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Pragmatism in clinical trials is focused on increasing the generalizability of research findings for routine clinical care settings. Hybridism in clinical trials (i.e., assessing both clinical effectiveness and implementation success) is focused on speeding up the process by which evidence-based practices are developed and adopted into routine clinical care. Even though pragmatic trial methodologies and implementation science evolved from very different disciplines, Pragmatic Trials and Hybrid Effectiveness-Implementation Trials share many similar design features. In fact, these types of trials can easily be conflated, creating the potential for investigators to mislabel their trial type or mistakenly use the wrong trial type to answer their research question. Blurred boundaries between trial types can hamper the evaluation of grant applications, the scientific interpretation of findings, and policy-making. Acknowledging that most trials are not pure Pragmatic Trials nor pure Hybrid Effectiveness-Implementation Trials, there are key differences in these trial types and they answer very different research questions. The purpose of this paper is to clarify the similarities and differences of these trial types for funders, researchers, and policy-makers. In addition, recommendations are offered to help investigators choose, label, and operationalize the most appropriate trial type to answer their research question. These recommendations complement existing reporting guidelines for clinical effectiveness trials (TIDieR) and implementation trials (StaRI). [ABSTRACT FROM AUTHOR]

The practice of clinical medicine is imbued with uncertainty. The ways in which clinicians and patients think about, communicate about, and act within situations of heightened uncertainty can have significant implications for the therapeutic alliance and for the trajectory and outcomes of clinical care. Despite this, there is limited guidance about the best methods for physicians to recognize, acknowledge, communicate about, and manage uncertainty in clinical settings. In this paper, we propose a structured approach for discussing and managing uncertainty within the context of a clinician-patient relationship. The approach involves four steps: Recognize, Acknowledge, Partner, and Seek Support (i.e., the RAPS framework). The approach is guided by existing literature on uncertainty as well as our own experience as clinicians working at different stages of career. We define each component of the approach and present sample language and actions for how to implement it in practice. Our aim is to empower clinicians to regard situations of high uncertainty as an opportunity to deepen the therapeutic alliance with the patient, and simultaneously to grow and learn as practitioners. [ABSTRACT FROM AUTHOR]

AIM: The Primary Medical Education (PRIME) program is an outpatient-based, internal medicine residency track nested within the University of California, San Francisco (UCSF) categorical medicine program. Primary Medical Education is based at the San Francisco Veteran's Affairs Medical Center (VAMC), 1 of 3 teaching hospitals at UCSF. The program accepts 8 UCSF medicine residents annually, who differentiate into PRIME after internship. In 2000, we implemented a novel research methods curriculum with the dual purposes of teaching basic epidemiology skills and providing mentored opportunities for clinical research projects during residency. SETTING: Single academic internal medicine program. PROGRAM DESCRIPTION: The PRIME curriculum utilizes didactic lecture, frequent journal clubs, work-in-progress sessions, and active mentoring to enable residents to ‘try out’ a clinical research project during residency. PROGRAM EVALUATION: Among 32 residents in 4 years, 22 residents have produced 20 papers in peer-reviewed journals, 1 paper under review, and 2 book chapters. Their clinical evaluations are equivalent to other UCSF medicine residents. DISCUSSION: While learning skills in evidence-based medicine, residents can conduct high-quality research. Utilizing a collaboration of General Internal Medicine researchers and educators, our curriculum affords residents the opportunity to ‘try-out’ clinical research as a potential future career choice. [ABSTRACT FROM AUTHOR]

Hospital discharges against medical advice (AMA) are common, costly, stigmatizing to patients, and are associated with excess morbidity and mortality. Achieving better quality care for patients discharged AMA has been limited both by the sparse research illuminating how best to care for this challenging patient population, as well as a lack of standards regarding this clinical practice. This paper will review elements of the AMA literature and highlight the gaps, including the predictors of AMA discharge, challenges to high quality informed consent in AMA discharges, problematic aspects of AMA discharge forms, and the stigma associated with patients discharged AMA. These gaps in the evidence base collectively limit the ability to adequately and completely address AMA discharges and improve health care quality. This paper will recommend future directions to answer remaining questions for the field, and offer guidance for providing ethically sound and high quality care for the affected population. Applying the widely accepted principles of patient-centered care and shared decision making to AMA discharges offers the opportunity to improve quality of care and promote ethical health care practice. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

Objective: To review the reported reliability (reproducibility, inter-examiner agreement) and validity (sensitivity, specificity and likelihood ratios) of respiratory physical examination (PE) signs, and suggest an approach to teaching these signs to medical students.Methods: Review of the literature. We searched Paper Chase between 1966 and June 2009 to identify and evaluate published studies on the diagnostic accuracy of respiratory PE signs.Results: Most studies have reported low to fair reliability and sensitivity values. However, some studies have found high specificites for selected PE signs. None of the studies that we reviewed adhered to all of the STARD criteria for reporting diagnostic accuracy.Conclusions: Possible flaws in study designs may have led to underestimates of the observed diagnostic accuracy of respiratory PE signs. The reported poor reliabilities may have been due to differences in the PE skills of the participating examiners, while the sensitivities may have been confounded by variations in the severity of the diseases of the participating patients. IMPLICATION FOR PRACTICE AND MEDICAL EDUCATION: Pending the results of properly controlled studies, the reported poor reliability and sensitivity of most respiratory PE signs do not necessarily detract from their clinical utility. Therefore, we believe that a meticulously performed respiratory PE, which aims to explore a diagnostic hypothesis, as opposed to a PE that aims to detect a disease in an asymptomatic person, remains a cornerstone of clinical practice. We propose teaching the respiratory PE signs according to their importance, beginning with signs of life-threatening conditions and those that have been reported to have a high specificity, and ending with signs that are "nice to know," but are no longer employed because of the availability of more easily performed tests. [ABSTRACT FROM AUTHOR]

Significant efforts have been invested in improving our understanding of how to accelerate and magnify the impact of research on clinical practice. While approaches to fostering translation of research into practice are numerous, none appears to be superior and the evidence for their effectiveness is mixed. Lessons learned from formative evaluation have given us a greater appreciation of the contribution of context to successful implementation of quality improvement interventions. While formative evaluation is a powerful tool for addressing context effects during implementation, lessons learned from the social sciences (including management and operations research, sociology, and public health) show us that there are also powerful preimplementation tools available to us. This paper discusses how we might integrate these tools into implementation research. We provide a theoretical framework for our need to understand organizational contexts and how organizational characteristics can alert us to situations where preimplementation tools will prove most valuable. [ABSTRACT FROM AUTHOR]

While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population. [ABSTRACT FROM AUTHOR]

