Physician Time Research Articles

Attitudes and access to resources and strategies to improve quality of radiotherapy among US radiation oncologists: A mixed methods study.

We aimed to assess contouring-related practices among US radiation oncologists and explore how access to and use of resources and quality improvement strategies vary based on individual- and organization-level factors. We conducted a mixed methods study with a sequential explanatory design. Surveys were emailed to a random 10% sample of practicing US radiation oncologists. Participating physicians were invited to a semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests and a multivariable regression model were used to evaluate associations. Interview data were coded using thematic content analysis. Survey overall response rate was 24%, and subsequent completion rate was 97%. Contouring-related questions arise in ≥50% of clinical cases among 73% of respondents. Resources accessed first include published atlases (75%) followed by consulting another radiation oncologist (60%). Generalists access consensus guidelines more often than disease-site specialists (P = 0.04), while eContour.org is more often used by generalists (OR 4.3, 95% CI 1.2-14.8) and younger physicians (OR 1.33 for each 5-year increase, 95% CI 1.08-1.67). Common physician-reported barriers to optimizing contour quality are time constraints (58%) and lack of access to disease-site specialists (21%). Forty percent (40%, n = 14) of physicians without access to disease-site specialists indicated it could facilitate the adoption of new treatments. Almost all (97%) respondents have formal peer review, but only 43% have contour-specific review, which is more common in academic centres (P = 0.02). Potential opportunities to improve radiation contour quality include improved access to disease-site specialists and contour-specific peer review. Physician time must be considered when designing new strategies.

ISOLATED DIASTOLIC HYPERTENSION IS NOT A BENIGN SITUATION REGARDING HYPERTENSION MEDIATED ORGAN DAMAGE IN PATIENTS WITH FIRST DIAGNOSED AND NEVER TREATED ESSENTIAL HYPERTENSION

Objective: Isolated diastolic hypertension (IDH) usually remains untreated as it is considered benign compared to isolated systolic or combined systolic/diastolic hypertension. Hypertension mediated organ damage (HMOD) needs to be assessed in each individual hypertensive patient in order to estimate cardiovascular risk. We aimed to investigate the HMOD differences between first diagnosed and never treated patients with IDH compared to normotensive subjects. Design and method: We studied 68 non-diabetic, first diagnosed and never-treated hypertensive patients with IDH (mean age = 49 + 9, 65% males, 24% smokers) and 30 normotensives (mean age = 51 + 10, 17% males, 20% smokers). Office and ambulatory blood pressure monitoring (24 h ABPM), CV risk factors [smoking, obesity (BMI), hyperlipidemia and HMOD [aortic stiffness (PWV), left ventricular diastolic dysfunction (EEa), cardiac hypertrophy (LVMI), coronary arteries microcirculation (CFR), carotid intima-media thickness (cIMT) were estimated in each hypertensive patient as well as normotensive subject. Results: IDH patients had similar age, BMI and smoking habit, decreased LDL-C and increased diastolic (89 + 9 vs. 84 + 9 mmHg, p = 0.02) and mean office BP (106 + 9 vs. 99 + 12 mmHg, p = 0.01) as well as 24 h systolic (126 + 3 vs. 119 + 6 mmHg, p < 0.001) and diastolic ABPM (84 + 4 vs. 73 + 4 mmHg, p < 0.001) compared to normotensives. Regarding HMOD, IDH patients had increased LVMI (78 + 17 vs. 68 + 19 g/m2, p = 0.03) and IMT (0.9 + 0.1 vs. 0.8 + 0.1 mm, p = 0.03) but similar PWV, E/Ea and CFR compared to normotensives. LVMI was related to diastolic (r = 0.32, p = 0.008) and mean (r = 0.32, p = 0.01) office BP in IDH patients. Conclusions: The presence of HMOD in patients with first diagnosed and never treated IDH underscores the need for antihypertensive treatment (life style changes and medication). As HMOD may regress with successful antihypertensive treatment, there is still time for physicians to reduce future CV events in those patients.

Dissemination and Use of Point-of-Care Ultrasound by Pediatricians in Europe: A Research in European Pediatric Emergency Medicine Network Collaborative Survey.

