Arlene Weissman

Use of internist's free time by ambulatory care Electronic Medical Record systems.

Methods | The Medical Expenditure Panel Survey is a nationally representative longitudinal household survey of health care use and expenditures for noninstitutionalized US civilians.2 The present study used 2010 Household Component and Prescribed Medicines files, which included information on the drug name, days of supply, and amount paid. Information on days of supply was not available before 2010. The institutional review board of the University of Tennessee Health Science Center approved the study and waived the need for informed consent. The study evaluated adults (aged >18 years) who had received at least 1 prescription drug in 2010. Users of the GDDP were defined as individuals who had used the GDDP at least once. If a prescribed medicine event had the total amount paid and days of supply equivalent to any GDDP offerings, the GDDP was coded as 1 (the coding was otherwise 0). Typical GDDP offerings were

Internists' attitudes toward prevention of firearm injury

4 for 30-day supplies and

Important Skills for Internship and the Fourth-year Medical School Courses to Acquire Them: A National Survey of Internal Medicine Residents

10 for 90-day supplies as provided by Walmart, Target, and Kroger. Rite Aid, CVS, Walgreens, and Kmart had other GDDP offerings. Andersen’s3 behavioral model was used to identify factors associated with use of the GDDP. The logistic regression procedure in SAS, version 9.4 (SAS Institute Inc), was used to predict probabilities for different patient groups while controlling for complex survey sampling. We assumed that all prescription drug users had an opportunity to use the GDDP. We also assumed that physician prescribing behaviors, pharmacist practice styles, and pharmacy benefit designs occurred independently of each factor affecting use of the GDDP.

U.S. Internal Medicine Residents' Knowledge and Practice of High-Value Care: A National Survey.

