HIV Providers’ Perceived Barriers and Facilitators to Implementing Pre-exposure Prophylaxis in Care Settings: A Qualitative Study

Oral pre-exposure prophylaxis (PrEP) can reduce HIV incidence among at-risk persons. However, for PrEP to have an impact in decreasing HIV incidence, clinicians will need to be willing to prescribe PrEP. HIV specialists are experienced in using antiretroviral medications, and could readily provide PrEP, but may not care for HIV-uninfected patients. Six focus groups with 39 Boston area HIV care providers were conducted (May–June 2012) to assess perceived barriers and facilitators to prescribing PrEP. Participants articulated logistical and theoretical barriers, such as concerns about PrEP effectiveness in real-world settings, potential unintended consequences (e.g., risk disinhibition and medication toxicity), and a belief that PrEP provision would be more feasible in primary care clinics. They identified several facilitators to prescribing PrEP, including patient motivation and normative guidelines. Overall, participants reported limited prescribing intentions. Without interventions to address HIV providers’ concerns, implementation of PrEP in HIV clinics may be limited.     

Primary Care Physicians’ Attitudes Regarding Race-Based Therapies

Background  

There is little to no information on whether race should be considered in the exam room by those who care for and treat patients. How primary care physicians understand the relationship between genes, race and drugs has the potential to influence both individual care and racial and ethnic health disparities.     

Communicating During an HIV Outbreak Among People Who Inject Drugs—West Virginia 2019

In 2019, the West Virginia Bureau for Public Health (WV BPH), Cabell-Huntington Health Department (CHHD), and CDC collaborated to respond to an HIV outbreak among people who inject drugs (PWID). CDC, WV BPH, and CHHD formed a cross-agency communications team to establish situational awareness, identify knowledge gaps, and establish key audiences for messages, including the general population, PWID, and clinical and social service providers. The team disseminated up-to-date information about the outbreak, and prioritized messages addressing stigma related to drug use, syringe services programs, and HIV. Messages were continually updated to address the evolving situation and to resonate with local values. Messages were disseminated via advertisements, local news media, and directly to PWID, people experiencing homelessness, and providers. The response supplemented CHHD’s assets, including strong relationships and community knowledge, with staff capacity and expertise from state and federal agencies. This collaborative approach is a useful model to address communication needs.

     

Teleconsultation Improves Primary Care Clinicians’ Confidence about Caring for HIV

BACKGROUND

Telemedicine can facilitate communication between primary care clinicians and specialists. Generalists who use telemedicine for consultation (teleconsultation) may be able to practice more independently and reduce the number of formal referrals to specialists. In the United States, a federally funded human immunodeficiency virus (HIV) teleconsultation service (HIV Warmline) offers clinicians live telephone access to HIV specialists; however, its impact on clinicians’ self-perceived clinical competence and referral rates has not been studied.

OBJECTIVE

To determine if primary care clinicians who used the HIV Warmline felt more capable of managing HIV in their own practices.

DESIGN

Online survey.

PARTICIPANTS

Primary care physicians and mid-level practitioners who used the HIV Warmline for teleconsultation between 1/2008 and 3/2010.

MAIN MEASURES

Participants compared the HIV Warmline to other methods of obtaining HIV clinical support, and then rated its impact on their confidence in their HIV skills and their referral patterns.

KEY RESULTS

Respondents (N = 191, 59 % response rate) found the HIV Warmline to be quicker (65 %), more applicable (70 %), and more trustworthy (57 %) than other sources of HIV information. After using the HIV Warmline, 90 % had improved confidence about caring for HIV, 67 % stated it changed the way they managed HIV, and 74 % were able to avoid referring patients to specialists. All valued the availability of live, free consultation.