We surveyed the dissemination and use of point-of-care ultrasound (POCUS), physician training levels, and barriers and limitations to use of POCUS among pediatricians and pediatric emergency medicine (PEM) physicians across Europe and Israel. A questionnaire was distributed through the PEM section of the European Society for Emergency Medicine and the Research in European Pediatric Emergency Medicine Network. A total of 581 physicians from 22 countries fully completed the questionnaire. Participants were primarily pediatric attending physicians (34.9% [203 of 581]) and PEM attending physicians (28.6% [166 of 581]). Most of the respondents, 58.5% (340 of 581), reported using POCUS in their practice, and 61.9% (359/581) had undergone POCUS training. Point-of-care ultrasound courses represented the most common method of becoming proficient in POCUS. Overall, the Focused Assessment with Sonography in Trauma scan was the mostly taught application, with 76.3% (274 of 359). Resuscitative, diagnostic, and procedural POCUS were rated as very useful or useful by the most of respondents.The lack of qualified personnel to train (76.9% [447 of 581]), and the insufficient time for physicians to learn, POCUS (63.7% [370 of 581]) were identified as the main limitations to POCUS implementation. The dissemination of pediatric POCUS in the European and Israeli centers we surveyed is limited, and its applications are largely restricted to the Focused Assessment with Sonography in Trauma examination. This is likely related to lack of training programs. In contrast, the potential value of use of POCUS in PEM practice is recognized by the majority of respondents.

Physician experiences with medical assistance in dying

To explore physician experiences with medical assistance in dying (MAID). An exploratory qualitative research approach using thematic analysis. Six communities in northwestern Ontario. Twenty-three physicians who perform, refer patients for, or are otherwise affected by MAID. One semistructured focus group and one-to-one interviews, transcribed and analyzed thematically. The legislation of MAID added a layer of complexity to the work of physicians in northwestern Ontario, as MAID requires physician leadership, knowledge, time, and careful implementation. Four themes were identified from the interviews that unpacked this additional layer of complexity: relationships, motivation, time and resources, and getting others on board. The logistics of health care delivery in northwestern Ontario communities are complex and layered, which contributes to the burden of physicians as they work to provide MAID.

Heuristics in the Delivery Room

(Abstracted from Science 2021;374:324–329) Studying the delivery setting provides a glimpse into physician's decision-making, whereas cognitive and time pressures create a uniquely high-stakes scenario. In such settings, individuals may be more likely to rely on heuristics to aid complex decision-making including the decision to suggest a vaginal or cesarean delivery.

Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment.

PurposePhysicians can limit upward trending healthcare costs, yet legal and ethical barriers prevent the use of direct financial incentives to engage physicians in cost-reduction initiatives. Physician-directed reinvestment is an alternative value-sharing arrangement in which a health system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into professional areas of the physicians’ choosing. Formal evaluations of such programs are lacking.MethodsTo understand the impact of Stanford Health Care’s physician-directed reinvestment in its first year (2017–2018) on physician engagement, adherence to program requirements around safety and fund use, and factors facilitating program dissemination, semi-structured qualitative interviews with physician participants, non-participants, and administrative stakeholders were conducted July-November 2019. Interview transcripts were qualitatively analyzed through an implementation science lens. To support contextual analysis of the qualitative data, a directional estimation of the program’s impact on cost from the perspective of the health system was calculated by subtracting annual maintenance cost (derived from interview self-reported time estimates and public salary data) from internal cost accounting of the total savings from first year cohort to obtain annual net benefit, which was then divided by the annual maintenance cost.ResultsPhysician participation was low compared with the overall physician population (n=14 of approximately 2300 faculty physicians), though 32 qualitative interviews suggested deep engagement across physician participants and adherence to target program requirements. Reinvestment funds activated intrinsic motivators such as autonomy, purpose and inter-professional relations, and extrinsic motivators, such as the direction of resources and external recognition. Ongoing challenges included limited physician awareness of healthcare costs and the need for increased clarity around which projects rise above one's existing job responsibilities. Administrative data excluding physician time, which was not directly compensated, showed a direct cost savings of $8.9M. This implied an 11-fold return on investment excluding uncompensated physician time.ConclusionA physician-directed reinvestment program appeared to facilitate latent frontline physician innovation towards value, though additional evaluation is needed to understand its long-term impact.