Context Recent events have prompted calls for medical community involvement in efforts to reduce firearm-related violence. Physicians attitudes about potential efforts at reducing firearm violence are not well-understood. Contribution This survey found that most internists believed that firearm-related violence is a public health issue and that physicians should have the right to discuss firearm safety with patients, although few reported doing so. Most respondents reported favoring various public policies aimed at reducing firearm-related violence. Limitation The study included only internists, and it could not evaluate actual practice. Implication Physician support may be useful in efforts to reduce firearm-related violence. The Editors The rate of firearm-related deaths in the United States is the highest among industrialized countries (1). More than 32000 persons are killed in the United States by firearms each year, including homicides, suicides, and accidental deaths, and amounts to 85 deaths per day. Firearms are the second-leading cause of death due to injury after motor vehicle crashes (2). Firearm homicides result in 11000 deaths each year (3), and more than 19000 deaths by firearms are suicides (4). Several mass shootings in the United States, including the fatal shooting of 20 children and 6 adults at Sandy Hook Elementary School in Newtown, Connecticut, have brought firearm violence to the forefront of national discussion. In 1996, the American College of Physicians (ACP) surveyed its membership about attitudes and practices of physicians related to firearms (5). Ninety-four percent of responding internists believed that firearm violence was a major public health issue, and 84% supported enacting legislation to restrict the possession or sale of handguns. Further, whereas 84% favored physician involvement in preventing firearm injury, only 15% reported providing counseling about injury prevention that included firearm ownership and storage. At the time, several medical organizations had called for increased attention from the medical community on the prevention of firearm injury (6, 7). ACP urged its members to get actively involved in efforts to prevent firearm injury within the medical field and in the larger community, inquire and counsel patients about firearm safety measures, obtain training related to the prevention of firearm injury, and support efforts to enact legislation to regulate the sale of legal firearms (5). After more recent tragedies, ACP reaffirmed its call for such legislation (8) and continues to advocate for measures to reduce firearm violence (9). Journal editors also urged their fellow physicians to speak out on firearm violence as a public health issue (10). As these conversations continue, it is important to understand physician attitudes about various policies and practices to prevent firearm injury. Physicians witness first-hand the devastating consequences of firearm violence to victims and their families. These unnecessary injuries and deaths affect their patients, families, and communities. Physicians can play an important role in intervening with patients who risk injuring themselves or others through the use of firearms (11, 12). We surveyed ACP members to better understand current attitudes toward firearms and firearm injury and compared these data to findings from the 1996 survey. We further wondered whether opinions among physicians vary according to whether there were gun owners in their homes. Methods Study Sample We did a cross-sectional survey among a large, nationally representative panel of ACP nonstudent members in the United States. The Internal Medicine Insider Research Panel, which was initiated in June 2011, is an exclusive community of U.S. ACP members (both in training and practicing) who participate in research surveys distributed by the ACP Research Center. One percent of ACP members (including trainees) are invited to participate in the panel via stratified random sampling to ensure that the panel is representative of ACP membership within the United States across multiple demographic characteristics. Panel members who complete surveys were awarded points that may be redeemed for gift cards. Questionnaire Design and Data Collection The survey was developed by ACP staff from 2 divisions: Government Affairs and Public Policy and the Research Center. The 1996 survey of ACP members on physician attitudes toward firearms and the prevention of firearm injury was used to guide development of the initial questions that were then expanded to include current options being considered by policymakers as ways to reduce firearm violence. All authors reviewed, tested, and edited multiple iterations of the survey for understandability. The final survey is available in the Supplement. Supplement. Survey Survey questions were designed to gather physician input on their beliefs about contributors of firearm violence, their attitudes toward public policies on the prevention of firearm injury, their overall experiences with firearms, factors affecting their clinical practice behaviors, and the perceived need for education and training. The final version of the instrument was e-mailed to 1014 panel members on 12 February 2013 and remained in the field for 8 days. Data Synthesis and Analysis Data were analyzed using descriptive statistics. Statistical analyses were done using SPSS Statistics, version 21 (IBM, Armonk, New York), and StatPac (StatPac, Bloomington, Minnesota). Role of the Funding Source No external funding was obtained for this survey. Results Demographic Characteristics Table 1 summarizes demographic characteristics for the 573 survey responders (56.5% response rate). Responders did not differ substantially from the 441 persons who did not respond on any of the demographic characteristics collected during panel registration (not shown). Table 1. Characteristics of Survey Respondents By design, respondents were representative of ACPs U.S. membership. Most respondents were men (70%), were white (57%), and specialized in general internal medicine (63%). In addition, they were fairly evenly divided across 3 age groups and represented the 4 regions of the country. Ninety-five percent of respondents reported involvement in patient care, with most of them providing these services in an office-based practice (35%) or in an academic medical center or a medical school (27%). Sixty-four percent of them reported having had patients who were injured or killed by a gun. Fourteen percent of respondents reported that they or someone in their family was threatened or injured by someone with a gun. As shown in Table 1, 21% of respondents reported that they or someone else in their home owned a gun. These respondents tended to be older, more often white, from the South, and delivering care in an office-based practice. Recreational reasons were the most commonly reported reason for gun ownership: target shooting (57%), hunting (30%), and part of a gun collection (28%). Forty-four percent reported keeping a gun for protection. Opinions About a U.S. Plan to Prevent Firearm Violence Fifty-one percent of respondents believed that the United States agreeing on a plan to prevent firearm violence is extremely important (Table 2). Persons most likely to personally believe that it is extremely important tend to be older than 55 years (55%), women (56%), nonwhite (59%), from the Northeast (60%), and from homes where there was no gun owner (56%). Table 2. Importance of a U.S. Plan to Prevent Firearm Violence, by Demographic Characteristics Attitudes Toward Prevention of Firearm Injury To prevent gun-related injury and death, 76% of respondents believed that controlling gun ownership is more important than protecting the right to own guns. Furthermore, most respondents (59%) reported being at least somewhat worried that a mass shooting could happen in their community. Eighty-five percent of respondents strongly or somewhat agreed that firearm injury is a public health issue, and 71% believed that gun violence is a bigger problem today than it was a decade ago. However, as shown in Figure 1, respondents from homes without a gun owner more often agreed somewhat or strongly that gun violence is a bigger problem today than did those from homes with a gun owner (75% vs. 57%). Sixty-eight percent of respondents without a gun owner in the home and 57% of those with a gun owner in the home agreed somewhat or strongly that it is appropriate for physicians to counsel patients about gun safety. Fifty-six percent of respondents from homes without gun owners and 47% from homes with gun owners agreed somewhat or strongly that physicians should be involved in the prevention of firearm injury and 52% and 43%, respectively, agree somewhat or strongly that physicians should obtain training on the prevention of firearm injury. Figure 1. Attitudes of respondents toward firearm injury and prevention. The y-axis shows the percentage of respondents with opinions about each category. Although 55% of respondents believed that inadequate treatment of persons with mental illness contributes a great deal to gun violence in America, only 22% believed that better mental health screening and treatment would help reduce gun violence a great deal; 49% of respondents believed that it would help somewhat and 23% not much or not at all. Public Policies on Firearms Ninety-five percent of respondents reported favoring mandatory background checks on all gun purchases regardless of whether through an authorized dealer, gun show, or other private sale. Eighty-seven percent of them favored banning armor-piercing bullets (Appendix Table 1). Ninety-seven percent of respondents favored improving access to mental health services, and 85% favored preventing persons with mental illness from purchasing guns. Appendix Table 1. Support by Internists for Specific Measures to Deal With Firearm Violence As shown in Figure 2, differences

Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009.

