Anita Varkey

Working Conditions in Primary Care: Physician Reactions and Care Quality

BACKGROUND Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care. OBJECTIVE To assess the relationship among adverse primary care work conditions, adverse physician reactions (stress, burnout, and intent to leave), and patient care. DESIGN Cross-sectional analysis. SETTING 119 ambulatory clinics in New York, New York, and in the upper Midwest. PARTICIPANTS 422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure. MEASUREMENTS Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits). RESULTS More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors. LIMITATION The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician. CONCLUSION Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care.

Chronic obstructive pulmonary disease in women: exploring gender differences

Purpose of review Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality throughout the world. This major public health threat is ranked twelfth as a worldwide burden of disease and is projected to rank fifth by the year 2020 as a cause of lost quantity and quality of life. The impact of this disease in women is significantly understudied but the evidence that does exist reveals potentially substantial gender differences in the susceptibility to, severity of, and response to management of COPD. Recent findings The best known risk factor for the development of COPD is tobacco smoking. While smoking rates in women have largely stabilized in developed countries, the rates are continuing to climb in developing countries. While it is not clear whether women are more susceptible to the toxic effects of cigarette smoke than men, it is known that the incidence and prevalence of COPD will continue to climb as more women smoke. Other known risk factors for the development of COPD include air pollution, infections, occupational exposures, and genetic factors. Air pollution, particularly fine particulate indoor air pollution from biomass fuels disproportionately affects women. Infections such as human immunodeficiency virus (HIV) and tuberculosis (TB) disproportionately affect vulnerable populations such as poor women and occupational exposures to various dusts and toxins are often gender specific. Genetic factors are still being explored but there seems a preponderance of women who are affected by early-onset and non-smoking related COPD. Women with COPD also seem to be underdiagnosed by physicians and may have different responses to medical treatment, smoking cessation interventions, and pulmonary rehabilitation programs. Summary Chronic obstructive pulmonary disease in women is an understudied subject but is gaining attention as a significant public health threat. In developed countries, efforts at preventing the initiation of tobacco smoking and targeting smoking cessation programs in women are needed. In developing countries, efforts to promote cleaner fuels, improved stoves, better home ventilation, reduce toxic dust and fume exposures, combat infectious diseases such as TB and HIV, and improve nutrition are all ways in which the lung health of women can be improved.

Separate and Unequal: Clinics Where Minority and Nonminority Patients Receive Primary Care

BACKGROUND Few studies have examined the influence of physician workplace conditions on health care disparities. We compared 96 primary care clinics in New York, New York, and in the upper Midwest serving various proportions of minority patients to determine differences in workplace organizational characteristics. METHODS Cross-sectional data are from surveys of 96 clinic managers, 388 primary care physicians, and 1701 of their adult patients with hypertension, diabetes mellitus, or congestive heart failure participating in the Minimizing Error, Maximizing Outcome (MEMO) study. Data from 27 clinics with at least 30% minority patients were contrasted with data from 69 clinics with less than 30% minority patients. RESULTS Compared with clinics serving less than 30% minority patients, clinics serving at least 30% minority patients have less access to medical supplies (2.7 vs 3.4, P < .001), referral specialists (3.0 vs 3.5, P < .005) on a scale of 1 (none) to 4 (great), and examination rooms per physician (2.2 vs 2.7, P =.002) . Their patients are more frequently depressed (22.8% vs 12.1%), are more often covered by Medicaid (30.2% vs 11.4%), and report lower health literacy (3.7 vs 4.4) on a scale of 1 (low) to 5 (high) (P < .001 for all). Physicians from clinics serving higher proportions of minority populations perceive their patients as frequently speaking little or no English (27.1% vs 3.4%, P =.004), having more chronic pain (24.1% vs 12.9%, P < .001) and substance abuse problems (15.1% vs 10.1%, P =.005), and being more medically complex (53.1% vs 39.9%) and psychosocially complex (44.9% vs 28.2%) (P < .001 for both). In regression analyses, clinics with at least 30% minority patients are more likely to have chaotic work environments (odds ratio, 4.0; P =.003) and to have fewer physicians reporting high work control (0.2; P =.003) or high job satisfaction (0.4; P =.01). CONCLUSION Clinics serving higher proportions of minority patients have more challenging workplace and organizational characteristics.

