Faculty Bibliography

BACKGROUND: While much is known about the importance of addressing Social Determinants of Health (SDoH), less is known about how physicians elicit, respond to, and act upon their patients' SDoH information. We report on the results of a study that 1) sent Unannounced Standardized Patients (USPs) with programmed SDoH into clinics to assess whether providers uncovered, explored and acted upon the SDoH, 2) provided audit/feedback reports with educational components to clinical teams, and 3) tracked the impact of that intervention on provider response to SDoH.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well-visit), each with specific housing (overcrowding, late rent, and mold) and social isolation (shyness, recent break up, and anxiety) concerns that they shared if asked broadly about. USPs assessed team and provider SDoH practices (eliciting, acknowledging/exploring, and providing resources and/or referrals). 383 USP visits were made to residents in 5 primary care teams in 2 urban, safety- net clinics. 123 visits were fielded during baseline period (Feb 2017-Jan 2018); 185 visits during intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed; and 75 follow-up phase visits were fielded (Apr-Dec 2019). Analyses compared rates of eliciting and responding to SDoH across the 3 periods (chi- square, z-scores). One team, by design, did not receive the intervention and serves as a comparison group.
RESULT(S): Among the intervention teams, the rate of eliciting the housing SDoH increased from 46% at baseline to 59% during the intervention period (p=.045) and also increased, but not significantly, for the social issue (40% to 52%, p=.077). There was a significant increase from baseline to intervention in providing resources/referrals for housing (from 7% to 24%, p=.001) and for social isolation (from 13% to 24%, p=.042) (mostly resources, very few referrals were made). The comparison team's rates followed a different pattern: eliciting the housing issue and the social isolation issue decreased from baseline to the intervention period (housing: 61% to 45%; social isolation: 39% to 33% of visits) and the rate of providing resources/referrals stayed steady at 13% for both. In the cases where SDoH were most clinically relevant, baseline rates of identifying the SDoH were high (>70%) but rates of acting on the SDoH increased significantly from baseline to intervention. Increases seen in the intervention period were not sustained in the follow-up period.
CONCLUSION(S): Giving providers SDoH data along with targeted education was associated with increased but unsustained rates of eliciting and responding to housing and social issues. The USP methodology was an effective means of presenting controlled SDoH and providing audit/feedback data. Ongoing education and feedback may be needed

BACKGROUND: While much is known about the importance of addressing Social Determinants of Health, less is known about how members of the care team respond to patient-volunteered SDoH - especially when the determinant is related to financial insecurity. With increasing calls for universal screening for SDoH - what do teams do when a patient shares a financial concern? We report on the use of Unannounced Standardized Patients (USP) to assess how primary care teams respond to volunteered information about financial insecurity and whether an audit/ feedback intervention (with targeted education included) improved that response.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six common scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well visit). USPs volunteered a financial concern (fear of losing job, challenges with financially supporting parent, trouble meeting rent) to the medical assistant (MA) and then again to their provider and assessed the response of both the MA (did they acknowledge and/ or forward the information to the provider?) and the provider (did they acknowledge/ explore and/or provide resources/referrals?). A total of 383 USP visits were delivered to 5 care teams in 2 safety-net clinics. Providers were medicine residents. 123 visits were fielded during the baseline period (Feb 2017-Jan 2018); 185 visits during the intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed. 75 follow-up phase visits were fielded (Apr- Dec 2019). Analyses compared rates of MA and provider response to the volunteered financial insecurity issue across the 3 periods (chi-square, z-scores).
RESULT(S): The baseline rate of responding in some way to the volunteered information was high for both the MA (86% acknowledged) and the providers (100% responded). These overall rates of response did not change substantially or significantly across the three time periods (MA: Intervention period = 87%, Follow- Up period=90%; Provider: Intervention period=98%; Follow-Up period=98%). Rates of acting upon the volunteered information also remained quite consistent across the time periods: from 29 to 35% of MA forwarded the information to the provider across the 3 time periods and from 22 to 28% of providers in each intervention period gave the patient resources or a referral (mostly resources).
