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BackgroundApproximately 30% of total US health care spending is thought to be "wasted" on activities like unnecessary and inefficiently delivered services.ObjectivesTo assess the perceptions of clinic-based physicians regarding their use of time and appropriateness of care provided.DesignCross-sectional online survey of all Southern California Permanente Medical Group partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers.Main outcome measuresThe proportion of time spent on direct patient care tasks perceived to require the respondent's clinical/specialty training as a physician or another physician who has similar years of clinical training (vs physicians with fewer years of clinical training, nonphysicians, or automated or computerized systems), and the proportion of care provided by the respondent and by other physicians with whom they are familiar that is perceived to be appropriate (vs equivocal or inappropriate).ResultsMore than 61% of respondents indicated that 15% of their time spent on direct patient care could be shifted to nonphysicians, and between 10% and 16% of care provided was equivocal or inappropriate.DiscussionThe low proportion of care perceived as equivocal or inappropriate indicates there is little room for reducing such care or that physicians have difficulty assessing care appropriateness. The latter suggests that attempts to reduce or to eliminate inappropriate care may be unsuccessful until physician beliefs, knowledge, or behaviors are better understood and addressed.ConclusionOn the basis of these findings, it is apparent that within at least one health care system, the opportunity to increase value through task shifting and avoiding inappropriate care is more narrow than commonly perceived on a national level.

ContextFor health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties.ObjectiveTo assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system.DesignCross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers.Main outcome measuresPrimary measure was satisfaction with one's day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income.ResultsOf the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2-9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income.ConclusionIt is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction.

ObjectiveSeveral barriers challenge resident engagement in learning quality improvement (QI). We investigated whether the incorporation of team-based game mechanics into an evidence-based online learning platform could increase resident participation in a QI curriculum.DesignRandomized, controlled trial.SettingTertiary-care medical center residency training programs.ParticipantsResident physicians (n = 422) from nine training programs (anesthesia, emergency medicine, family medicine, internal medicine, ophthalmology, orthopedics, pediatrics, psychiatry and general surgery) randomly allocated to a team competition environment (n = 200) or the control group (n = 222).InterventionSpecialty-based team assignment with leaderboards to foster competition, and alias assignment to de-identify individual participants.Main outcome measuresParticipation in online learning, as measured by percentage of questions attempted (primary outcome) and additional secondary measures of engagement (i.e. response time). Changes in participation measures over time between groups were assessed with a repeated measures ANOVA framework.ResultsResidents in the intervention arm demonstrated greater participation than the control group. The percentage of questions attempted at least once was greater in the competition group (79% [SD ± 32] versus control, 68% [SD ± 37], P= 0.03). Median response time was faster in the competition group (P= 0.006). Differences in participation continued to increase over the duration of the intervention, as measured by average response time and cumulative percent of questions attempted (each P< 0.001).ConclusionsTeam competition increases resident participation in an online course delivering QI content. Medical educators should consider game mechanics to optimize participation when designing learning experiences.

ObjectivesDespite the potential benefits of shared decision-making (SDM), its integration into emergency care is challenging. Emergency physician (EP) perceptions about the frequency with which they use SDM, its potential to reduce medically unnecessary diagnostic testing, and the barriers to employing SDM in the emergency department (ED) were investigated.MethodsAs part of a larger project examining beliefs on overtesting, questions were posed to EPs about SDM. Qualitative analysis of two multispecialty focus groups was done exploring decision-making around resource use to generate survey items. The survey was then pilot-tested and revised to focus on advanced diagnostic imaging and SDM. The final survey was administered to EPs recruited at four emergency medicine (EM) conferences and 15 ED group meetings. This report addresses responses regarding SDM.ResultsA purposive sample of 478 EPs from 29 states were approached, of whom 435 (91%) completed the survey. EPs estimated that, on average, multiple reasonable management options exist in over 50% of their patients and reported employing SDM with 58% of such patients. Respondents perceived SDM as a promising solution to reduce overtesting. However, despite existing research to the contrary, respondents also commonly cited beliefs that 1) "many patients prefer that the physician decides," 2) "when offered a choice, many patients opt for more aggressive care than they need," and 3) "it is too complicated for patients to know how to choose."ConclusionsMost surveyed EPs believe SDM is a potential high-yield solution to overtesting, but many perceive patient-related barriers to its successful implementation.

