk, whereas experienced physicians were split evenly among low, medium, and high risk. There is substantial variability in physician perception of the risk of infection of many immunomodulatory medications. Experienced physicians are more concerned than peers about the risk of infection of intermediate doses of prednisone. Opinions regarding anti-TNF therapy range broadly even among experienced providers.

Impact of a Cleft and Craniofacial Center on an Academic Health System.

The contributions of all physician specialties and ancillary services involved in cleft and craniofacial center care must be evaluated to fairly assess the financial impact of a cleft and craniofacial center. The authors hypothesized that the cleft and craniofacial center generates profitable downstream productivity for the academic health system. This was a retrospective cohort study of all patients who presented to a cleft and craniofacial center in the first quarter of 2011. Analysis included all health system encounters for each patient over a 2-year period using the electronic medical record and health system financial database. Sixty-two patients were seen (mean age, 11.4 years; 38 boys and 24 girls; 18 new and 44 established patients). Over 2 years, there were 618 health system encounters (599 outpatient and 19 inpatient encounters), 68 hospital days, and 110 procedures. The most common physician specialty was plastic surgery [312 encounters (50.5 percent)] and the most common ancillary service was speech therapy [256 encounters (41.4 percent)]. The overall reimbursement rate was 39.9 percent, with a majority payor-mix of government payors (62.1 percent). The total profit margin percentage from all encounters was 13.7 percent, which was greater for managed care compared with government payor (38.9 percent versus -10.8 percent; p = 0.022), inpatient compared to outpatient (24.5 percent versus -2.8 percent; p < 0.001), and plastic surgery compared to other specialty encounters (19.7 percent versus 8.7 percent; p = 0.003). The cleft and craniofacial center generated profitable downstream productivity for the academic health system with referrals to 39 different physician and nonphysician specialties. Health system providers and the business team should align to analyze the center, enhance patient outcomes, and improve specialty care access for patients.

A Clinical Practice Guideline for the Management of Degenerative Cervical Myelopathy: Introduction, Rationale, and Scope.

Degenerative cervical myelopathy (DCM) is a progressive spine disease and the most common cause of spinal cord dysfunction in adults worldwide. Patients with DCM may present with common signs and symptoms of neurological dysfunction, such as paresthesia, abnormal gait, decreased hand dexterity, hyperreflexia, increased tone, and sensory dysfunction. Clinicians across several specialties encounter patients with DCM, including primary care physicians, rehabilitation specialists, therapists, rheumatologists, neurologists, and spinal surgeons. Currently, there are no guidelines that outline how to best manage patients with mild (defined as a modified Japanese Orthopedic Association (mJOA) score of 15-17), moderate (mJOA = 12-14), or severe (mJOA ≤ 11) myelopathy, or nonmyelopathic patients with evidence of cord compression. This guideline provides evidence-based recommendations to specify appropriate treatment strategies for these populations. The intent of our recommendations is to (1) help identify patients at high risk of neurological deterioration, (2) define the role of nonoperative and operative management in each patient population, and (3) determine which patients are most likely to benefit from surgical intervention. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with DCM by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.

Comparing virtual consults to traditional consults using an electronic health record: an observational case–control study

BackgroundPatients have typically received health care through face-to-face encounters. However, expansion of electronic communication and electronic health records (EHRs) provide alternative means for patient and physicians to interact. Electronic consultations may complement regular healthcare by providing “better, faster, cheaper” processes for diagnosing, treating, and monitoring health conditions. Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients the time and expense of added visits. The purpose of this study was to compare physician usage and patient satisfaction with virtual consultations (VCs) with traditional consultations (TCs) facilitated within an EHR.MethodsWe conducted an observational case–control survey study within Kaiser Permanente, Colorado. A sample of patients who had VCs requested by physicians (N = 270) were matched with patients who had TCs requested by physicians (N = 270), by patient age, gender, reason for the consult, and specialty department. These patients (VC and TC), were invited to participate in a satisfaction survey. In addition, 205 primary care physicians who submitted a VC or TC were surveyed.ResultsDuring the study period, 58,146 VC or TC were requested (TC = 96.3%). Patients who completed a satisfaction survey (267 out of 540 patients, 49.4% response rate) indicated they were satisfied with their care, irrespective of the kind of consult (mean 10-point Likert score of 8.5). 88 of 205 primary care physicians surveyed (42.9%) returned at least one survey; VC and TC survey response rates and consulted departments were comparable (p = 0.13). More TCs than VCs requested transfer of patient care (p = 0.03), assistance with diagnosis (p = 0.04) or initiating treatment (p =0.04). Within 3 weeks of the consultation request, 72.1% of respondents reported receiving information from VCs, compared with 33.9% of the TCs (p < 0.001). Utility of information provided by consultants and satisfaction with consultations did not differ between VCs and TCs.ConclusionsReferring physicians received information from consultants more quickly from VCs compared with TCs, but the value and application of information from both types of consultations were similar. VCs may decrease the need for face-to-face specialty encounters without a decrease in the patient’s perception of care.