CONCLUSION(S): Our findings highlight the importance of patients directly telling team members about a financial concern. Future research should explore whether screening tools are effective in instigating a response. Audit/feedback reports with targeted educational components did not appear to influence the teams' response unlike what we found for housing and social concerns that had to be elicited. Whether this is due to differences in volunteered vs. elicited SDoH or to the nature of the SDoH (financial vs housing/social) warrants further investigation

BACKGROUND: There's been a recent shift toward addressing social determinants of health (SDoH) during the clinical encounter through discussion and documentation. SDoH documentation in the problem list and through billing-related z-code use is necessary for accurate, individual patient and population level tracking andmay improve quality of care.We sought to better understand if/how providers document their patient's SDoH when elicited during a clinical visit.
METHOD(S): Unannounced Standardized Patients (USPs) were sent to two safety-net clinics to assess how medicine residents care for a new patient presenting with one of six unique chief complaints, and accompanying underlying financial, housing, and social concerns. USPs assessed resident practices after the encounter through a behaviorally anchored checklist and systematic chart review. USPs volunteered financial concerns while housing insecurity and social isolation needed to be elicited by the provider. Checklist items assessed if the USP was able to fully disclose their SDoH to the provider. Provider documentation in the electronic medical record (EMR) in one of three spaces: the history of present illness (HPI), the problem list, or through use of a social determinant-specific Zcode was examined when a USP was able to share their concerns.
RESULT(S): 384 USP visits were sent to medical residents from 2017 to 2019. USPs were able to share their financial concerns during 84% of the encounters, but were less likely to be able to share their housing or social concerns with providers (35% and 28%, respectively). Documentation in the HPI and treatment list remained low across cases (<15%) and only one Z-code was used across all visits. On an individual case level, providers addressed housing insecurity most frequently in the asthma case (discussion 65%; documentation: HPI 39%, Plan 16%) and social isolation in the fatigue case (discussion 57%; documentation: HPI 49%, Plan 2%). Providers were least likely to discuss and document SDoH for patients presenting with acute pain.
CONCLUSION(S): In clinical scenarios where SDoH concerns were elicited, residents documented SDoH in less than half of visits. Omission of SDoH not only effects clinical care but also panel management and SDoH population-level estimations. New education strategies are needed to address resident's ability to elicit and accurately document SDoH

Corrigendum to: Jeffrey A. Wilhite*, Khemraj Hardowar, Harriet Fisher, Barbara Porter, Andrew B. Wallach, Lisa Altshuler, Kathleen Hanley, Sondra R. Zabar and Colleen C. Gillespie. Clinical problem solving and social determinants of health: a descriptive study using unannounced standardized patients to directly observe how resident physicians respond to social determinants of health. Diagnosis 2020, Volume 7, Issue 3, pages 313-324. https://urldefense.proofpoint.com/v2/url?u=https-3A__doi.org_10&d=DwIBAg&c=j5oPpO0eBH1iio48DtsedeElZfc04rx3ExJHeIIZuCs&r=CY_mkeBghQnUPnp2mckgsNSbUXISJaiBQUhM-Uz9W58&m=TyoCBAKzCpBZ4-uIICybN67eGKr9ePdBC-WexDhSuSM&s=-H9hUl6CWWk07_DiPQFbSmQyI2qWxw4tQLZIEBIpIVY&e= . 1515/dx-2020-0002. Unfortunately, a typographic error in the results portion of the abstract was missed during final stages of proofing and editing. The count of full elicitors should read as 38/68 rather than 28/68, and the % of negative elicitors is 23%. The corrected results read as follows: Residents fell into three groups when it came to clinical problem-solving around a housing trigger for asthma: those who failed to ask about housing and therefore did not uncover mold as a potential trigger (neglectors - 21%; 14/68); those who asked about housing in negative ways that prevented disclosure and response (negative elicitors - 23%, 16/68); and those who elicited and explored the mold issue (full elicitors - 56%; 38/68).