A difficult ethical conundrum in clinical medicine is determining when to withdraw or withhold treatments deemed medically futile. These decisions are particularly complex when physicians have less experience with these discussions, when families and providers disagree about benefits from treatment, and when cultural disparities are involved in misunderstandings. This paper elucidates the concept of“medical futility,” demonstrates the application of futility to practical patient care decisions, and suggests means for physicians to negotiate transitions from aggressive treatment to comfort care with patients and their families. Ultimately, respect of persons and beneficent approaches can lead to ethically and morally viable solutions.J GEN INTERN MED 2004;19:1053–1056. [ABSTRACT FROM AUTHOR]

Physicians play a critical role in controlling resource use in medicine. This paper describes an innovative, interdisciplinary conference that teaches housestaff and medical students about resource and information management in the hospital setting. The objectives are to help foster communication between physicians and other members of the health care team, to improve the understanding of hospital reimbursement, and to influence attitudes toward practicing cost effectiveness. The conference structure includes the following components: case presentation by the treating physician and follow-up information provided by the primary care physician, a review of the itemized hospital bill, discussion of coding issues, discussion of hospital reimbursement comparing case data to institutional and state averages, and a summary of key take-home points and lessons. [ABSTRACT FROM AUTHOR]

Background: The Providence Diabetes Collective Impact Initiative (DCII) was designed to address the clinical challenges of type 2 diabetes and the social determinants of health (SDoH) challenges that exacerbate disease impact. Objective: We assessed the impact of the DCII, a multifaceted intervention approach to diabetes treatment that employed both clinical and SDoH strategies, on access to medical and social services. Design: The evaluation employed a cohort design and used an adjusted difference-in-difference model to compare treatment and control groups. Participants: Our study population consisted of 1220 people (740 treatment, 480 control), aged 18–65 years old with a pre-existing type 2 diabetes diagnosis who visited one of the seven Providence clinics (three treatment and four control) in the tri-county area of Portland, Oregon, between August 2019 and November 2020. Interventions: The DCII threaded together clinical approaches such as outreach, standardized protocols, and diabetes self-management education and SDoH strategies including social needs screening, referral to a community resource desk, and social needs support (e.g., transportation) to create a comprehensive, multi-sector intervention. Main Measures: Outcome measures included SDoH screens, diabetes education participation, HbA1c, blood pressure, and virtual and in-person primary care utilization, as well as inpatient and emergency department hospitalization. Key Results: Compared to patients at the control clinics, patients at DCII clinics saw an increase in diabetes education (15.5%, p<0.001), were modestly more likely to receive SDoH screening (4.4%, p<0.087), and had an increase in the average number of virtual primary care visits of 0.35 per member, per year (p<0.001). No differences in HbA1c, blood pressure, or hospitalization were observed. Conclusions: DCII participation was associated with improvements in diabetes education use, SDoH screening, and some measures of care utilization. [ABSTRACT FROM AUTHOR]

Background: Physicians' interest in the health and well-being of their patients is a tenet of medical practice. Physicians' ability to act upon this interest by caring for and about their patients is central to high-quality clinical medicine and may affect burnout. To date, a strong theoretical and empirical understanding of physician caring does not exist. To establish a practical, evidence-based approach to improve health care delivery and potentially address physician burnout, we sought to identify and synthesize existing conceptual models, frameworks, and definitions of physician caring. Methods: We performed a scoping review on physician caring. In November 2019 and September 2020, we searched PubMed MEDLINE, Embase, PsycINFO, CINAHL, and CENTRAL Register of Controlled Trials to identify conceptual models, frameworks, and definitions of physician caring. Eligible articles involved discussion or study of care or caring among medical practitioners. We created a content summary and performed thematic analysis of extracted data. Results: Of 11,776 articles, we reviewed the full text of 297 articles; 61 articles met inclusion criteria. Commonly identified concepts referenced Peabody's "secret of care" and the ethics of care. In bioethics, caring is described as a virtue. Contradictions exist among concepts of caring, such as whether caring is an attitude, emotion, or behavior, and the role of relationship development. Thematic analysis of all concepts and definitions identified six aspects of physician caring: (1) relational aspects, (2) technical aspects, (3) physician attitudes and characteristics, (4) agency, (5) reciprocity, and (6) physician self-care. Discussion: Caring is instrumental to clinical medicine. However, scientific understanding of what constitutes caring from physicians is limited by contradictions across concepts. A unifying concept of physician caring does not yet exist. This review proposes six aspects of physician caring which can be used to develop evidence-based approaches to improve health care delivery and potentially mitigate physician burnout. [ABSTRACT FROM AUTHOR]

The author discusses the innovations in clinical performance measures in healthcare delivery and administration. He refers to the recommendations of the U.S. Department of Veterans Affairs (VA) to use the electronic health record system in measuring quality of care and clinical performance. The author believes that research plays a critical role in improving the quality of care and performance of clinicians.

OBJECTIVES: To determine effectiveness and costs of different guideline dissemination and implementation strategies. DATA SOURCES: MEDLINE (1966 to 1998), HEALTHSTAR (1975 to 1998), Cochrane Controlled Trial Register (4th edn 1998), EMBASE (1980 to 1998), SIGLE (1980 to 1988), and the specialized register of the Cochrane Effective Practice and Organisation of Care group. REVIEW METHODS: INCLUSION CRITERIA: Randomized-controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series evaluating guideline dissemination and implementation strategies targeting medically qualified health care professionals that reported objective measures of provider behavior and/or patient outcome. Two reviewers independently abstracted data on the methodologic quality of the studies, characteristics of study setting, participants, targeted behaviors, and interventions. We derived single estimates of dichotomous process variables (e.g., proportion of patients receiving appropriate treatment) for each study comparison and reported the median and range of effect sizes observed by study group and other quality criteria. RESULTS: We included 309 comparisons derived from 235 studies. The overall quality of the studies was poor. Seventy-three percent of comparisons evaluated multifaceted interventions. Overall, the majority of comparisons (86.6%) observed improvements in care; for example, the median absolute improvement in performance across interventions ranged from 14.1% in 14 cluster-randomized comparisons of reminders, 8.1% in 4 cluster-randomized comparisons of dissemination of educational materials, 7.0% in 5 cluster-randomized comparisons of audit and feedback, and 6.0% in 13 cluster-randomized comparisons of multifaceted interventions involving educational outreach. We found no relationship between the number of components and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. CONCLUSIONS: Current guideline dissemination and implementation strategies can lead to improvements in care within the context of rigorous evaluative studies. However, there is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgment about how best to use the limited resources they have for quality improvement activities. [ABSTRACT FROM AUTHOR]