Behavioral economics in neonatology-balancing provider wellness and departmental finances.

High work relative value units (wRVU) per clinical full-time-equivalent (cFTE) productivity by Neonatologists have played a key role in enhancing departmental revenue in Pediatrics. However, such high productivity is not sustainable due to recent changes in trainee schedules and global daily codes and is likely to impact physician morale and wellness. Incentives based on wRVU benchmarks have the capacity to promote desirable behavior such as better documentation and in-person attendance in delivery room resuscitation and consults but comes at a cost of physician time providing care. An alternate method of funding academic Pediatric departments using time- or point-based staffing models, a reduction in productivity benchmarks for academic neonatologists through more accurate reporting of effort and physician leadership that promotes transparency and mutual respect are warranted to improve neonatologist well-being and morale.

Trends in High-Severity Billing of Hospitalized Medicare Beneficiaries Treated by Hospitalists vs Nonhospitalists

As US hospital expenditures continue to rise, understanding drivers of high-severity billing for hospitalized patients among inpatient physicians is critically important. To evaluate high-severity billing trends of Medicare beneficiaries treated by hospitalists vs nonhospitalists. This cohort study used Medicare fee-for-service claims of hospitalized patients from 2009 through 2018 to compare the proportion of high-severity billing between general medicine physicians classified as hospitalists vs nonhospitalists across initial, subsequent, and discharge hospital encounters. We compared physicians within the same hospital using hospital fixed effects and adjusted for patient demographics and comorbidities. Changes in the billing practices were assessed by investigating differences in slopes using an interaction term between physician type and time. Analyses were conducted between August 2021 and January 2022. Treatment by hospitalists vs nonhospitalists. High-severity billing for initial, subsequent, and discharge hospital encounters. The sample included 3 121 260 and 1 855 678 Medicare beneficiaries treated by hospitalists vs nonhospitalists, respectively. In each year, mean age, proportion female, proportion Black and Hispanic dual status, and mean number of chronic conditions were similar among those treated by hospitalists vs nonhospitalists (standardized mean difference < .01). The number of hospitalists grew by 76%, from 23 390 in 2009 to 41 084 in 2018, whereas nonhospitalists decreased by 43.6% (53 758 to 30 289). The proportion of encounters performed by hospitalists increased for the initial hospital encounters (46.3% to 76%), subsequent encounters (46.8% to 76.7%), and discharge encounters (46.1% to 78.5%) over the 10-year period. The proportion of high-severity billing across the hospital, subsequent, and discharge encounters was consistently higher among hospitalists relative to nonhospitalists across all years. Compared with the trends for nonhospitalists, the proportion of high-severity billing grew by 0.46% per year (95% CI, 0.44% to 0.49%; P < .001) for initial encounters, 0.38% per year (95% CI, 0.37% to 0.39%; P < .001) for subsequent encounters, and by 1.1% per year (95% CI, 1.1% to 1.15%; P < .001) for discharge encounters among hospitalists. In this cohort study of Medicare fee-for-service beneficiaries treated in hospitals, high-severity billing increased over time for hospital encounters at higher rates for hospitalists than for nonhospitalists. These differences do not appear to be explained by patient complexity. The increase in the number of hospitalists over time may be contributing to rising national costs related to hospital care.

Different Types of Ultrasound Probes Usage for Multi-Angle Conventional 3D Ultrasound Compound Imaging: A Breast Phantom Study

Three-dimensional automated breast ultrasound (ABUS) systems seem to offer excellent results in breast cancer screening tests and its early detection, comparable to handheld ultrasound B-mode scanning, with the benefit of saving physician time and reducing handheld ultrasound issues. Nevertheless, the ABUS systems are not very popular, due to the cost and very narrow application. The multi-angle conventional 3D ultrasound compound imaging method (MACUI) is intended for use with standard B-mode scanners in order to reduce cost but preserve the advantages of ABUS systems. The rotational probe movement is utilized in order to collect images for the three-dimensional reconstruction of the scanned tissue’s anatomy. The authors evaluate the capabilities to increase the scanned volume and quality of reconstructions, which are limited in current MACUI implementations, with a probe tilt and shift. The study shows and discusses the results of the imaging using different probes available for SmartUs Telemed B-Mode scanner at different scanning geometry in order to determine the capabilities of such an ultrasound imaging system. The results discussed in the paper highlight the benefits in quality improvement and scanning area obtained with tilted and shifted probes, as well as the advantages of using a relatively simple convex probe that does not incorporate software beam steering over more advanced devices.