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Background: It is well documented that few ordered tests are " high value" a significant percentage of those ordered are " low-value." Residency offers an opportunity to teach high-value care and educational interventions to do so have been effective. However, the relationship between high-value care and residents' ability to communicate effectively with patients has not been explored. Ability to establish rapport, gather information effectively, and be patient-centered may impact residents' use of tests. We hypothesize that residents with poor skills in these areas may order tests less efficiently.
Method(s): Unannounced Standardized Patients (USPs) were introduced into residents' primary care clinics in a large urban, safety net hospital to portray 3 clinical scenarios: a well visit, a chief complaint of fatigue, and a diagnosis of asthma. Orders were extracted via chart review. Appropriateness of orders was determined by reference to United States Preventive Services Task Force (USPSTF) and clinical practice guidelines. Excessive tests were defined as not explicitly indicated for the scenario-indicated tests were the converse. Number of excessive and % of indicated tests were calculated across the 3 visits for 48 residents. Communication skills in information gathering (5 items) and developing a relationship (6 items) and a patient-centeredness score (4 items: took a personal interest, answered all my questions) were computed as % of behaviorally anchored items rated as " well done" and included in regression models predicting test utilization.
Result(s): On average, residents ordered 15% of indicated tests (SD 9%, 0-38%) across the 3 visits and a mean of 1.3 unnecessary tests (SD 1.7, 0-6). In the regression model, the 3 skills explained 16% of variation in unnecessary tests (p=.047). Information gathering explained the greatest share (8%, p=.041). With all 3 variables in the model, patient-centeredness was positively associated with unnecessary tests (Std Be-ta=.42, p=.016) and information gathering was negatively associated with unnecessary tests (Std Beta=-.34, p=.041). Mirroring these Results, superutilizers (10 residents ordering > =3 excessive tests) had lower information gathering and relationship development scores than other residents (66% vs 75% and 72% vs 76%) but higher patient centeredness scores (80% vs 74%)-although differences were not significant.
Conclusion(s): Our findings suggest that information gathering skills may have a small influence on residents' ordering of excessive tests. Further research with larger samples (adequate power) will help clarify the effect sizes. If our Results stand, interventions for high-value care should include information gathering skills and residency programs should continue to reinforce core communication skills training. In addition, our finding that patient centeredness was associated with ordering unnecessary tests suggests that residency programs could caution residents about conflating ordering of tests with patient-centeredness

Background: Inter-provider variability is a major source of low-value care. The dissemination of clinical practice guidelines (CPGs) has targeted this variability, yet 44% of physicians are non-adherent to CPG. This may be due to factors including exceptionalism and incentive misalignment that present a conflict between comprehensiveness and prudence in work-up. A subset of super-utilizers are notable outliers: fewer than 0.5% of physicians account for 10% of healthcare costs. Super-utilizers order labs, request consults, order imaging, and prescribe medications at rates 30%, 140%, 14%, and 25% higher than the general population. We sought to quantify provider-specific low-value test ordering behaviors across three cases.
Method(s): Unannounced standardized patients (USPs) were trained for standardized simulation of three clinical scenarios: a "Well" visit, a chief complaint of "Fatigue," and a diagnosis of "Asthma." USPs were introduced into medicine residents' clinics in a large urban, safety-net hospital. Diagnostic orders were extracted via retrospective chart review. Scenario-specific appropriateness of diagnostic testing was determined by referencing United States Preventative Services Task Force (USPSTF) and specialty society CPGs. "Excessive" tests were those not explicitly indicated for a given scenario in either USPSTF or society CPGs (versus "indicated" tests). "Discretionary" tests were those conditionally indicated, pending patient-specific factors (such as hemoglobin A1C, pending BMI).
Result(s): One or more excessive tests were ordered in 44%, 22%, and 17% of Well (n=124), Fatigue (n=148), and Asthma (n=148) encounters respectively. Percent of orders that were excessive were 18%, 8%, and 10%, respectively. On average, 1.3 (+/-1.7) excessive orders were made. Within each case, rates of excessive ordering were positively correlated with rates of indicated and discretionary ordering, and negatively correlated with rates of omitting indicated tests. For example, in Fatigue, the correlation between excessive and indicated orders was 0.38, between excessive and discretionary orders rates was 0.59, and between excessive and omitted-indicated tests was-0.25 (all p< 0.05). A similar, statistically-significant pattern was found for the other two cases. 10 (21%) and 4 (8%) of 48 residents completing all scenarios demonstrated excessive ordering at rates atleast 1 and 2 standard deviations above the mean, respectively.