Background: Alcohol screening and brief intervention have demonstrated efficacy but limited effectiveness and implementation in real-world primary care settings. Objective: To evaluate the effectiveness of a computerized Relational Agent programmed to provide alcohol screening, brief intervention, and referral to treatment. We hypothesized that participants in the experimental condition would report greater reductions in their drinking and higher rates of brief intervention and referrals to specialty care compared to those in treatment as usual (TAU). Design: This was a Hybrid I implementation design and stratified RCT. Participants were randomized to TAU or Relational Agent + TAU and assessed at baseline and 3-month follow-up. Participants: A total of 178 veteran participants were recruited by referral from primary care staff after a positive alcohol screen, or via letter sent do patients screening positive during recent visit. Intervention(s): TAU involved yearly reminders to screen alcohol use and provide brief intervention and treatment referrals, as needed. The Relational Agent added an automated brief intervention, a 1-month follow-up Relational Agent visit, and referral to treatment if needed. Main Measures: We measured average drinks per day, drinking days per week, number of brief interventions, and number of referrals over 3 months. Key Results: Participants decreased their drinking in both study conditions, with no significant between-group differences on primary alcohol measures. However, Relational Agent + TAU participants evidenced greater improvements regarding negative alcohol-related consequences over 3 months, and were significantly more likely to receive a brief intervention and referral to specialty care. Conclusions: The Relational Agent successfully provided brief intervention and referred many more patients to specialty care and was able to intervene with patients with less severe drinking without increasing primary care burden. Trial Registration: clinicaltrials.gov, NCT02030288, https://clinicaltrials.gov/ct2/home [ABSTRACT FROM AUTHOR]

Background: Prior studies using aggregated data suggest that better care coordination is associated with higher performance on measures of clinical care process; it is unclear whether this relationship reflects care coordination activities of health plans or physician practices. Objective: Estimate within-plan relationships between beneficiary-reported care coordination measures and HEDIS measures of clinical process for the same individuals. Design: Mixed-effect regression models in cross-sectional data. Participants: 2013 Medicare Advantage CAHPS respondents (n=152,069) with care coordination items linked to independently collected HEDIS data on clinical processes. Main Measures: Care coordination measures assessed follow-up, whether doctors had medical records during visits, whether doctors discussed medicines being taken, how informed doctors seemed about specialist care, and help received with managing care among different providers. HEDIS measures included mammography, colorectal cancer screening, cardiovascular LDL-C screening, controlling blood pressure, 5 diabetes care measures (LDL-C screening, retinal eye exam, nephropathy, blood sugar/HbA1c <9%, LCL-C<100 mg/dL), glaucoma screening in older adults, BMI assessment, osteoporosis management for women with a fracture, and rheumatoid arthritis therapy. Key Results: For 9 of the 13 HEDIS measures, within health plans, beneficiaries who reported better care coordination also received better clinical care (p<0.05) and none of the associations went in the opposite direction; HEDIS differences between those with excellent and poor coordination exceeded 5 percentage points for 7 measures. Nine measures had positive associations (breast cancer screening, colorectal cancer screening, cardiovascular care LDL-C screening, 4 of 5 diabetes care measures, osteoporosis management, and rheumatoid arthritis therapy). Conclusions: Within health plans, beneficiaries who report better care coordination also received higher-quality clinical care, particularly for care processes that entail organizing patient care activities and sharing information among different healthcare providers. These results extend prior research showing that health plans with better beneficiary-reported care coordination achieved higher HEDIS performance scores. [ABSTRACT FROM AUTHOR]

Extant MT research has only focused on a narrow scope of healthcare-related communication: written communication (e.g., patient education, discharge instructions, and portal messages). Research may show that MT is inadequate when communicating medically focused content, but for non-healthcare-focused communication, MT provides value. Machine translation (MT) presents a tempting solution. [Extracted from the article]

General internal medicine (GIM) fellowships play an important role in the development of physician scientists and clinical educators, as well as leaders in academic medicine. Nevertheless, the challenges of developing another novel aspect to one's career, along with balancing coursework, research productivity, clinical duties, and personal life during fellowship, can be overwhelming. Similarly, successfully securing a job at the end of fellowship can be a daunting process. In this article, we discuss the foundational tenets and themes of the GIM fellowship. These themes include (1) finding your purpose and passion, with a focus on selecting research coursework and developing an area of study; (2) the role and importance of mentorship, including the various kinds of mentorship that fellows require (traditional and peer mentorship, sponsors, and coaches), as well as how to be an effective mentee; (3) securing research funding; (4) landing a job; (5) and protecting time to meet personal goals. There is an increased need for a vibrant, diverse, and successful generation of general internal medicine researchers to advance our understanding of complex issues in clinical medicine and healthcare delivery and to inform health policy. It is our hope that this piece helps to support that mission. [ABSTRACT FROM AUTHOR]

Background: While barriers to physician wellness have been well detailed, concrete solutions are lacking.Objective: We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness.Design: We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals.Participants: Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor).Approach: Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach.Key Results: Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment.Limitations: In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings.Conclusion: Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions. [ABSTRACT FROM AUTHOR]

The authors reflect on aspects regarding evidence-based medicine (EBM) and the challenges of multimorbidity. Topics discussed include the method of knowing, clinical practice guidelines on the management of single diseases, and multimorbidity agnosia. Also mentioned are heterogeneity of treatment effects (HTE), cross-design synthesis, and randomized trials in medical research.

Bedside point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. At present, no consensus exists for what POCUS curriculum is appropriate for internal medicine residency training programs. This document details the consensus-based recommendations by the Canadian Internal Medicine Ultrasound (CIMUS) group, comprising 39 members, representing 14 institutions across Canada. Guiding principles for selecting curricular content were determined a priori. Consensus was defined as agreement by at least 80% of the members on POCUS applications deemed appropriate for teaching and assessment of trainees in the core (internal medicine postgraduate years [PGY] 1-3) and expanded (general internal medicine PGY 4-5) training programs. We recommend four POCUS applications for the core PGY 1-3 curriculum (inferior vena cava, lung B lines, pleural effusion, and abdominal free fluid) and three ultrasound-guided procedures (central venous catheterization, thoracentesis, and paracentesis). For the expanded PGY 4-5 curriculum, we recommend an additional seven applications (internal jugular vein, lung consolidation, pneumothorax, knee effusion, gross left ventricular systolic function, pericardial effusion, and right ventricular strain) and four ultrasound-guided procedures (knee arthrocentesis, arterial line insertion, arterial blood gas sampling, and peripheral venous catheterization). These recommendations will provide a framework for training programs at a national level. [ABSTRACT FROM AUTHOR]

Point-of-care clinical knowledge systems play an increasingly important role in providing information for health care providers in high-resource settings, and there is evidence of strong interest among providers within low-resource settings. Unfortunately, systems developed for high-resource settings have a range of elements that make them suboptimal for low-resource settings. We discuss what a point-of-care clinical knowledge system designed for low-resource settings would ideally contain, and argue that such a system is worthy of further study and funding, towards the overarching goal of reducing global health inequity. [ABSTRACT FROM AUTHOR]