CONCLUSIONS

Primary care clinicians who called the HIV Warmline reported increased confidence in their HIV care and less need to refer patients to specialists. Teleconsultation may be a powerful tool to help consolidate HIV care in the primary care setting, and could be adapted for use with a variety of other medical conditions. The direct impact of teleconsultation on actual referral rates, quality of care and clinical outcomes needs to be studied.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-013-2332-5) contains supplementary material, which is available to authorized users.KEY WORDS: telemedicine, primary care, consultation, infectious disease, HIV, AIDS     

Use of Hospitalists and Office-Based Primary Care Physicians’ Productivity

BACKGROUND

Growth in the care of hospitalized patients by hospitalists has the potential to increase the productivity of office-based primary care physicians (PCPs) by allowing them to focus on outpatient practice.

OBJECTIVE

Our aim was to examine the association between utilization of hospitalists and the productivity of office-based PCPs.

DESIGN/PARTICIPANTS

The cross-sectional study was conducted using the 2008 Health Tracking Physician Survey Restricted Use File linked to the Area Resource File. We analyzed a total of 1,158 office-based PCPs representing a weighted total of 97,355 physicians.

MAIN MEASURES

Utilization of hospitalists was defined as the percentage of a PCP’s hospitalized patients treated by a hospitalist. The measures of PCPs’ productivity were: (1) number of hospital visits per week, (2) number of office and outpatient clinic visits per week, and (3) direct patient care time per visit.

KEY RESULTS

We found that the use of hospitalists was significantly associated with a decreased number of hospital visits. The use of hospitalists was also associated with an increased number of office visits, but this was only significant for high users. Physicians who used hospitalists for more than three-quarters of their hospitalized patients had an extra 8.8 office visits per week on average (p = 0.05), which was equivalent to a 10 % increase in productivity over the predicted mean of 87 visits for physicians who did not use hospitalists. We did not find any significant differences in direct patient care time per visit.

CONCLUSIONS

Our study demonstrates that the increase in productivity for the one-third of PCPs who use hospitalists extensively may not be sufficient to offset the current loss of PCP workforce. However, our findings provide cautious optimism that if more PCPs effectively and efficiently used hospitalists, this could help mitigate a PCP shortage and improve access to primary care services.KEY WORDS: hospitalists, primary care physician shortage, productivity     

Primary Care Physicians’ Decisions About Discharging Patients from Their Practices

Objective There are few data available about factors which influence physicians’ decisions to discharge patients from their practices. To study general internists’ and family medicine physicians’ attitudes and experiences in discharging patients from their practices. Design A cross-sectional mailed survey was used. Participants One thousand general internists and family medicine physicians participated in this study. Measurements and Main Results We studied the likelihood physicians would discharge 12 hypothetical patients from their practices, and whether they had actually discharged such patients. The effect of demographic data on the number of scenarios in which patients were likely to be discharged, and the number of patients actually discharged were analyzed via ANOVA and multiple logistic regression analysis. Of 977 surveys received by subjects, 526 (54%) were completed and returned. A majority of respondents were willing to discharge patients in 5 of 12 hypothetical scenarios. Eighty-five percent had actually discharged at least one patient from their practices. Most respondents (71%) had discharged 10 or fewer patients, but 14% had discharged 11 to 200 patients. Respondents who were in private practice (p < 0.000001) were more likely to discharge both hypothetical and actual patients from their practices. Older physicians (≥48 years old) were more likely to discharge actual patients from their practices (p = 0.005) as were physicians practicing in rural settings (p = 0.003). Conclusions Most physicians in our sample were willing to discharge actual and hypothetical patients from their practices. This tendency may have significant implications for the initiation of pay-for-performance programs. Physicians should be educated about the importance of the patient–physician relationship and their fiduciary obligations to the patient.     

Practice Constraints,Behavioral Problems,and Dementia Care: Primary Care Physicians’ Perspectives

Objectives To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care. Design Cross-sectional qualitative interview study of primary care physicians. Setting Physicians’ offices. Participants Forty primary care physicians in Northern California. Measurements Open-ended interviews lasted 30–60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process. Results Recurring themes (i.e., those present in ≥25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, “reactive” as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches. Conclusion Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short.     