Patients' Satisfaction with Ophthalmology Clinic Services in a Public Teaching Hospital.

PurposeTo evaluate patients’ satisfaction with ophthalmology health services in a teaching clinic of a tertiary public hospital.Patients and MethodsThis was a cross-sectional study in ophthalmology clinic of Dr. Sardjito teaching hospital, Yogyakarta, Indonesia conducted in 2019. Patients were surveyed using the Patient Satisfaction Questionnaire-18 (PSQ-18). PSQ-18 subscale score was analyzed based on patients’ characteristics. The main outcome was the odds of reaching top satisfaction score (TSS) of 4–5 from a Likert scale 1 to 5.ResultsOur study recorded 269 participants who consisted of 138 males (51.3%) and 131 females (48.7%) with median age of 52 (18–87) years old. Variables with higher odds of reaching TSS on “patient overall satisfaction” was public health insurance (OR: 7.959 [95% CI: 1.989–31.852], p=0.003) while examination time (OR: 0.955 [95% CI: 0.923–0.988], p=0.008) had lower odds. Examination waiting time (OR: 0.992 [95% CI: 0.985–0.999], p=0.027) and examination time (OR: 0.941 [95% CI: 0.908–0.976], p=0.001) had lower odds of reaching TSS in “general satisfaction”. Family monthly income (OR: 1.829 [95% CI: 1.038–3.223], p=0.037) had higher odds of reaching TSS in “technical quality” while examination time (OR: 0.961 [95% CI: 0.931–0.993], p=0.017) and education (OR: 0.549 [95% CI: 0.322–0.934], p=0.027) had lower odds. Comorbidities (OR: 0.533 [95% CI: 0.301–0.944], p=0.031) had lower odds of reaching TSS in “financial aspects”. Retina subspecialty clinic (OR: 3.436 [95% CI: 1.154–10.232], p=0.027) had higher odds of reaching TSS in “time spent with doctor”. Registrar as attending physician (OR: 0.427 [95% CI: 0.205–0.89], p=0.0230) and examination time (OR: 0.957 [95% CI: 0.924–0.991], p=0.013) had lower odds of reaching TSS in “accessibility-convenience”.ConclusionExamination time and examination waiting time should be shortened, specialist doctors should always see the patients whenever possible, and registrars' technical and communication skill should be improved. Alternative funding for patients without health insurance also should be provided to increase satisfaction.

Association of Asthma Exacerbation Risk and Physician Time Expenditure With Provision of Asthma Action Plans and Education for Pediatric Patients.

To provide information about factors underlying provision of asthma action plans (AAPs) to a minority of pediatric patients with asthma, assess whether risk of exacerbation acts on provision of AAP and asthma education directly, suggesting targeting to highest-risk patients, or indirectly by influencing physician-patient interaction time. This study was a retrospective cross-sectional analysis of a nationally representative sample of physician office visits that consisted of patients aged 2 to 18 years with asthma. Exacerbation risk comprised proxy indicators of control and severity. Direct and time-mediated effects of exacerbation risk on provision of AAP and education were calculated from logistic regression models. Asthma action plans were provided in 14.3% of visits, education in 23.9%. Total direct effects of exacerbation risk (ORs = 3.88-4.69) far exceeded indirect, time-mediated effects (both ORs = 1.03) on AAPs. Direct effects on education were similar but smaller. After adjusting for risk, physician time expenditure of ≥30 minutes was associated with nearly doubled odds of providing AAP or education (ORs = 1.90-1.99). Visits that included allied health professionals alongside physician care were significantly associated with all 4 outcomes in multivariate analyses (ORs = 3.06-5.28). Exacerbation risk has a strong, direct association with AAP provision in pediatric asthma, even controlling for physician time expenditure. Provision of AAP and education to pediatric patients with asthma may be facilitated by increasing available time for office visits and involving allied health professionals.