Background: Patient-reported experience measures (PREMs) are useful for assessing health care quality and safety and patients' perceptions of health care.Objective: We aimed to assess the relationship between PREMS [e.g., measures of patient-centered care (PCC)] and health care quality metrics.Design: We conducted a national survey via mail. Survey data were supplemented with US Department of Veteran Affairs (VA) administrative data.Participants: Veteran (n = 5512) VA health care users participated in the study.Main Measures: PCC measures included: patient activation; shared decision-making (SDM); empathy and holistic care; chronic illness care; perceptions of participation, respect for choices, and support; and overall health care experience. Health care quality measures included: preventive care screening receipt; chronic condition management (diabetes, hypertension); and health care utilization (hospitalizations, emergency room (ER) visits). Analyses included: bivariate comparisons of PCC measures by health care quality measures; and multivariate linear regression to identify variables associated with attaining multiple positive health care quality indicators (when controlling for potential confounders).Key Results: PREMs assessing factors relating to patient-provider communication (e.g., empathic provider care, shared decision-making) are mainly related to clinical indicators representing good chronic condition management, while those relating more broadly to health care in general (e.g., patient activation, chronic illness care) are mainly related to measures of appropriate health care use (e.g., preventive care screening receipt; potentially avoidable hospitalizations; unscheduled care, such as ER visits). When controlling for potential confounders, higher perceptions of the decision-making effectiveness component of SDM (β = 0.004, p = 0.03) and empathy and holistic care (β = 0.01, p = 0.02) showed a weak but positive relationship with attaining a greater number of positive health care quality indicators, while a weak but negative relationship emerged for perceptions of participation, respect for choices, and support (β = -0.003, p = 0.03) and overall VA experiences (β = -0.10, p = 0.04).Conclusions: PREMs that measure PCC offer rich data about health care quality while engaging patients, and considering patient experiences and preferences, in performance assessment. PREMs may be used to supplement existing performance metrics. [ABSTRACT FROM AUTHOR]

Background: Clinical-performance measurement has helped improve the quality of health-care; yet success in attaining high levels of quality across multiple domains simultaneously still varies considerably. Although many sources of variability in care quality have been studied, the difficulty required to complete the clinical work itself has received little attention.Objective: We present a task-based methodology for evaluating the difficulty of clinical-performance measures (CPMs) by assessing the complexity of their component requisite tasks.Design: Using Functional Job Analysis (FJA), subject-matter experts (SMEs) generated task lists for 17 CPMs; task lists were rated on ten dimensions of complexity, and then aggregated into difficulty composites.Participants: Eleven outpatient work SMEs; 133 VA Medical Centers nationwide.Main Measures: Clinical Performance: 17 outpatient CPMs (2000-2008) at 133 VA Medical Centers nationwide. Measure Difficulty: for each CPM, the number of component requisite tasks and the average rating across ten FJA complexity scales for the set of tasks comprising the measure.Key Results: Measures varied considerably in the number of component tasks (M = 10.56, SD = 6.25, min = 5, max = 25). Measures of chronic care following acute myocardial infarction exhibited significantly higher measure difficulty ratings compared to diabetes or screening measures, but not to immunization measures ([Formula: see text] = 0.45, -0.04, -0.05, and -0.06 respectively; F (3, 186) = 3.57, p = 0.015). Measure difficulty ratings were not significantly correlated with the number of component tasks (r = -0.30, p = 0.23).Conclusions: Evaluating the difficulty of achieving recommended CPM performance levels requires more than simply counting the tasks involved; using FJA to assess the complexity of CPMs' component tasks presents an alternate means of assessing the difficulty of primary-care CPMs and accounting for performance variation among measures and performers. This in turn could be used in designing performance reward programs, or to match workflow to clinician time and effort. [ABSTRACT FROM AUTHOR]

Background: Most existing performance measures focus on underuse of care, but there is growing interest in identifying and reducing overuse.Objective: We aimed to develop a valid and reliable electronic performance measure of overuse of screening colonoscopy in the Veterans Affairs Health Care System (VA), and to quantify overuse in VA.Design: This was a cross-sectional study with multiple cross-sections.Subjects: U.S. Veterans who underwent screening colonoscopy between 2011 and 2013.Main Measures: Overuse of screening colonoscopy, using a validated electronic measure developed by an expert workgroup.Key Results: Compared to results obtained from manual record review, the electronic measure was highly specific (97 %) for overuse, but not sensitive (20 %). After exclusion of diagnostic and high-risk screening or surveillance procedures, the validated electronic measure identified 88,754 average-risk screening colonoscopies performed in VA during 2013. Of these, 20,530 (23 %) met the definition for probable (17 %) or possible (6 %) overuse. Substantial variation in colonoscopy overuse was noted between Veterans Integrated Care Networks (VISNs) and between facilities, with a nearly twofold difference between the maximum and minimum rates of overuse at the VISN level and a nearly eightfold difference at the facility level. Overuse at the VISN and facility level was relatively stable over time.Conclusions: Overuse of screening colonoscopy can be measured reliably and with high specificity using electronic data, and is common in a large integrated healthcare system. Overuse measures, such as those we have specified through a consensus workgroup process, could be combined with underuse measures to improve the appropriateness of colorectal cancer screening. [ABSTRACT FROM AUTHOR]

BACKGROUND: Driving for older adults is a matter of balancing independence, safety and mobility, and prematurely relinquishing the car keys can impact morbidity and mortality. Discussions about “when to hang up the keys” are difficult for clinicians, drivers, and family members, and therefore are often avoided or delayed. “Advance Driving Directives” (ADDs) may facilitate conversations between health care providers and older drivers focused on prevention and advance planning for driving cessation. OBJECTIVE: To examine clinician and older driver perspectives on ADDs and driving discussions. DESIGN: Qualitative descriptive study using iterative focus groups and interviews with clinicians and drivers. PARTICIPANTS: (1) Eight practicing internal medicine physicians, physician assistants or nurse practitioners working at three university-affiliated clinics; and (2) 33 community-dwelling current drivers aged 65 years or older. APPROACH: Theme analysis of semi-structured focus groups and interviews with clinicians and older drivers was used to explore clinician and driver perspectives on “ADDs” and driving conversations. General inductive qualitative techniques were used to identify barriers and facilitators to conversations between older drivers and their healthcare providers about driving and health. KEY RESULTS: Five dominant themes emerged: (1) clinicians usually initiate conversations, but typically not until there are “red flags;” (2) drivers are open to conversations, especially if focused on prevention rather than interventions; (3) family input influences clinicians and drivers; (4) clinical setting factors like short appointments affect conversations; and (5) both clinicians and drivers thought ADDs could be useful in some situations and recommended making general questions about driving a part of routine care. CONCLUSIONS: Clinicians and older drivers often wait to discuss driving until there are specific “red flags”, but both groups support a new framework in which physicians routinely and regularly bring up driving with patients earlier in order to facilitate planning for the future. [ABSTRACT FROM AUTHOR]