Evaluating the Performance of Inpatient Attending Physicians: A New Instrument for Today's Teaching Hospitals

OBJECTIVE: Instruments available to evaluate attending physicians fail to address their diverse roles and responsibilities in current inpatient practice. We developed a new instrument to evaluate attending physicians on medical inpatient services and tested its reliability and validity.DESIGN: Analysis of 731 evaluations of 99 attending physicians over a 1-year period.SETTING: Internal medicine residency program at a university-affiliated public teaching hospital.PARTICIPANTS: All medical residents (N=145) and internal medicine attending physicians (N=99) on inpatient ward rotations for the study period.MEASUREMENTS: A 32-item questionnaire assessed attending physician performance in 9 domains: evidence-based medicine, bedside teaching, clinical reasoning, patient-based teaching, teaching sessions, patient care, rounding, professionalism, and feedback. A summary score was calculated by averaging scores on all items.RESULTS: Eighty-five percent of eligible evaluations were completed and analyzed. Internal consistency among items in the summary score was 0.95 (Cronbach’s α). Interrater reliability, using an average of 8 evaluations, was 0.87. The instrument discriminated among attending physicians with statistically significant differences on mean summary score and all 9 domain-specific mean scores (all comparisons, P<.001). The summary score predicted winners of faculty teaching awards (odds ratio [OR], 17; 95% confidence interval [CI], 8 to 36) and was strongly correlated with residents’ desire to work with the attending again (r=.79; 95% CI, 0.74 to 0.83). The single item that best predicted the summary score was how frequently the physician made explicit his or her clinical reasoning in making medical decisions (r2=.90).CONCLUSION: The new instrument provides a reliable and valid method to evaluate the performance of inpatient teaching attending physicians.

Prophylactic vaccinations in chronic obstructive pulmonary disease: current status

Purpose of review Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a major cause of morbidity and mortality worldwide. Most acute exacerbations are triggered by community-acquired respiratory infections. Medications to treat COPD exacerbations are limited; therefore, identifying effective ways to prevent exacerbations are needed. Influenza and pneumococcal vaccines are currently recommended for all persons with COPD. However, current immunization rates are far lower than the Healthy People 2010 Goals. The reasons for nonadherence are multifactorial and strategies for overcoming these barriers are discussed. Recent findings Influenza vaccine clearly reduces the number of acute exacerbations that occur in persons with COPD. Influenza vaccine may reduce hospitalizations and mortality from COPD, but the evidence is not conclusive. Pneumococcal vaccine reduces the incidence of invasive pneumococcal disease. However, there is not enough evidence to conclude that pneumococcal vaccination in persons with COPD has a significant impact on reducing morbidity or mortality. Vaccination with both influenza and pneumococcal vaccine may produce an additive effect that reduces exacerbations more effectively than either vaccine alone. Whole genome sequencing of bacteria and genome mining may represent a powerful way to identify novel potential vaccine antigens for future vaccine development. Summary Although clinical trial data are limited, vaccinations can prevent some of the infections that cause COPD exacerbations and should be administered to all patients with COPD. Vaccines do not cause exacerbations of COPD. Patient and physician barriers to vaccination can be overcome with targeted education and system-wide interventions. Further research efforts should focus on improving current vaccines and identifying novel targets for future vaccine development.

Effects of 2- vs 4-Week Attending Physician Inpatient Rotations on Unplanned Patient Revisits, Evaluations by Trainees, and Attending Physician Burnout: A Randomized Trial