A Comparison of Men Who Have Sex with Men,People Who Inject Drugs and High-Risk Heterosexuals’ Risk for HIV Infection,San Francisco

HIV in the United States is concentrated in populations such as men who have sex with men (MSM), people who inject drugs (PWID), women of color and people living in poverty. These populations are labeled high-risk for HIV infection because of the higher levels of HIV or HIV risk taking behaviors seen in these groups compared to other sub-populations. It is also possible that a group may engage in behaviors that are “high-risk” for HIV infection but never become infected since HIV is not present or not present to a great extent in their social or sexual networks. We analyzed samples of MSM, PWID and high-risk heterosexuals (HRH) collected through the National HIV Behavioral Surveillance (NHBS) system in San Francisco to examine HIV risk taking and HIV burden to determine if the label “high-risk” is appropriately applied. NHBS samples MSM using time location sampling and PWID and HRH using Respondent Driven Sampling. We sampled 508 MSM in 2011, 570 PWID in 2012 and 267 HRH in 2013. There were, as expected, differences in demographic characteristics across the three groups. HRH had a greater number of high-risk behaviors compared to MSM and PWID but had the lowest HIV prevalence. Focusing on risk behavior alone to label populations without considering the background HIV prevalence in communities, the types of risks engaged in and actual HIV infections may obscure which populations truly merit the label “high-risk” for HIV infection.     

Now What Should I Do? Primary Care Physicians’ Responses to Older Adults Expressing Thoughts of Suicide

BACKGROUND  

Many older adults who die by suicide have had recent contact with a primary care physician. As the risk-assessment and referral process for suicide is not readily comparable to procedures for other high-risk behaviors, it is important to identify areas in need of quality improvement (QI).     

A Spiritual Problem? Primary Care Physicians’ and Psychiatrists’ Interpretations of Medically Unexplained Symptoms

BACKGROUND

Patients commonly present to their physicians with medically unexplained symptoms (MUS), and there is no consensus about how physicians should interpret or treat such symptoms.

OBJECTIVE

To examine how variations in physicians’ interpretations of MUS are associated with physicians’ religious characteristics and with physician specialty (primary care vs. psychiatry).

DESIGN AND PARTICIPANTS

A national survey of a stratified random sample of 1,504 primary care physicians and 512 psychiatrists in 2009–2010.

MAIN MEASURES

The extent to which physicians believe MUS reflect a root problem that is spiritual in nature or result from conditions that scientific research will eventually explain, and whether such patients would benefit from attention to their relationships, attention to their spiritual life, taking medications, and/or treatment by physicians.

KEY RESULTS

Response rate was 63 % (1,208/1,909). More religious/spiritual physicians were more likely to believe that MUS reflect a spiritual problem (55 % for high vs. 24 % for low spirituality; OR?=?2.8, 1.7–4.5) and that these patients would benefit from paying attention to their spiritual life (79 % for high vs. 55 % for low spirituality; OR?=?3.1, 1.8–5.3). Psychiatrists were more likely to believe that scientific research will one day explain MUS (66 % vs. 52 %; OR?=?1.9, 1.4–2.5) and that these symptoms will improve with treatment by a physician (54 % vs. 35 %; OR?=?2.4, 1.8–3.3). They were less likely to believe that MUS reflect a spiritual problem (23 % vs. 38 %; OR?=?0.5, 0.4–0.8).

CONCLUSIONS

Physicians’ interpretations of MUS vary widely, depending in part on physicians’ religious characteristics and specialty. One in three physicians believes that patients with MUS have root problems that are spiritual in nature. Physicians who are more religious or spiritual are more likely to think of MUS as stemming from spiritual concerns. Psychiatrists are more optimistic that these patients will get better with treatment by physicians.     