Conclusion(s): Introducing USPs representing clinical scenarios revealed marked inter-provider variability. Positive associations between rates of excessive, discretionary and indicated ordering suggest tendencies for comprehensiveness over prudence. Over one-fifth of residents completing all 3 cases were high-utilizers, and nearly one in ten were super-utilizers. Awareness of provider-level ordering tendencies can guide education and interventions supporting appropriate diagnostic use

Needs and Objectives: Didactic training in motivation interviewing (MI) lacks efficacy, because opportunities to practice skills while being directly observed are rare. The goal of our educational innovation was to train interns in the advanced communication skills of motivation interviewing through a group observed standardized clinical experience (GOSCE). Our Learning Objectives were as follows: After an experiential learning session on MI, interns will be able to: 1. Identify opportunities to use MI with patients 2. Recognize "change talk" from a patient as an opportunity to use MI techniques 3. Use MI techniques when discussing behavior change with a patient Setting and Participants: 46 internal medicine interns in an academic internal medicine residency program. Description: Each session began with a 20 minute review of MI for behavior change given by a psychologist trained in Motivational Interviewing. Then, interns participated in a 3 station, one-hour long Group Observed Standardized Clinical Exercise (GOSCE). Interns worked in teams of 3, and for each station, one of the 3 interns was the active physician, while the other 2 observed the encounter. Each intern had an opportunity to be the active physician for a case. Each case was observed by one or two faculty members, one of whom was a psychologist trained in MI. After a 10 minute interaction with the standardized patient, the active physician received feedback on their MI skills and debriefed the encounter with the faculty and their peers. After the 3 cases, the session concluded with a group debrief and summary of the experience. Interns completed a retrospective pre/post survey to assess the impact of the session. Evaluation: Residents reported statistically significant improvement in all domains, including confidence with identifying opportunities to use MI, comfort using reflective and summary statements during MI, and likelihood of using motivational interviewing in future patient encounters. Qualitative comments after the session reflect that residents developed an appreciation for silence as a tool during MI, felt comfortable with tools such as decisional balance, and recognized the value of patient centered-ness during MI. Discussion/Reflection/Lessons Learned: Our interprofessional educational team (psychologists and internists) provided different perspective for both learners and our internal medicine faculty. Our residents appreciated practicing skills and receiving feedback in real time. This academic year (one year after the intern GOSCE), these same learners will participate in an OSCE that includes a case requiring motivational internviewing skills, and we will evaluate the durability of motivation interviewing skills taught during this session. We are interested in expanding opportunities to use GOSCE as a low stakes skills practice and development tool

Background: Low-value tests, defined as inappropriate for a given clinical scenario, are ordered in one in five clinic visits. Residents tend to over-order diagnostic tests to "minimize uncertainty" of presenting cases, even though these tests are not useful according to Bayesian statistics; a pursuit deemed the "Ulysses syndrome". Simultaneously, evidence suggests residents misuse preventive tests in half of relevant clinical scenarios. We sought to quantify ordering behaviors in urban primary care clinics across three unannounced standardized cases.
Method(s): Unannounced standardized patients (USPs) were trained for standardized simulation of three clinical scenarios: a "Well" visit, a chief complaint of "Fatigue," and a diagnosis of "Asthma." USPs were introduced into medicine residents' clinics in an urban, safety-net hospital. All electronic orders were extracted via chart review. Scenario-specific appropriateness of diagnostic testing was determined by referencing United States Preventive Services Task Force (USPSTF) and society clinical practice guidelines (CPGs). "Preventive" tests (such as lipid panels or hemoglobin A1C) were derived from USPSTF guidelines whereas "Diagnostic" tests (such as pulmonary function testing for Asthma or heterophile antibodies for Fatigue) were from CPGs. "Excessive" tests were those not explicitly indicated for a given scenario in either USPSTF or CPGs (versus "indicated" tests).