The Case for Ethical Efficiency: A System That Has Run Out of Time.

The American health care system increasingly conflates physician "productivity" with true clinical efficiency. In reality, inordinate time pressure on physicians compromises quality of care, decreases patient satisfaction, increases clinician burnout, and costs the health care system a great deal in the long term even if it is financially expedient in the short term. Inadequate time to deliver care thereby conflicts with the core principles of biomedical ethics, including autonomy, beneficence, nonmaleficence, and justice. We propose that the health care system adjust its focus to recognize the nonmonetary value of physician time while still realizing the need to deploy resources as effectively as possible, a concept we describe as "ethical efficiency."

Variations and Challenges to Performing Outside Study Interpretations in Breast Imaging: A National Survey of the Society of Breast Imaging Membership.

Second-opinion interpretations of outside facility breast imaging provide value-added care but are operationally challenging for breast radiologists. Our objective was to survey members of the Society of Breast Imaging (SBI) to assess practice patterns and perceived barriers to performing outside study interpretations (OSIs). An anonymous survey was developed by the Patient Care and Delivery Committee of the SBI and distributed via e-mail to SBI radiologist members. Survey questions included practice demographics and OSI volumes, billing practices, clinical scenarios, and imaging modalities, logistics, and barriers. Responses were aggregated and comparisons were made by univariate analysis using likelihood ratio tests, t-tests, and Spearman's rank correlation tests as appropriate. Ordinal or nominal logistic modeling and linear regression modeling was also performed. There were 371 responses (response rate of 13%). Most respondents practice at an affiliated specialty breast care center (306/371, 83%) and said their practice performed OSIs (256/371, 69%). Academic practices reported the highest OSI volumes (median 75 per month) and were most likely to indicate increases in OSI volumes over time (100/144, 69%). The most common indication for OSI was second opinion for a biopsy recommendation (245/256, 96%). Most practices provide a final BI-RADS assessment (183/261, 70%). The most cited barrier to performing OSIs was physician time constraints (252/369, 68%). Breast imaging OSI practice patterns are variable among SBI members with notable differences by practice setting and multiple barriers identified. More unified guidelines and recommendations may be needed for radiologists to better perform this valuable task.

Peripartum Hypertensive Crisis Simulation and Education Initiative among Rural Emergency Departments.

To determine whether the introduction of hypertensive bundles through simulation and education would result in the timely assessment and treatment of a simulated patient in a peripartum hypertensive crisis. This prospective observational pilot study evaluates the use of simulation and education on hypertension bundled care for peripartum patients in eight rural hospitals. Unannounced simulation exercises were conducted at each hospital. Emergency department staff response was assessed with a checklist. Primary outcomes included time to first antihypertensive medication administered, time to registered nurse assessment, and time to physician assessment. After the initial simulation, nurse educators conducted an in-person didactic on the management of peripartum hypertensive crisis, providing each hospital with materials for local bundle initiation and implementation for hypertensive emergency. The nurse educators conducted the same simulation at the individual sites 3 to 4 months later. Time of intervention improvement pre- and posteducation training scores were analyzed for each of these using a paired t test followed by a Wilcoxon signed-rank test. The average time of intervention improvement among delivering hospitals versus nondelivering hospitals was compared. Eight training simulation and training sessions were conducted at four delivering and four nondelivering hospitals. Seventy-three healthcare workers attended training. The average time decreased from pre- to postsimulation at all of the hospitals (this was not statistically significant, however). The average reduction in time for first nurse assessment was 1.25 ± 10.05 minutes (P = 0.99). The average reduction in time to physician assessment was 4.88 ± 14.74 minutes (P = 0.45). The average reduction of time to administration of first hypertensive medication was 12.0 ± 25.79 minutes (P = 0.15). The average times for nurse or physician assessment and time to first hypertension medication administration were similar between delivering and nondelivering hospitals. Our study demonstrates a trend toward improved treatment of a peripartum hypertensive emergency through bundled care and simulation. The training reduced the time to first medication given and improved the selection process for the preferred hypertensive medication. The time from nurse care to physician assessment also was reduced. Education in bundled peripartum hypertension care may improve patient outcomes by decreasing hypertension-related maternal morbidity and mortality.