BACKGROUND: Leaders in academic medicine are often selected from the ranks of physician-researchers, whose demanding careers involve multiple professional commitments that must also be balanced with demands at home. OBJECTIVE: To gain a more nuanced understanding of work–life balance issues from the perspective of a large and diverse group of faculty clinician-researchers and their mentors. DESIGN: A qualitative study with semi-structured, in-depth interviews conducted from 2010 to 2011, using inductive analysis and purposive sampling. PARTICIPANTS: One hundred former recipients of U.S. National Institutes of Health (NIH) K08 or K23 career development awards and 28 of their mentors. APPROACH: Three researchers with graduate training in qualitative methods conducted the interviews and thematically coded verbatim transcripts. KEY RESULTS: Five themes emerged related to work–life balance: (1) the challenge and importance of work–life balance for contemporary physician-researchers, (2) how gender roles and spousal dynamics make these issues more challenging for women, (3) the role of mentoring in this area, (4) the impact of institutional policies and practices intended to improve work–life balance, and (5) perceptions of stereotype and stigma associated with utilization of these programs. CONCLUSIONS: In academic medicine, in contrast to other fields in which a lack of affordable childcare may be the principal challenge, barriers to work–life balance appear to be deeply rooted within professional culture. A combination of mentorship, interventions that target institutional and professional culture, and efforts to destigmatize reliance on flexibility (with regard to timing and location of work) are most likely to promote the satisfaction and success of the new generation of clinician-researchers who desire work–life balance. [ABSTRACT FROM AUTHOR]

Although the idea of preventing type 2 diabetes has been articulated since the discovery of insulin, only in the past decade have clinical trials demonstrated that diabetes can be prevented or delayed. These trials found lifestyle intervention reduces diabetes incidence by over 50% and is more efficacious than metformin. Evidence from prevention trials comes from persons with "pre-diabetes" in which blood glucose levels are elevated but not yet in the diabetes range. In normoglycemic persons, lifestyle or drug intervention has little impact on diabetes incidence. Prevention programs are often conducted outside the clinical sector where participants' glycemic status is usually unknown; these programs may include many normoglycemic participants, which greatly reduces cost-effectiveness. An economically sustainable system for diabetes prevention will require effective partnerships among the clinical sector, community-based lifestyle programs, and third-party payers to ensure that limited resources for diabetes prevention are focused on persons at high risk of diabetes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Assessing resident well-being is becoming increasingly important from a programmatic standpoint. Two measures that have been used to assess this are the Clance Impostor Scale (CIS) and the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). However, little is known about the relationship between the two phenomena.Objectives: To explore the prevalence and association between impostorism and burnout syndrome in a sample of internal medicine residents.Design: Anonymous, cross-sectional postal survey.Participants: Forty-eight internal medicine residents (postgraduate year [PGY] 1-3) at the Schulich School of Medicine & Dentistry (62.3% response rate).Measurements and Main Results: Short demographic questionnaire, CIS and MBI-HSS. Impostorism and burnout syndrome were identified in 43.8% and 12.5% of residents, respectively. With the exception of a negative correlation between CIS scores and the MBI's personal accomplishment subscale (r = -.30; 95% CI -.54 to -.02), no other significant relations were identified. Foreign-trained residents were more likely to score as impostors (odds ratio [OR] 10.7; 95% CI 1.2 to 98.2) while senior residents were more likely to experience burnout syndrome (OR 16.5 95% CI 1.6 to 168.5).Conclusions: Both impostorism and burnout syndrome appear to be threats to resident well-being in our program. The lack of relationship between the two would suggest that programs and researchers wishing to address the issue of resident distress should consider using both measures. The finding that foreign-trained residents appear to be more susceptible to impostorism warrants further study. [ABSTRACT FROM AUTHOR]

Background: Increased clinical demands and decreased available time accentuate the need for efficient learning in postgraduate medical training. Adapting Web-based learning (WBL) to learners' prior knowledge may improve efficiency.Objective: We hypothesized that time spent learning would be shorter and test scores not adversely affected for residents who used a WBL intervention that adapted to prior knowledge.Design: Randomized, crossover trial.Setting: Academic internal medicine residency program continuity clinic.Participants: 122 internal medicine residents.Interventions: Four WBL modules on ambulatory medicine were developed in standard and adaptive formats. The adaptive format allowed learners who correctly answered case-based questions to skip the corresponding content.Measurements and Main Results: The measurements were knowledge posttest, time spent on modules, and format preference. One hundred twenty-two residents completed at least 1 module, and 111 completed all 4. Knowledge scores were similar between the adaptive format (mean +/- standard error of the mean, 76.2 +/- 0.9) and standard (77.2 +/- 0.9, 95% confidence interval [CI] for difference -3.0 to 1.0, P = .34). However, time spent was lower for the adaptive format (29.3 minutes [CI 26.0 to 33.0] per module) than for the standard (35.6 [31.6 to 40.3]), an 18% decrease in time (CI 9 to 26%, P = .0003). Seventy-two of 96 respondents (75%) preferred the adaptive format.Conclusions: Adapting WBL to learners' prior knowledge can reduce learning time without adversely affecting knowledge scores, suggesting greater learning efficiency. In an era where reduced duty hours and growing clinical demands on trainees and faculty limit the time available for learning, such efficiencies will be increasingly important. For clinical trial registration, see http://www.clinicaltrials.gov NCT00466453 ( http://www.clinicaltrials.gov/ct/show/NCT00466453?order=1 ). [ABSTRACT FROM AUTHOR]

Background: The synthesis of basic and clinical science knowledge during the clerkship years has failed to meet educational expectations.Objectives: We hypothesized that a small-group course emphasizing the basic science underpinnings of disease, Foundations of Clinical Medicine (FCM), could be integrated into third year clerkships and would not negatively impact the United States Medical Licensure Examination (USMLE) step 2 scores.Design: In 2001-2002, all third year students met weekly in groups of 8-12 clustered within clerkships to discuss the clinical and basic science aspects of prescribed, discipline-specific cases.Participants: Students completing USMLE step 2 between 1999 and 2004 (n = 743).Measurements: Course evaluations were compared with the overall institutional average. Bivariate analyses compared the mean USMLE steps 1 and 2 scores across pre- and post-FCM student cohorts. We used multiple linear regression to assess the association between USMLE step 2 scores and FCM cohort controlling for potential confounders.Results: Students' average course evaluation score rose from 66 to 77 (2001-2004) compared to an institutional average of 73. The unadjusted mean USMLE step 1 score was higher for the post-FCM cohort (212.9 vs 207.5, respectively, p < .001) and associated with step 2 scores (estimated coefficient = 0.70, p < .001). Post-FCM cohort (2002-2004; n = 361) mean step 2 scores topped pre-FCM (1999-2001; n = 382) scores (215.9 vs 207.7, respectively, p < .001). FCM cohort remained a significant predictor of higher step 2 scores after adjustment for USMLE step 1 and demographic characteristics (estimated coefficient = 4.3, p = .002).Conclusions: A curriculum integrating clinical and basic sciences during third year clerkships is feasible and associated with improvement in standardized testing. [ABSTRACT FROM AUTHOR]