Study objectivesTo characterize the nature and impact of sleep disturbances on quality of life (QOL) in women with interstitial cystitis/bladder pain syndrome (IC/BPS).MethodsParticipants were 3,397 women from a telephone probability survey who met IC/BPS symptom criteria. Sleep quality, duration, and IC/BPS nocturnal symptoms (i.e., trouble sleeping due to bladder pain, urgency, or needing to use the bathroom), general QOL (mental and physical health and sexual functioning), and IC/BPS QOL impairment were assessed via self-report during telephone interview.ResultsOver half of the sample reported poor sleep quality, sleep duration ≤ 6 hours, or trouble sleeping due to IC/BPS symptoms. After covariate adjustment, short sleep duration was significantly associated with greater IC/BPS QOL impairment (β = -0.04; p < 0.001) and poorer self-reported physical health (β = 1.86; p < 0.001). Poor sleep quality was significantly associated with greater IC/BPS QOL impairment (β = 0.06; p < 0.001), poorer self-reported physical health (β = -2.86; p < 0.001), and greater sexual dysfunction (β = -0.04; p < 0.05). IC/BPS nocturnal symptoms were significantly associated with greater IC/BPS impairment (β = 0.14; p < 0.001), poorer physical health (β = -2.76; p < 0.001) and mental health (β = 0.52; p < 0.01), and greater sexual dysfunction (β = -0.10; p < 0.001), after covariate adjustment. After further adjustment for IC/BPS nocturnal symptoms, we found that poor sleep quality and short sleep duration were independent correlates of poor self-reported physical health.ConclusionsPoor sleep quality and short sleep duration, as well as disorder-specific sleep disturbances, are highly prevalent in women with IC/BPS and are associated with poorer disease-specific and general QOL.

Introduction and hypothesisThe persistence of interstitial cystitis/bladder pain syndrome (IC/BPS) symptoms has been described in women seeking medical care. The purpose of this study was to determine whether symptoms persist among a population-based sample of women.MethodsA probability sample of US women was identified through a two-stage telephone screening process using the Research and Development (RAND) Interstitial Cystitis Epidemiology (RICE) high-sensitivity case definition. A randomly selected subgroup (n = 508) was enrolled in a longitudinal study and interviewed about their symptoms at baseline, 3, 6, 9, and 12 months. Bivariate and multivariate linear regression analyses determined predictors of persistence of symptoms over the four waves.ResultsA total of 436 women with a mean age of 47.5 years responding to all waves were included in the analysis. Forty-one percent met the RICE high-sensitivity case definition at baseline and in all four waves; an additional 21 % met the definition at baseline and in three waves. Women with a college degree (+12 % vs. no college, p = 0.02) and who were younger (-5 % per decade of age, p

PurposeTo estimate the association of chronic non-urologic conditions [i.e., fibromyalgia (FM), chronic fatigue syndrome (CFS), and irritable bowel syndrome (IBS)] with health-related quality of life (HRQOL) in patients with interstitial cystitis/bladder pain syndrome (IC/BPS).MethodsA total of 276 women with established diagnoses of IC/BPS completed a telephone interview which included demographics, self-reported medical conditions, the SF-36 health survey, and the interstitial cystitis symptom index (ICSI). Multivariate linear regression analysis was used to identify correlates of SF-36 physical and mental component summary scores.ResultsMean patient age was 45.1 (SD 15.9) years, and 83% of the subjects were white. Mean values for the SF-36 Physical Component Score (PCS) and Mental Component Score (MCS) means were 39 (SD 14) and 45 (SD 12), respectively, indicating significant HRQOL reductions. Mean ICSI score was 11.27 (SD = 4.86). FM and IBS were significantly associated with worse SF-36 scores: -8 points on the PCS (p < 0.001) and -6 points on the MCS (p < 0.001). CFS and the presence of other pelvic conditions (overactive bladder, vulvodynia, endometriosis) were not significantly associated with SF-36 PCS and MCS scores.ConclusionsIn patients with IC/BPS, the presence of FM, CFS, and IBS has a significant association with HRQOL, equivalent in impact to the bladder symptoms themselves. These results emphasize the importance of a multidisciplinary approach to treating patients with IC/BPS and other conditions.