Certain Rooms in Intensive Care Units May Harbor Risk for Clostridioides difficile Infection.

Abstract Background: Clostridioides difficile infection (CDI) is a common and sometimes life-threatening illness. Patient-, care-, and room hygiene-specific factors are known to impact CDI genesis, but care provider training and room topography have not been explored. We sought to determine if care in specific intensive care unit (ICU) rooms asymmetrically harbored CDI cases. Patients and Methods: Surgical intensive care unit (SICU) patients developing CDI (July 2009 to June 2018) were identified and separated by service (green/gold). Each service cared for their respective 12 rooms, otherwise differing only in resident team composition (July 2009 to August 2017: green, anesthesia; gold, surgery; August 2017 to June 2018: mixed for both). Fixed/mobile room features and provider traffic in three room zones (far/middle/near in relation to the toilet) were compared between high-/low-incidence rooms using observation via telecritical care video cameras. Results: Seventy-four new CDI cases occurred in 7,834 consecutive SICU admissions. In period one, green CDI cases were almost double gold cases (39 vs. 21; p = 0.02) but were similar in period two in which trainee service allocation intermixed. High-incidence rooms had closer toilet-to-intravenous pole proximity than low-incidence rooms (7.7 + 1.8 feet vs. 3.9 + 1.5 feet; p = 0.02). High-incidence rooms consistently housed mobile objects (patient bed, table-on-wheels) farther away from the toilet. Although physician time spent in each zone was similar, nurses spending more than 15 minutes in-room more frequently stayed in the far/middle zones in high-incidence rooms. Conclusions: Distinct SICU room features relative to toilet location and bedside clinician behaviors interact to alter patient CDI acquisition risk. This suggests that CDI risk occurs as a structural aspect of ICU care, offering the potential to reduce patient risk through deliberate room redesign.

White Paper on the Value of Time Savings for Patients and Healthcare Providers of Breast Cancer Therapy: The Fixed-Dose Combination of Pertuzumab and Trastuzumab for Subcutaneous Injection as an Example.

Health technology assessments and value frameworks are becoming increasingly important for clinical decision-making. Most of these frameworks, however, focus on value to payers rather than patients and healthcare providers and may ignore other sources of economic value such as patient and physician time cost, impact on productivity, and direct health system costs. This article focusses on fixed-dose combination of pertuzumab and trastuzumab for subcutaneous injection (PH FDC SC) in the treatment of HER2-positive breast cancer. We review relevant clinical evidence, examine data on time and resource use of the subcutaneous administration of trastuzumab compared with intravenous treatment and how it can be extrapolated to PH FDC SC, and discuss the value PH FDC SC can bring to patients and healthcare providers. We will also provide our own experiences of PH FDC SC from the healthcare (oncologist, healthcare economist, pharmacist) and patient point of view. The data, combined with our personal experiences, suggest that switching from intravenous pertuzumab and trastuzumab to PH FDC SC could reduce non-drug costs for healthcare providers treating patients with HER2-positive breast cancer through time savings and other economic benefits. Furthermore, PH FDC SC could also save patient time given its shorter administration and post-injection observation time versus intravenous infusions, potentially resulting in reduced productivity loss. These benefits could be applied to other subcutaneous formulations, either currently available or in development.

Primary care physicians' electronic health record proficiency and efficiency behaviors and time interacting with electronic health records: a quantile regression analysis.