Background: RIME is a descriptive framework in which students and their teachers can gauge progress throughout a clerkship from R (reporter) to I (interpreter) to M (manager) to E (educator). RIME, as described in the literature, is complemented by residents and attending physicians meeting with a clerkship director to discuss individual student progress, with group discussion resulting in assignment of a RIME stage.Objective: 1) to determine whether a student's RIME rating is associated with end-of-clerkship examination performance; and 2) to determine whose independent RIME rating is most predictive of a student's examination performance: attendings, residents, or interns.Design: Prospective cohort study.Participants: Third year medical students from academic years 2004-2005 and early 2005-2006 at 1 medical school.Measurements and Main Results: Each attending, resident, and intern independently assessed the student's final RIME stage attained. For the purpose of analysis, R stage=1, I=2, M=3, and E=4. Regression analyses were performed with examination scores as dependent variables (National Board of Medical Examiners [NBME] medicine subject examination and a clinical performance examination [CPE]), with independent variables of mean attending RIME score, mean resident score, and mean intern score. For the 122 students, significant predictors of NBME subject exam score were resident RIME rating (p = .008) and intern RIME rating (p = .02). Significant predictor of CPE performance was resident RIME rating (p = .01).Conclusion: House staff RIME ratings of students are associated with student performance on written and clinical skills examinations. [ABSTRACT FROM AUTHOR]

Background: Low health literacy and low cognitive abilities both predict mortality, but no study has jointly examined these relationships.Methods: We conducted a prospective cohort study of 3,260 community-dwelling adults age 65 and older. Participants were interviewed in 1997 and administered the Short Test of Functional Health Literacy in Adults and the Mini Mental Status Examination. Mortality was determined using the National Death Index through 2003.Measurements and Main Results: In multivariate models with only literacy (not cognition), the adjusted hazard ratio was 1.50 (95% confidence of interval [CI] 1.24-1.81) for inadequate versus adequate literacy. In multivariate models without literacy, delayed recall of 3 items and the ability to serial subtract numbers were associated with higher mortality (e.g., adjusted hazard ratios [AHR] 1.74 [95% CI 1.30-2.34] for recall of zero versus 3 items, and 1.32 [95% CI 1.09-1.60] for 0-2 vs 5 correct subtractions). In multivariate analysis with both literacy and cognition, the AHRs for the cognition items were similar, but the AHR for inadequate literacy decreased to 1.27 (95% CI 1.03 - 1.57).Conclusions: Both health literacy and cognitive abilities independently predict mortality. Interventions to improve patient knowledge and self-management skills should consider both the reading level and cognitive demands of the materials. [ABSTRACT FROM AUTHOR]

Background: Teamwork is important for improving care across transitions between providers and for increasing patient safety.Objective: This review's objective was to assess the characteristics and efficacy of published curricula designed to teach teamwork to medical students and house staff.Design: The authors searched MEDLINE, Education Resources Information Center, Excerpta Medica Database, PsychInfo, Cumulative Index of Nursing and Allied Health Literature, and Scopus for original data articles published in English between January 1980 and July 2006 that reported descriptions of teamwork training and evaluation results.Measurements: Two reviewers independently abstracted information about curricular content (using Baker's framework of teamwork competencies), educational methods, evaluation design, outcomes measured, and results.Results: Thirteen studies met inclusion criteria. All curricula employed active learning methods; the majority (77%) included multidisciplinary training. Ten curricula (77%) used an uncontrolled pre/post design and 3 (23%) used controlled pre/post designs. Only 3 curricula (23%) reported outcomes beyond end of program, and only 1 (8%) >6 weeks after program completion. One program evaluated a clinical outcome (patient satisfaction), which was unchanged after the intervention. The median effect size was 0.40 (interquartile range (IQR) 0.29, 0.61) for knowledge, 0.38 (IQR 0.32, 0.41) for attitudes, 0.41 (IQR 0.35, 0.49) for skills and behavior. The relationship between the number of teamwork principles taught and effect size achieved a Spearman's correlation of .74 (p = .01) for overall effect size and .64 (p = .03) for median skills/behaviors effect size.Conclusions: Reported curricula employ some sound educational principles and appear to be modestly effective in the short term. Curricula may be more effective when they address more teamwork principles. [ABSTRACT FROM AUTHOR]

Background: The effects of disclosing financial interests to potential research participants are not well understood.Objective: To examine the effects of financial interest disclosures on potential research participants' attitudes toward clinical research.Design and Participants: Computerized experiment conducted with 3,623 adults in the United States with either diabetes mellitus or asthma, grouped by lesser and greater severity. Respondents read a description of a hypothetical clinical trial relevant to their diagnosis that included a financial disclosure statement. Respondents received 1 of 5 disclosure statements.Measurements: Willingness to participate in the hypothetical clinical trial, relative importance of information about the financial interest, change in trust after reading the disclosure statement, surprise regarding the financial interest, and perceived effect of the financial interest on the quality of the clinical trial.Results: Willingness to participate in the hypothetical clinical trial did not differ substantially among the types of financial disclosures. Respondents viewed the disclosed information as less important than other factors in deciding to participate. Disclosures were associated with some respondents trusting the researchers less, although trust among some respondents increased. Most respondents were not surprised to learn of financial interests. Researchers owning equity were viewed as more troubling than researchers who were compensated for the costs of research through per capita payments.Conclusions: Aside from a researcher holding an equity interest, the disclosure to potential research participants of financial interests in research, as recommended in recent policies, is unlikely to affect willingness to participate in research. [ABSTRACT FROM AUTHOR]

Background: The growing interest in pay-for-performance and other quality improvement programs has generated concerns about potential performance measurement penalties for providers who care for more complex patients, such as patients with more chronic conditions. Few data are available on how multimorbidity affects common performance metrics.Objective: To examine the relationship between multimorbidity and patients' ratings of communication, a common performance metric.Design: Cross-sectional studySetting: Nationally representative sample of U.S. residentsParticipants: A total of 15,709 noninstitutionalized adults living in the United States participated in a telephone interview.Measurements: We used 2 different measures of multimorbidity: 1) "individual conditions" approach disregards similarities/concordance among chronic conditions and 2) "condition-groups" approach considers similarities/concordance among conditions. We used a composite measure of patients' ratings of patient-physician communication.Results: A higher number of individual conditions is associated with lower ratings of communication, although the magnitude of the relationship is small (adjusted average communication scores: 0 conditions, 12.20; 1-2 conditions, 12.06; 3+ conditions, 11.90; scale range 5 = worst, 15 = best). This relationship remains statistically significant when concordant relationships among conditions are considered (0 condition groups 12.19; 1-2 condition groups 12.03; 3+ condition groups 11.94).Conclusions: In our nationally representative sample, patients with more chronic conditions gave their doctors modestly lower patient-doctor communication scores than their healthier counterparts. Accounting for concordance among conditions does not widen the difference in communication scores. Concerns about performance measurement penalty related to patient complexity cannot be entirely addressed by adjusting for multimorbidity. Future studies should focus on other aspects of clinical complexity (e.g., severity, specific combinations of conditions). [ABSTRACT FROM AUTHOR]