PurposeAs part of the RICE (RAND Interstitial Cystitis Epidemiology) study, we developed validated case definitions to identify interstitial cystitis/bladder pain syndrome in women and chronic prostatitis/chronic pelvic pain syndrome in men. Using population based screening methods, we applied these case definitions to determine the prevalence of these conditions in men.Materials and methodsA total of 6,072 households were contacted by telephone to screen for men who had symptoms of interstitial cystitis/bladder pain syndrome or chronic prostatitis/chronic pelvic pain syndrome. An initial 296 men screened positive, of whom 149 met the inclusionary criteria and completed the telephone interview. For interstitial cystitis/bladder pain syndrome 2 case definitions were applied (1 with high sensitivity and 1 with high specificity), while for chronic prostatitis/chronic pelvic pain syndrome a single case definition (with high sensitivity and specificity) was used. These case definitions were used to classify subjects into groups based on diagnosis.ResultsThe interstitial cystitis/bladder pain syndrome weighted prevalence estimates for the high sensitivity and high specificity definitions were 4.2% (3.1-5.3) and 1.9% (1.1-2.7), respectively. The chronic prostatitis/chronic pelvic pain syndrome weighted prevalence estimate was 1.8% (0.9-2.7). These values equate to 1,986,972 (95% CI 966,042-2,996,924) men with chronic prostatitis/chronic pelvic pain syndrome and 2,107,727 (95% CI 1,240,485-2,974,969) men with the high specificity definition of interstitial cystitis/bladder pain syndrome in the United States. The overlap between men who met the high specificity interstitial cystitis/bladder pain syndrome case definition or the chronic prostatitis/chronic pelvic pain syndrome case definition was 17%.ConclusionsSymptoms of interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome are widespread among men in the United States. The prevalence of interstitial cystitis/bladder pain syndrome symptoms in men approaches that in women, suggesting that this condition may be underdiagnosed in the male population.

The Sexual Acquisition and Transmission of HIV Cooperative Agreement Program (SATHCAP) examined the role of drug use in the sexual transmission of the human immunodeficiency virus (HIV) from traditional high-risk groups, such as men who have sex with men (MSM) and drug users (DU), to lower risk groups in three US cities and in St. Petersburg, Russia. SATHCAP employed respondent-driven sampling (RDS) and a dual high-risk group sampling approach that relied on peer recruitment for a combined, overlapping sample of MSM and DU. The goal of the sampling approach was to recruit an RDS sample of MSM, DU, and individuals who were both MSM and DU (MSM/DU), as well as a sample of sex partners of MSM, DU, and MSM/DU and sex partners of sex partners. The approach efficiently yielded a sample of 8,355 participants, including sex partners, across all four sites. At the US sites—Los Angeles, Chicago, and Raleigh–Durham—the sample consisted of older (mean age = 41 years), primarily black MSM and DU (both injecting and non-injecting); in St. Petersburg, the sample consisted of primarily younger (mean age = 28 years) MSM and DU (injecting). The US sites recruited a large proportion of men who have sex with men and with women, an important group with high potential for establishing a generalized HIV epidemic involving women. The advantage of using the dual high-risk group approach and RDS was, for the most part, the large, efficiently recruited samples of MSM, DU, and MSM/DU. The disadvantages were a recruitment bias by race/ethnicity and income status (at the US sites) and under-enrollment of MSM samples because of short recruitment chains (at the Russian site).

Pay-for-performance is being applied at the physician level to stimulate improvements in quality of care and cost efficiency; however, little is known about how physicians will respond. We interviewed physicians [...]

This study used multiple-group structural equation modeling to test a model explaining the association between exposure to televised sexual content and initiation of intercourse among all ethnically diverse national sample of 1,292 adolescents. The authors hypothesized, on the basis of social cognitive theory, that exposure to televised sexual content would influence adolescents' safe-sex sell' efficacy, sex-related outcome expectancies, and perceived peer norms regarding sex, and that each of these would, in turn, influence intercourse initiation. Findings support a model in which the relationship between exposure to TV's sexual content and intercourse initiation is mediated by safe-sex self-efficacy among African Americans and Whites but not among Hispanics. Outcome expectancies and perceived peer norms may also mediate the link between exposure and intercourse initiation among all 3 racial/ethnic groups, although evidence of this could not be confirmed. Keywords: adolescent sexual behavior, intercourse initiation, social cognitive theory, television