This study aimed to understand the association between primary care physician (PCP) proficiency with the electronic health record (EHR) system and time spent interacting with the EHR. We examined the use of EHR proficiency tools among PCPs at one large academic health system using EHR-derived measures of clinician EHR proficiency and efficiency. Our main predictors were the use of EHR proficiency tools and our outcomes focused on 4 measures assessing time spent in the EHR: (1) total time spent interacting with the EHR, (2) time spent outside scheduled clinical hours, (3) time spent documenting, and (4) time spent on inbox management. We conducted multivariable quantile regression models with fixed effects for physician-level factors and time in order to identify factors that were independently associated with time spent in the EHR. Across 441 primary care physicians, we found mixed associations between certain EHR proficiency behaviors and time spent in the EHR. Across EHR activities studied, QuickActions, SmartPhrases, and documentation length were positively associated with increased time spent in the EHR. Models also showed a greater amount of help from team members in note writing was associated with less time spent in the EHR and documenting. Examining the prevalence of EHR proficiency behaviors may suggest targeted areas for initial and ongoing EHR training. Although documentation behaviors are key areas for training, team-based models for documentation and inbox management require further study. A nuanced association exists between physician EHR proficiency and time spent in the EHR.

Individual head and neck screening: Initiating a dialogue about best approach

PurposeWe aim to investigate the true benefits of free individual HNC screening in a high-risk urban population as well as the associated risks. Materials and methodsThis is a retrospective descriptive study. Free HNC screening was performed from 2014 to 2019. Participants were issued a questionnaire at the time of screening. After exemption by the Institutional Review Board, completed screening questionnaires were entered into a database and descriptive statistics were generated. The primary outcome measure for this study was the detection rate for HNC. We hypothesized that screening would be low yield based on previous studies (Gogarty et al., 2016). ResultsThis was a volunteer sample with a total of 410 participants, and the highest yield screening year was 2019 (n = 187). For all years, the cancer detection rate was 0%. In 2019, 134 (77.9%) of participants did not recognize the early symptoms of HNC, and 120 (73.2%) reported the screening program increased their awareness of the disease. 13 (7.6%) reported HPV vaccination while 126 (71.2%) were unaware that HPV has been linked with head and neck cancer. ConclusionsHNC screening is an excellent opportunity for education regarding HNC risk factors. However, it is not a cost-effective use of physician time, does not increase detection rates even in high-risk segments of the general population, and is not completely without risk in the context of COVID-19. Perhaps the focus of HNC screening should shift from individualized screening to education and health promotion.

DIPS (Dystonia Image-based Programming of Stimulation: a prospective, randomized, double-blind crossover trial)

IntroductionDeep brain stimulation of the internal globus pallidus is an effective treatment for dystonia. However, there is a large variability in clinical outcome with up to 25% non-responders even in highly selected primary dystonia patients. In a large cohort of patients we recently demonstrated that the variable clinical outcomes of pallidal DBS for dystonia may result to a large degree by the exact location and stimulation volume within the pallidal region. Here we test a novel approach of programing based on these insights: we first defined probabilistic maps of anti-dystonic effects by aggregating individual electrode locations and volumes of tissue activated of > 80 patients collected in a multicentre effort. We subsequently modified the algorithms to be able to test all possible stimulation settings of de novo patients in silico based on the expected clinical outcome and thus potentially predict the best possible stimulation parameters for the individual patients.MethodsWithin the framework of a BMBF-funded study, this concept of a computer-based prediction of optimal stimulation parameters for patients with dystonia will be tested in a randomized, controlled crossover study. The main parameter for clinical efficacy and primary endpoint is based on the blinded physician rating of dystonia severity reflected by Clinical Dystonia Rating Scales for both interventions (best clinical settings and model predicted settings) after 4 weeks of continuous stimulation. The primary endpoint is defined as “successful treatment with model predicted settings” (yes or no). The value is “yes” if the motor symptoms with model predicted settings are equal or better (tolerance 5% of absolute difference in percentages) to clinical settings. Secondary endpoints will include measures of quality of life, calculated energy consumption of the neurostimulation system and physician time for programming.PerspectiveWe envision, that computer-guided deep brain stimulation programming in silico might provide optimal stimulation settings for patients with dystonia without the burden of months of programming sessions. The study protocol is designed to evaluate which programming method is more effective in controlling motor symptom severity and improving quality of life in dystonia (best clinical settings and model predicted settings).Trial registration Registered with ClinicalTrials.gov on Oct 27, 2021 (NCT05097001).

The toll of cascading crises on Lebanon's health workforce

The toll of cascading crises on Lebanon's health workforce