Purpose To obtain feedback from internal medicine residents, a key stakeholder group, regarding both the skills needed for internship and the fourth-year medical school courses that prepared them for residency. This feedback could inform fourth-year curriculum redesign efforts. Method All internal medicine residents taking the 2013–2014 Internal Medicine In-Training Examination were asked to rank the importance of learning 10 predefined skills prior to internship and to use a dropdown menu of 11 common fourth-year courses to rank the 3 most helpful in preparing for internship. The predefined skills were chosen based on a review of the literature, a national subinternship curriculum, and expert consensus. Chi-square statistics were used to test for differences in responses between training levels. Results Of the 24,820 internal medicine residents who completed the exam, 20,484 (83%) completed the survey, had complete identification numbers, and consented to have their responses used for research. The three skills most frequently rated as very important were identifying when to seek additional help and expertise, prioritizing clinical tasks and managing time efficiently, and communicating with other providers around care transitions. The subinternship/acting internship was most often selected as being the most helpful course in preparing for internship. Conclusions These findings indicate which skills and fourth-year medical school courses internal medicine residents found most helpful in preparing for internship and confirm the findings of prior studies highlighting the perceived value of subinternships. Internal medicine residents and medical educators agree on the skills students should learn prior to internship.

Vaccination practices in patients with inflammatory bowel disease among general internal medicine physicians in the USA

Purpose To determine U.S. internal medicine (IM) residents’ knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments. Method The authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age–sex–race–illness standardized measure of hospital days and inpatient physician visits by Medicare recipients). Results Of 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they “share estimated costs of tests and treatments with patients”; 15,549 of 17,626 (88.2%) agreed that they “incorporate patients’ values and concerns into clinical decisions.” Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital’s care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors. Conclusions U.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents’ competency in providing value-based care.

The Right Idea for the Wrong Patient: Results of a National Survey on Stopping PPIs

Purpose To gauge internal medicine (IM) trainees’ perceptions regarding aspects of their inpatient rotations, including supervision, educational opportunities, the perceived effect of duty hours regulations on quality of patient care, the causes of medical errors, and sleep. Method The authors analyzed the results of questionnaires administered to trainees following the October 2009 in-training examinations (ITE). Results Of the 21,768 IM trainees in postgraduate years 1 through 3 who took the IM-ITE, 18,272 (83.9%) responded. The majority of these trainees (87.7%) reported that supervision was adequate, and nearly half (46.3%) reported insufficient or minimal time to participate in learning activities. Two-thirds or more thought that specific work regulations such as limited shift length and more time off after nights and extended shifts would at least “occasionally,” if not “usually” or “always,” improve patient care. IM trainees at least “occasionally” attributed errors to workload (68.8% of respondents), fatigue (66.9%), inexperience or lack of knowledge (61.0%), incomplete handoffs (60.2%), and insufficient ancillary staff (53.5%). IM trainees’ sleep hours were limited during extended and overnight shifts. Conclusions IM trainees agree that limited educational opportunities are the weakest part of the average inpatient rotation. Few have complaints about the adequacy of supervision. These trainees’ optimism regarding the positive influence of potential work hours restrictions on patient care and their views of likely causes of medical errors suggest the need for innovative patient care schedules and education curricula.

The Effect of Emphasizing Patient, Societal, and Institutional Harms of Inappropriate Antibiotic Prescribing on Physician Support of Financial Penalties: A Randomized Trial