This article examines the evolution of psychological and behavioral reactions following the September 2001 terrorist attacks in a nationally representative sample, and describes where people turned for support, information, and counseling. From November 9 to November 28, 2001, we resurveyed 395 (71%) of the original 560 adults 19 years or older within the United States who participated in our national random-digit-dialing telephone survey conducted on September 14 to September 16, 2001, about their terrorism-related psychological distress and behavior. Sixteen percent of adults had persistent distress, reporting one or more substantial distress symptoms in both September and November. Adults with persistent distress reported accomplishing less at work (65%); avoiding public gathering places (24%); and using alcohol, medications, or other drugs to relax, sleep, or feel better because of worries about terrorism (38%). Seventy-five percent talked with family and friends; however, 43% reported sometimes feeling unable to share their terrorism-related thoughts and feelings with others because it made others uncomfortable. Few reported receiving counseling or information about psychological distress from general medical providers (11%). These findings suggest that a significant number of adults across the country were continuing to experience terrorism-related distress and disruption of their daily lives approximately 2 months after September 11; many turned to family and friends for support, but at times many felt uncomfortable doing so, and few used clinicians as a source of information or support. Clinicians and policymakers should consider how the healthcare system and other community organizations might provide a coordinated community-wide response for individuals needing information and counseling following terrorist events.

Context. Television is often decried as a negative influence on the sexual attitudes and behavior of America&apos;s adolescents. However, television occasionally includes messages about the risks of having sex that may have a positive effect on youth. Objective. To assess the impact of condom-efficacy messages in an episode of Friends on teens. Design, Setting, and Participants. A national sample of 506 adolescents 12 to 17 years old who had been regular viewers of Friends the previous year were surveyed by telephone shortly after the episode aired. Outcome Measures. Viewership of the Friends episode, recall of the condom-efficacy message, beliefs about condoms, self-reported change in condom knowledge, and discussions of condom efficacy with parents. Results. At least 27% of the sample saw the episode, and 65% of these viewers recalled its depiction of condom failure resulting in pregnancy. Forty percent of the viewers watched with an adult. Ten percent of viewers talked to an adult about condom efficacy as a result of the show. Compared with other viewers, youth who talked with an adult were more likely to report learning about condoms from the episode and appeared less likely to reduce their perceptions of condom efficacy after the episode. Conclusions. Entertainment television can serve as a healthy sex educator and can work in conjunction with parents to improve adolescent sexual knowledge. Pediatrics 2003;112:1115-1121; entertainment television, condoms, teens, media, sex., ABBREVIATION. TAS, Television and Adolescent Sexuality (study). Forty-six percent of all high school students in the United States have had sex, and rates of sexually transmitted diseases and unintended pregnancy [...]

Doctors and hospitals spend about 6.5% more on cancer patients who are enrolled in clinical trials than on cancer patients who are not, according to a study of 1,628 cancer patients. This added up to $16 million more in 1999 for all clinical trials sponsored by the US National Cancer Institute. More money was spent on cancer patients who died while participating in a clinical trial than on other cancer patients who died.

The authors discuss HIV care in rural areas. The research results indicate the functional health illiteracy in these areas, revealing that high percentage of patients have difficulties in understanding medical information, and that the studies based on medical record review and patient interviews demonstrate that there are potential limitations in health services.

HIV patients who live in rural areas are not receiving appropriate treatment, perhaps because they are treated by doctors who have little experience treating HIV patients. In a study of 367 HIV patients in rural areas and 2,806 HIV patients in urban areas, those in rural areas were less likely to take highly active antiretroviral therapy (HAART) or drugs to prevent Pneumocystis carinii pneumonia.

About 90% of all Americans may have experienced stress resulting from the attacks on the World Trade Center and the Pentagon, according to a survey of 560 Americans between three and five days after the attacks. Doctors should be prepared to assist people with stress even if they live far from the scene of the event.

The cost of treating HIV infection has decreased since the use of highly active antiretroviral therapy (HAART). Between 1996 and 1998, the annual cost per patient dropped from $20,300 to $18, 300. Although the drugs are expensive, a reduction in hospital costs produced a net savings.