Differences Between Primary Care Physicians’ and Oncologists’ Knowledge,Attitudes and Practices Regarding the Care of Cancer Survivors

Background  

The growing number of cancer survivors combined with a looming shortage of oncology specialists will require greater coordination of post-treatment care responsibilities between oncologists and primary care physicians (PCPs). However, data are limited regarding these physicians’ views of cancer survivors’ care.     

Variation in Primary Care Physicians’ Colorectal Cancer Screening Recommendations by Patient Age and Comorbidity

BACKGROUND

Screening patterns among primary care physicians (PCPs) may be influenced by patient age and comorbidity. Colorectal cancer (CRC) screening has little benefit among patients with limited life expectancy.

OBJECTIVE

To characterize the extent to which PCPs modify their recommendations for CRC screening based upon patients’ increasing age and/or worsening comorbidity

DESIGN

Cross-sectional, nationally representative survey.

PARTICIPANTS

The study comprised primary care physicians (n = 1,266) including general internal medicine, family practice, and obstetrics-gynecology physicians.

MAIN MEASURES

Physician CRC screening recommendations among patients of varying age and comorbidity were measured based upon clinical vignettes. Independent variables in adjusted models included physician and practice characteristics.

KEY RESULTS

For an 80-year-old patient with unresectable non-small cell lung cancer (NSCLC), 25 % of PCPs recommended CRC screening. For an 80-year-old patient with ischemic cardiomyopathy (New York Heart Association, Class II), 71 % of PCPs recommended CRC screening. PCPs were more likely to recommend fecal occult blood testing than colonoscopy as the preferred screening modality for a healthy 80-year-old, compared to healthy 50- or 65-year-old patients (19 % vs. 5 % vs. 2 % p < 0.001). For an 80-year-old with unresectable NSCLC, PCPs who were an obstetrics-gynecology physician were more likely to recommend CRC screening, while those with a full electronic medical record were less likely to recommend screening.

CONCLUSIONS

PCPs consider comorbidity when screening older patients for CRC and may change the screening modality from colonoscopy to FOBT. However, a sizable proportion of PCPs would recommend screening for patients with advanced cancer who would not benefit. Understanding the mechanisms underlying these patterns will facilitate the design of future medical education and policy interventions to reduce unnecessary care.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-2093-6) contains supplementary material, which is available to authorized users.KEY WORDS: cancer screening, health services, colorectal cancer, primary care physicians     

Setting a Fair Performance Standard for Physicians’ Quality of Patient Care

Background  

Assessing physicians’ clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable.     

Road to Better Work-Life Balance? Lean Redesigns and Daily Work Time among Primary Care Physicians

PurposeTo assess the impact of Lean primary care redesigns on the amount of time that physicians spent working each day.MethodsThis observational study was based on 92 million time-stamped Epic® EHR access logs captured among 317 primary care physicians in a large ambulatory care delivery system. Seventeen clinic facilities housing 46 primary care departments were included for study. We conducted interrupted time series analysis to monitor changes in physician work patterns over 6 years. Key measures included total daily work time; time spent on “desktop medicine” outside the exam room; time spent with patients during office visits; time still working after clinic, i.e., after seeing the last patient each day; and remote work time.ResultsThe amount of time that physicians spent on desktop EHR activities throughout the day, including after clinic hours, decreased by 10.9% (95% CI: −22.2, −2.03) and 8.3% (95% CI: −13.8, −2.12), respectively, during the first year of Lean implementation. Total daily work hours among physicians, which included both desktop activity and time in office visits, decreased by 20% (95% CI: −29.2, −9.60) by the third year of Lean implementation.ConclusionsThese findings suggest that Lean redesign may be associated with time savings for primary care physicians. However, since this was an observational analysis, further study is warranted (e.g., randomized trial) —to determine the impact of Lean interventions on physician work experiences.KEY WORDS: primary care redesign, lean management, work efficiency, physician work time, time-stamped EHR access logs, interrupted time series analysis, longitudinal data     

Primary Care Physicians’ Use of an Electronic Medical Record System: A Cognitive Task Analysis

OBJECTIVE  To describe physicians’ patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient–doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. DESIGN  Cognitive task analysis using semi-structured interviews and field observations. PARTICIPANTS  Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. RESULTS  The comprehensiveness, organization, and readability of data in the EMR system reduced physicians’ need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient’s chart. EMR use interfered with patient–doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians’ communication skills also helped. CONCLUSIONS  There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians’ offices and by enhancing physicians’ computer and communication skills.     