Background Increasing prevalence of inflammatory bowel disease (IBD) poses significant challenges to medical community. Preventive medicine, including vaccination against opportunistic infections, is important in decreasing morbidity and mortality in patients with IBD. We conduct first study to evaluate general awareness and adherence to immunisation guidelines by primary care physicians in the USA. Methods We administered an electronic questionnaire to the research panel of the American College of Physicians (ACP) assessing current vaccination practices, barriers to vaccination and provider responsibility for administering vaccinations and compared responses with the European Crohns and Colitis Organization consensus guidelines and expert opinion from the USA. Results All of surveyed physicians (276) had experience with patients with IBD and spent majority of their time in direct patient care. 49% of physicians took immunisation history frequently or always, and 76% reported never or rarely checking immunisation antibody titres with only 2% doing so routinely. 65% of physicians believed that primary care providers (PCPs) were responsible for determining patients immunisation. Vaccine administration was felt to be the duty of primary care doctor 80% of the time. 2.5% of physicians correctly recommended vaccinations all the time. Physicians were more likely to recommend vaccination to immunocompetent than immunocompromised patients. Up to 23% of physicians would incorrectly recommend live vaccine to immunocompromised patients with IBD. Conclusions Current knowledge and degree of comfort among PCPs in the USA in preventing opportunistic infections in IBD population remain low. Management of patients with IBD requires structured approach to their healthcare maintenance in everyday practice, including enhanced educational policy aimed at primary care physicians.

Trends in High-Value Care as Reported by Internal Medicine Program Directors

*Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Research Center, American College of Physicians, Philadelphia, Pennsylvania; kDepartment of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan; and VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan

Who is Responsible for What Happens Before, During, and After Colonoscopy? Results of a National Survey of Primary Care Physicians.

Background: Physicians commonly prescribe antibiotics for uncomplicated upper respiratory infections despite consensus about their low value and efforts emphasizing their societal costs and harms (1, 2). To deter low-value services, policymakers have begun proposing financial penalties for physicians who prescribe them (3, 4). Objective: To determine whether physician support of financial penalties targeting inappropriate antibiotic prescribing is influenced by emphasis on patient, societal, or institutional harms of such prescribing. Methods and Findings: We conducted a Web-based survey among a panel of physicians identified by stratified random sampling to represent members of the American College of Physicians in the United States who are not medical students. We excluded subspecialists, retirees, and those who do not see patients. We used a clinical vignette to measure how likely respondents were to recommend antibiotics for uncomplicated upper respiratory infection. Low value was defined using established evidence and guidelines (1, 5). We also evaluated physician attitudes about cost control in patient care. Physicians were randomly assigned to 1 of 4 versions of the principal question, which evaluated the likelihood of supporting a policy that financially penalized organizations and physicians for routinely prescribing antibiotics to treat uncomplicated upper respiratory symptoms. We used a 5-point scale to elicit responses and defined responses of somewhat likely or very likely as positive answers. The first version described harms to patients, such as increased costs and iatrogenic infections. The second described harms to society, such as increased bacterial resistance to antibiotics and diversion of limited health care resources to less productive uses. The third described harms as increased costs to hospitals and insurers as institutions. All 3 stated, According to research and expert opinion, mild to moderate upper respiratory symptoms lasting less than 7 days are frequently due to viruses and therefore resolve on their own. A fourth control version provided no information. A question related to back pain evaluation was planned but abandoned because of a coding error in survey administration. The University of Pennsylvania Institutional Review Board exempted the study from informed consent requirements. Of 694 eligible respondents, 47% completed the survey. The mean age of respondents was 48 years (interquartile range, 37 to 53 years). Most were male (55%) and practicing physicians (90%). In their clinical practice, 29% reported having incentives based on cost performance and 55% reported having incentives not related to cost (for example, those based on quality or patient satisfaction). All groups were similar with respect to these characteristics and attitudes about cost control in patient care (Table). Table. Physician Attitudes About Cost Control in Patient Care* Thirty-one percent of respondents supported financial penalties, but responses varied by version. Penalties were supported by 41% of recipients of the patient harm version, 23% of recipients of the societal harm version, 36% of recipients of the institutional harm version, and 25% of recipients of the control version. In response to the clinical vignette, 27% of physicians recommended care adherent to guidelines governing inappropriate antibiotic prescription for upper respiratory infections. Support for a policy that financially penalizes organizations and physicians for routinely prescribing antibiotics to treat uncomplicated upper respiratory symptoms was higher among physicians who adhered to these guidelines (44% vs. 26% among those who were nonadherent). Policy support was also consistent with attitudes about cost control in patient care. For example, support was higher among respondents who agreed that clinicians should play an active role in cost control (31% vs. 14% among those who disagreed) and lower among those who agreed that only clinicians and patients should decide whether a test or treatment is worth the cost (28% vs. 36% among those who disagreed). Discussion: Support for financial penalties targeting inappropriate antibiotic prescribing was highest among physicians who received information about patient harms. Although more work is needed, these preliminary results suggest that policymakers might increase the acceptability of penalties by implementing them while explicitly emphasizing the harms and costs to patients.