Some experts have argued that patients should routinely be told the specific magnitude and absolute probability of potential risks and benefits of screening tests. This position is motivated by the idea that framing risk information in ways that are less precise violates the ethical principle of respect for autonomy and its application in informed consent or shared decision-making. In this Perspective, we consider a number of problems with this view that have not been adequately addressed. The most important challenges stem from the danger that patients will misunderstand the information or have irrational responses to it. Any initiative in this area should take such factors into account and should consider carefully how to apply the ethical principles of respect for autonomy and beneficence. [ABSTRACT FROM AUTHOR]

Addressing upstream or fundamental causes (such as poverty, limited education, and compromised healthcare access) is essential to reduce healthcare disparities. But such approaches are not sufficient, and downstream interventions, addressing the consequences of those fundamental causes within the context of any existing health system, are also necessary. We present a definition of healthcare disparities and two key principles (that healthcare is a social good and disparities in outcomes are a quality problem) that together provide a framework for addressing disparities downstream. Adapting the chronic care model, we examine a hierarchy of three domains for interventions (health system, provider-patient interactions, and clinical decision making) to reduce disparities downstream and discuss challenges to implementing the necessary changes. [ABSTRACT FROM AUTHOR]

Computerized physician order entry (CPOE) with clinical decision support (CDS) has been promoted as an effective strategy to prevent the development of a drug injury defined as an adverse drug event (ADE). To systematically review studies evaluating the effects of CPOE with CDS on the development of an ADE as an outcome measure. PUBMED versions of MEDLINE (from inception through March 2007) were searched to identify relevant studies. Reference lists of included studies were also searched. We searched for original investigations, randomized and nonrandomized clinical trials, and observational studies that evaluated the effect of CPOE with CDS on the rates of ADEs. The studies identified were assessed to determine the type of computer system used, drug categories being evaluated, types of ADEs measured, and clinical outcomes assessed. Of the 543 citations identified, 10 studies met our inclusion criteria. These studies were grouped into categories based on their setting: hospital or ambulatory; no studies related to the long-term care setting were identified. CPOE with CDS contributed to a statistically significant ( P ≤ .05) decrease in ADEs in 5 (50.0%) of the 10 studies. Four studies (40.0%) reported a nonstatistically significant reduction in ADE rates, and 1 study (10.0%) demonstrated no change in ADE rates. Few studies have measured the effect of CPOE with CDS on the rates of ADEs, and none were randomized controlled trials. Further research is needed to evaluate the efficacy of CPOE with CDS across the various clinical settings. [ABSTRACT FROM AUTHOR]

Background: Older adults are commonly prescribed sedative-hypnotic (SH) medications when hospitalized, yet these drugs are associated with important adverse effects such as falls and delirium.Objective: To identify provider-perceived benefits or barriers of a computer-based reminder regarding appropriate use of SH medications.Design: Qualitative study using semi-structured interviews.Participants and Setting: Thirty-six house staff physicians at a university hospital.Measurements: Information was collected regarding the experiences of prescribing an SH using a computer order entry system with a reminder intervention. Clinicians were asked about their perceptions of the reminder and what they found most and least useful about it. Responses were analyzed using grounded theory methodology.Results: The 36 participants (including 29 interns) had prescribed an SH medication for a hospitalized patient over age 65 years. Three themes associated with benefits of a computer reminder were identified: increasing awareness of safety, including risk of delirium, falls, and general patient safety risks; usefulness of information technology; and the value of the educational content, including geriatric pharmacology review and nonpharmacologic treatment options. Barriers included the demands of the reminder with regard to time needed to read the reminder, the role of clinician experience with regard to preserving clinical autonomy, and the information content of the reminder, including its being too basic or not relevant for a particular patient. The mean satisfaction rating for the reminder was 8.5 (+/-0.9 SD), with 10 indicating high satisfaction.Conclusions: Improving decision support systems involves an understanding of how clinicians respond to real-time strategies encouraging better prescribing. [ABSTRACT FROM AUTHOR]

Colorectal cancer (CRC) screening has been supported by strong research evidence and recommended in clinical practice guidelines for more than a decade. Yet screening rates in the United States remain low, especially relative to other preventable diseases such as breast and cervical cancer. To understand the reasons, the National Cancer Institute and Agency for Healthcare Research and Quality sponsored a review of CRC screening implementation in primary care and a program of research funded by these organizations. The evidence base for improving CRC screening supports the value of a New Model of Primary Care Delivery: 1. a team approach, in which responsibility for screening tasks is shared among other members of the practice, would help address physicians' lack of time for preventive care; 2. information systems can identify eligible patients and remind them when screening is due; 3. involving patients in decisions about their own care may enhance screening participation; 4. monitoring practice performance, supported by information systems, can help target patients at increased risk because of family history or social disadvantage; 5. reimbursement for services outside the traditional provider-patient encounter, such as telephone and e-mail contacts, may foster enhanced screening delivery; 6. training opportunities in communication, cultural competence, and use of information technologies would improve provider competence in core elements of screening programs. Improvement in CRC screening rates largely depends on the efforts of primary care practices to implement effective systems and procedures for screening delivery. Active engagement and support of practices are essential for the enormous potential of CRC screening to be realized. [ABSTRACT FROM AUTHOR]

The quality of diabetes care delivered to patients falls below the expectations of practice guidelines and clinical trial evidence. Studies in many jurisdictions with varying health care systems have shown that recommended processes of care occur less often than they should; hence, outcomes of care are inadequate. Many studies comparing care between specialists and generalists have found that specialists are more likely to implement processes of care. However, this provides little insight into improving quality of care, as the difference between specialists and generalists in these studies is small compared to the overall deficiency in quality. Therefore, future research should instead focus on ways to implement high quality care, regardless of specialty. To date, few methodologically rigorous studies have uncovered interventions that can improve quality of care. The development of such interventions to help all physicians implement better quality care could greatly benefit people with diabetes. [ABSTRACT FROM AUTHOR]