CONTEXT Data are sparse on the effect of varying the durations of internal medicine attending physician ward rotations. OBJECTIVE To compare the effects of 2- vs 4-week inpatient attending physician rotations on unplanned patient revisits, attending evaluations by trainees, and attending propensity for burnout. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized crossover noninferiority trial, with attending physicians as the unit of crossover randomization and 4-week rotations as the active control, conducted in a US university-affiliated teaching hospital in academic year 2009. Participants were 62 attending physicians who staffed at least 6 weeks of inpatient service, the 8892 unique patients whom they discharged, and the 147 house staff and 229 medical students who evaluated their performance. INTERVENTION Assignment to random sequences of 2- and 4-week rotations. MAIN OUTCOME MEASURES Primary outcome was 30-day unplanned revisits (visits to the hospitals emergency department or urgent ambulatory clinic, unplanned readmissions, and direct transfers from neighboring hospitals) for patients discharged from 2- vs 4-week within-attending-physician rotations. Noninferiority margin was a 2% increase (odds ratio [OR] of 1.13) in 30-day unplanned patient revisits. Secondary outcomes were length of stay; trainee evaluations of attending physicians; and attending physician reports of burnout, stress, and workplace control. RESULTS Among the 8892 patients, there were 2437 unplanned revisits. The percentage of 30-day unplanned revisits for patients of attending physicians on 2-week rotations was 21.2% compared with 21.5% for 4-week rotations (mean difference, -0.3%; 95% CI, -1.8% to +1.2%). The adjusted OR of a patient having a 30-day unplanned revisit after 2- vs 4-week rotations was 0.97 (1-sided 97.5% upper confidence limit, 1.07; noninferiority P = .007). Average length of stay was not significantly different (geometric means for 2- vs 4-week rotations were 67.2 vs 67.5 hours; difference, -0.9%; 95% CI, -4.7% to +2.9%). Attending physicians were more likely to score lower in their ability to evaluate trainees after 2- vs 4-week rotations by both house staff (41% vs 28% rated less than perfect; adjusted OR, 2.10; 95% CI, 1.50-3.02) and medical students (82% vs 69% rated less than perfect; adjusted OR, 1.41; 95% CI, 1.06-2.10). They were less likely to report higher scores of both burnout severity (16% vs 35%; adjusted OR, 0.39; 95% CI, 0.26-0.58) and emotional exhaustion (19% vs 37%; adjusted OR, 0.45; 95% CI, 0.31 to 0.64) after 2- vs 4-week rotations. CONCLUSIONS The use of 2-week inpatient attending physician rotations compared with 4-week rotations did not result in an increase in unplanned patient revisits. It was associated with better self-rated measures of attending physician burnout and emotional exhaustion but worse evaluations by trainees. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00930111.

Chronic obstructive pulmonary disease: the impact of gender.

Purpose of review Chronic obstructive pulmonary disease (COPD) is a widely prevalent and potentially preventable cause of death worldwide. The purpose of this review is to summarize the influence of gender on various attributes of this disease, which will help physicians provide more personalized care to COPD patients. Recent findings Cultural trends in smoking have morphed the epidemiology of this traditionally male disease. There is an increasing ‘disease burden’ among women with COPD as suggested by the higher prevalence and slower decline in death rates as compared with men. Biologic differences between the genders account for some, but not all of these differences. In women, distinct features need to be considered to boost success of therapeutic interventions such as smoking cessation, addressing comorbidities, and attendance to pulmonary rehabilitation. Summary COPD in women is distinct from that in men with respect to phenotype, symptom burden, and comorbidities. Women are more predisposed to develop chronic bronchitis, have more dyspnea, and suffer more frequently from coexistent anxiety or depression. They may be more subject than men to misdiagnoses and/or underdiagnoses of COPD, often as a result of physician bias. Knowledge of these gender differences can lead to more effective tailored care of the COPD patient.

Impact of Work Conditions and Minority Patient Populations on Quality and Errors

Objectives: To determine whether workplace conditions affect care quality and errors, especially in primary care clinics serving minority patients. Methods: We conducted a 3-year assessment of work conditions and patient outcomes in 73 primary care clinics in the upper Midwest and New York City. Study participants included 287 physicians and 1204 patients with hypertension and/or diabetes. Chart audit data were contrasted between clinics with ≥30% minority patients (minority-serving clinics, or MSCs) and those with <30% (nonminority-serving clinics, or NMSCs). Physicians reported on time pressure, work control, clinical resources, and specialty referral access; managers described room availability; and chart audits determined care errors and quality. Two-level hierarchical models tested work conditions as mediators between MSC status and clinical outcomes. Results: Error rates were higher in MSCs than NMSCs (29.6% vs 24.8%, P < .05). Lack of clinical resources explained 41% of the effect of MSC status on errors (P < .05). Diabetes control was poorer in MSCs than in NMSCs (53.8% controlled vs 76.1%, P < .05); lack of clinical resources explained 24% of this difference (P < .05). Room availability increased quality in both MSCs and NMSCs by 5.95% for each additional room per clinician per session. Lack of access to rooms and specialists decreased the likelihood of blood pressure control in MSCs. Conclusion: Work conditions such as clinical resources, examination room availability, and access to referrals are significantly associated with errors and quality, especially in MSCs.