Does Physicians’ Case Volume Impact Inpatient Care Costs for Pneumonia Cases?

Summary Background Increasing physician case volumes are documented to reduce costs and improve outcomes for many surgical procedures but not for medical conditions such as pneumonia that consume significant health care resources. Objective This study explored the association between physicians’ inpatient pneumonia case volume and cost per discharge. Design The design was a retrospective, population-based, cross-sectional study, using National Health Insurance administrative claims data. Setting The setting was Taiwan. Participants The participants were a universal sample of 270,002 adult, acute pneumonia hospitalizations, during 2002–2004, excluding transferred cases and readmissions. Measurements Hierarchical linear regression modeling was used to examine the association of physician’s volume (three volume groups, designed to classify patients into approximately equal sized groups) with cost, adjusting for hospital random effects, case severity, physician demographics and specialty, hospital characteristics, and geographic location. Results Mean cost was NT$2,255 (US$1 = NT$33 in 2004) for low-volume physicians (≤100 cases) and NT$1,707 for high-volume physicians (≥316 cases). The adjusted patient costs for low-volume physicians were higher (US$264 and US$235 than high- and medium-volume physicians, respectively; both P < .001), with no difference between high- and medium-volume physicians. High-volume physicians had lower in-hospital mortality and 14-day readmission rates than low-volume physicians. Conclusions Data support an inverse volume–cost relationship for pneumonia care. Decision processes and clinical care of high-volume physicians versus low-volume physicians should be studied to develop effective care algorithms to improve pneumonia outcomes and reduce costs.     

Personal Characteristics Associated with Resident Physicians’ Self Perceptions of Preparedness to Deliver Cross-Cultural Care

BACKGROUND  Recent reports from the Institute of Medicine emphasize patient-centered care and cross-cultural training as a means of improving the quality of medical care and eliminating racial and ethnic disparities. OBJECTIVE  To determine whether, controlling for training received in medical school or during residency, resident physician socio-cultural characteristics influence self-perceived preparedness and skill in delivering cross-cultural care. DESIGN  National survey of resident physicians. PARTICIPANTS  A probability sample of residents in seven specialties in their final year of training at US academic health centers. MEASUREMENT  Nine resident characteristics were analyzed. Differences in preparedness and skill were assessed using the χ² statistic and multivariate logistic regression. RESULTS  Fifty-eight percent (2047/3500) of residents responded. The most important factor associated with improved perceived skill level in performing selected tasks or services believed to be useful in treating culturally diverse patients was having received cross-cultural skills training during residency (OR range 1.71–4.22). Compared with white residents, African American physicians felt more prepared to deal with patients with distrust in the US healthcare system (OR 1.63) and with racial or ethnic minorities (OR 1.61), Latinos reported feeling more prepared to deal with new immigrants (OR 1.88) and Asians reported feeling more prepared to deal with patients with health beliefs at odds with Western medicine (1.43). CONCLUSIONS  Cross-cultural care skills training is associated with increased self-perceived preparedness to care for diverse patient populations providing support for the importance of such training in graduate medical education. In addition, selected resident characteristics are associated with being more or less prepared for different aspects of cross-cultural care. This underscores the need to both include medical residents from diverse backgrounds in all training programs and tailor such programs to individual resident needs in order to maximize the chances that such training is likely to have an impact on the quality of care.