Background: Reactions to uncertainty in clinical medicine can affect decision making.Objective: To assess the extent to which radiologists' reactions to uncertainty influence diagnostic mammography interpretation.Design: Cross-sectional responses to a mailed survey assessed reactions to uncertainty using a well-validated instrument. Responses were linked to radiologists' diagnostic mammography interpretive performance obtained from three regional mammography registries.Participants: One hundred thirty-two radiologists from New Hampshire, Colorado, and Washington.Measurement: Mean scores and either standard errors or confidence intervals were used to assess physicians' reactions to uncertainty. Multivariable logistic regression models were fit via generalized estimating equations to assess the impact of uncertainty on diagnostic mammography interpretive performance while adjusting for potential confounders.Results: When examining radiologists' interpretation of additional diagnostic mammograms (those after screening mammograms that detected abnormalities), a 5-point increase in the reactions to uncertainty score was associated with a 17% higher odds of having a positive mammogram given cancer was diagnosed during follow-up (sensitivity), a 6% lower odds of a negative mammogram given no cancer (specificity), a 4% lower odds (not significant) of a cancer diagnosis given a positive mammogram (positive predictive value [PPV]), and a 5% higher odds of having a positive mammogram (abnormal interpretation).Conclusion: Mammograms interpreted by radiologists who have more discomfort with uncertainty have higher likelihood of being recalled. [ABSTRACT FROM AUTHOR]

Incorporating evidence-based medicine (EBM) into clinical practice is an important competency that residency training must address. Residency program directors, and the clinical educators who work with them, should develop curricula to enhance residents' capacity for independent evidence-based practice. In this article, the authors argue that residency programs must move beyond journal club formats to promote the practice of EBM by trainees. The authors highlight the limitations of journal club, and suggest additional curricular approaches for an integrated EBM curriculum. Helping residents become effective evidence users will require a sustained effort on the part of residents, faculty, and their educational institutions. [ABSTRACT FROM AUTHOR]

Recent research underscores the gaps that exist between evidence-based medical practices and the care that many patients actually receive. Recognizing this, large purchasers are experimenting with new reimbursement arrangements called pay-for-performance (P4P) that tie a portion of payments for physician services to measures of quality. Agency theory, from the discipline of economics, provides a perspective on the challenges P4P is likely to encounter. The focus of most P4P initiatives on medical group performance raises additional questions about its potential effectiveness as a catalyst for change. [ABSTRACT FROM AUTHOR]

BACKGROUND: Older adults with dementia may have diminished capacity to make medical treatment decisions. OBJECTIVE: To examine rates and neuropsychological predictors of treatment decision making, or consent capacity, among older adults with dementia over 9 months. DESIGN: Consent capacity was assessed initially and 9 months later in subjects with and without dementia using a longitudinal repeated measures design. PARTICIPANTS: Fifty-three older adults with dementia and 53 similarly aged adults without dementia. MEASUREMENTS: A standardized measure MacArthur Competence Assessment Toot-Treatment of 4 legal standards for capacity (Understanding, Appreciation, Reasoning, and Expressing a Choice) and a neuropsychological battery. RESULTS: In the dementia group, 9.4% had impaired capacity initially. and 26.4% had impaired capacity at 9 months. Mean scores in the dementia group were impaired relative to controls initially and at 9 months for Understanding (initial t=2.49, P=.01: 9-month t=3.22, P<.01) and Reasoning (initial t=2.18, P=.03; 9-month t=4.77. P<.01) Declining capacity over 9 months was attributable to a further reduction in Reasoning (group ⊗ time F=9.44. P=.0031. Discriminant function analysis revealed that Initial scores on naming, delayed Logical Memory, and Trails B were associated with impaired capacity at 9 months. CONCLUSIONS: Some patients with mild-to-moderate dementia develop a clinically relevant impairment of consent capacity within a year. Consent capacity in adults with mild-to-moderate dementia should be reassessed periodically to ensure that it is adequate for each specific informed consent situation. Interventions that maximize Understanding and Reasoning by supporting naming, memory, and flexibility may help to optimize capacity in this patient group. [ABSTRACT FROM AUTHOR]

Context: Optimal ages of breast cancer screening cessation remain uncertain.Objective: To evaluate screening policies based on age and quartiles of life expectancy (LE).Design and Population: We used a stochastic model with proxies of age-dependent biology to evaluate the incremental U.S. societal costs and benefits of biennial screening from age 50 until age 70, 79, or lifetime.Main Outcome Measures: Discounted incremental costs per life years saved (LYS).Results: Lifetime screening is expensive (151,434 dollars per LYS) if women have treatment and survival comparable to clinical trials (idealized); stopping at age 79 costs 82,063 dollars per LYS. This latter result corresponds to costs associated with an LE of 9.5 years at age 79, a value expected for 75% of 79-year-olds, about 50% of 80-year-olds, and 25% of 85-year-olds. Using actual treatment and survival patterns, screening benefits are greater, and lifetime screening of all women might be considered (114,905 dollars per LYS), especially for women in the top 25% of LE for their age (50,643 dollars per LYS, life expectancy of approximately 7 years at age 90).Conclusions: If all women receive idealized treatment, the benefits of mammography beyond age 79 are too low relative to their costs to justify continued screening. However, if treatment is not ideal, extending screening beyond age 79 could be considered, especially for women in the top 25% of life expectancy for their age. [ABSTRACT FROM AUTHOR]

This study explores the alignment between physicians' confidence in their diagnoses and the“correctness” of these diagnoses, as a function of clinical experience, and whether subjects were prone to over-or underconfidence.Prospective, counterbalanced experimental design.Laboratory study conducted under controlled conditions at three academic medical centers.Seventy-two senior medical students, 72 senior medical residents, and 72 faculty internists.We created highly detailed, 2-to 4-page synopses of 36 diagnostically challenging medical cases, each with a definitive correct diagnosis. Subjects generated a differential diagnosis for each of 9 assigned cases, and indicated their level of confidence in each diagnosis.A differential was considered“correct” if the clinically true diagnosis was listed in that subject's hypothesis list. To assess confidence, subjects rated the likelihood that they would, at the time they generated the differential, seek assistance in reaching a diagnosis. Subjects' confidence and correctness were“mildly” aligned (κ=.314 for all subjects, .285 for faculty, .227 for residents, and .349 for students). Residents were overconfident in 41% of cases where their confidence and correctness were not aligned, whereas faculty were overconfident in 36% of such cases and students in 25%.Even experienced clinicians may be unaware of the correctness of their diagnoses at the time they make them. Medical decision support systems, and other interventions designed to reduce medical errors, cannot rely exclusively on clinicians' perceptions of their needs for such support. [ABSTRACT FROM AUTHOR]

The article discusses a clinical case presentation involving rash, arthralgias, and injection drug use. Based on the clinical facts presented regarding the case of a 45-year old man with rash and arthralgias, it can be noted that mixed cyroglobulinemia is related to chronic hepatitis C infection (HCV) and that patients with HCV infection may have a rheumatoid factor reaching 95 percent. The clinical features of cyroglobulinemia are provided.