Result(s): Indicated tests were ordered in 29% of Well (124 encounters), 16% of Fatigue (148 encounters), and 12% of Asthma (170 encounters) cases. One or more excessive tests were ordered in 44%, 22%, and 17% of Well, Fatigue, and Asthma encounters respectively. The distribution of indicated and excessive tests for preventive versus diagnostic purposes varied by case: In Well visits, the majority (71%) of excessive testing was in pursuit of a diagnosis, while three-quarters of indicated testing was for preventive purposes. In Fatigue and Asthma visits, the reverse patterns were true: the majority of indicated tests ordered were diagnostic (81% and 68%, respectively) while the majority of excessive tests were preventive (78% and 63%, respectively).
Conclusion(s): Introducing USPs to resident clinics revealed that, for patients presenting without a chief complaint (Well visit), residents successfully ordered less than one-third of indicated tests, and over 75% of inappropriately ordered tests pursued a diagnosis. For patients presenting with chief complaints (Fatigue and Asthma), rates of appropriate ordering were even lower (16% and 12%), and tended to overlook preventive care. In these cases, inappropriate tests tended to be ordered for preventive purposes. Awareness of resident mis-utilization of preventive and diagnostic testing in distinct clinical circumstances can guide educational efforts towards evidence-based care and resource stewardship

Background: Diagnostic tests account directly for 5% of healthcare costs, but influence decisions constituting 70% of health spending. Only 5% of ordered labs are actually " high value," depending on clinical circumstances. Low-value tests, defined as not appropriate for a given clinical scenario, are ordered in one in five clinic visits. Up to $ 750 billion is spent on these low-value tests, contributing to the estimated one-quarter to one-third of healthcare spending is on wasteful services. We sought to quantify test-specific low-value ordering behaviors in urban outpatient clinics across three standardized patient cases.
Method(s): Unannounced standardized patients (USPs-highly trained actors portraying patients with standardized case presentations) were introduced into medicine residents' primary care clinics in a large urban, safety net hospital over the past five years. The USPs simulated three common outpatient clinical scenarios: a " Well" visit, a visit with a chief complaint of " Fatigue," and a visit with a diagnosis of " Asthma." Diagnostic orders were extracted via retrospective chart review for these standardized visits. For each scenario, appropriateness of diagnostic testing was determined by reference to United States Preventative Services Task Force (USPSTF) and relevant specialty society clinical practice guidelines (CPGs). " Wasteful" (over-ordered) tests were defined as those not explicitly indicated for the given scenario. Costs were derived from GoodRx.com according to local ZIP codes.
Result(s): The most commonly wasteful tests for the Asthma case were CBC (8% of 170 visits) and Chem-7 (6%), though the relative risk of over-ordering TSH was 3.8x that of other scenarios. The most commonly over-ordered tests for the Fatigue case were LFTs (14% of 148 visits) and HBV (5%), with LFTs ordered up to 15-fold more frequently than in other scenarios. The most commonly over-ordered tests for the Well case were BMP (35% of 124 visits), CBC (15%), LFTs (15%), and HBV (11%) ordered at rates up to 6.3x, 2.0x, 14.2x, and 7.4x higher than other scenarios. Finally, the average per patient excess costs were $ 8.27 (+/-$ 1.76), $ 6.79 (+/-$ 4.5), and $ 23.5 (+/-$ 9.34) for Asthma, Fatigue, and Well cases respectively.
Conclusion(s): Inappropriateness in test ordering patterns were observed through USP simulated cases. Certain tests (CBC, BMP, LFTs, and HBV) were more likely used wastefully across cases. Between cases, specific tests were ordered in an inappropriate manner (such as TSH for Asthma, LFTs for Fatigue, and BMP for Well visits). The per patient direct cost of low value testing rose above $ 20 per visit for the Well visit, though the Fatigue case exhibited the most variation. Notably, this excludes downstream (indirect) costs inestimatable from standardized encounters alone. Knowledge of wasteful utilization patterns associated with specific clinical scenarios can guide interventions targeting appropriate use of testing