Faculty Bibliography

BACKGROUND: Physicians frequently report negative attitudes about obesity which is thought to affect patient care. However, little is known about how attitudes toward treating obese patients are formed. We conducted a cross-sectional survey of physicians in order to better characterize their attitudes and explore the relationships among attitudes, perceived competency in obesity care, including report of weight loss in patients, and other key physician, training, and practice characteristics. METHODS: We surveyed all 399 physicians from internal medicine, pediatrics, and psychiatry specialties at one institution regarding obesity care attitudes, competency, including physician report of percent of their patients who lose weight. We performed a factor analysis on the attitude items and used hierarchical regression analysis to explore the degree to which competency, reported weight loss, physician, training and practice characteristics explained the variance in each attitude factor. RESULTS: The overall response rate was 63%. More than 40% of physicians had a negative reaction towards obese patients, 56% felt qualified to treat obesity, and 46% felt successful in this realm. The factor analysis revealed 4 factors-Physician Discomfort/Bias, Physician Success/Self Efficacy, Positive Outcome Expectancy, and Negative Outcome Expectancy. Competency and reported percent of patients who lose weight were most strongly associated with the Physician Success/Self Efficacy attitude factor. Greater skill in patient assessment was associated with less Physician Discomfort/Bias. Training characteristics were associated with outcome expectancies with newer physicians reporting more positive treatment expectancies. Pediatric faculty was more positive and psychiatry faculty less negative in their treatment expectancies than internal medicine faculty. CONCLUSION: Physician attitudes towards obesity are associated with competency, specialty, and years since postgraduate training. Further study is necessary to determine the direction of influence and to explore the impact of these attitudes on patient care

BACKGROUND: Nonadherence to asthma medications is associated with increased emergency department visits and hospitalizations. If adherence is to be improved, first-fill adherence is the first goal to meet after the physician and patient have decided to begin treatment. Little is known about first-fill adherence with asthma medications and the factors for no-fill. OBJECTIVE: The goal of the study was to examine the proportion of patients who fill a new prescription for an asthma medication and analyze characteristics associated with this first-fill. METHODS: This retrospective cohort study linked electronic health records with pharmacy claims. The cohort was comprised of 2023 patients aged 18 years or older who sought care from the Geisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthma medication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescription filled by the patient within 30 days of the prescription order date. Covariates examined included factors related to the patient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office visits, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy copay amount. A logistic-regression model was used to determine covariates associated with first-fill. RESULTS: The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with a copay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients prescribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11). CONCLUSIONS: SEVERAL FACTORS ASSOCIATED WITH FAILING TO FILL AN INITIAL PRESCRIPTION FOR ASTHMA CAN BE ADDRESSED THROUGH SIMPLE INTERVENTIONS: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary medications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreasing copay may improve adherence and, therefore, asthma control.

BACKGROUND AIMS: Objective structured clinical encounters (OSCEs) are used widely to educate and assess the competence of medical students and residents; they generally are absent from fellowship training. The Accreditation Council for Graduate Education has cited OSCEs as a best practice for assessing the 6 core competencies. This article reports on the use of an OSCE to assess the competence of second-year gastroenterology fellows in the difficult-to-assess core competencies: interpersonal and communication skills and professionalism. METHODS: We developed a 4-station, faculty-observed OSCE with 4 standardized patients. Information gathering, relationship development, patient education, and counseling skills were assessed. Professionalism skills assessed included obtaining informed consent, delivering bad news, managing difficult situations, and showing interdisciplinary respect. In each station, faculty and standardized patients completed an 18- to 24-item checklist evaluating fellows' performance and provided feedback to the fellows. Nine fellows and 5 faculty from 4 gastroenterology training programs in NYC participated. RESULTS: Fellows and faculty generally highly rated the realism of the OSCE and favorably rated the OSCE for its difficulty and their overall experience. Across all cases, fellows were rated as receiving "well dones" for 56.4% of the communication items (SD, 18.3%) and for 79.1% of the professionalism items (SD, 16.4%). CONCLUSIONS: Integrating OSCEs into gastroenterology fellowship training may help enhance communication skills and prepare fellows for dealing with difficult clinical situations and provides mechanisms for constructive feedback. OSCEs developed collaboratively can assist in program self-evaluation and reduce costs by sharing resources, in addition to fulfilling Accreditation Council for Graduate Education mandates.

OBJECTIVE: Food label use is associated with better food choices, an essential part of the management of many chronic diseases. Previous studies suggest lack of comprehension of food labels. We studied a multimedia intervention to improve food label comprehension in a sample of low income patients in New York City. METHODS: This randomized study took place at Gouverneur Healthcare Services from 2005 until 2007. The intervention group (n=29) received a Nutrition Facts Label pocket card and viewed a video explaining card use. The control group (n=27) received written materials. Participants completed a 12-item pre- and post-intervention nutrition food label quiz. Quiz scores were analyzed using repeated measures analysis of variance. RESULTS: The intervention group had greater improvement on the quiz than the control group (p<0.001). There was a three way interaction by time with health literacy and treatment group where the greatest improvement occurred in patients with adequate health literacy in the intervention group (p<0.05). There was no improvement in patients with limited health literacy. CONCLUSION: A multimedia intervention is an effective way to improve short-term food label comprehension in patients with adequate health literacy. Further research is necessary to improve understanding of food labels in patients with limited health literacy

Research Objective: For a subset of fee-for-service Medicaid patients with frequent hospital admissions, contact with the health care system remains acute and episodic at high cost to Medicaid, while less costly outpatient primary and preventive care services are underutilized. Previous work validated the accuracy of a predictive case-finding algorithm to identify complex Medicaid patients at risk for future high costs who might benefit from more intensive services, and identified remediable risk factors such as substance use, homelessness, and lack of social support associated with frequent hospital admissions. We aimed to pilot an intervention for a limited number of high-cost patients to address unmet health and social needs in both the hospital and community, to improve care while reducing hospital admissions and associated costs in this population. Our intention was to expand the program based on pilot success. Study Design: Community and hospital-based care management intervention with process and implementation evaluation, and pre-post cost analysis. Eligible patients were offered intervention enrollment during an admission to an urban public hospital. Patients underwent in-depth psychosocial interviews by study social workers to identify immediate and long-term needs such as housing, primary care, transportation to and advocacy during appointments, medication management, entitlements enrollment, improved connections to psychiatric and substance use treatment, and home visits. Patients who met criteria for chronic homelessness were evaluated in-hospital by a community-housing partner who initiated housing applications based on a housing first model. Pre-paid cell phones were provided to patients when needed to maintain close contact with study staff for reminder calls and crisis management. Study staff worked closely with inpatient providers to facilitate appropriate discharge planning and follow-up. Population Studied: Consecutive English-speaking Medicaid fee-for-service patients aged 18-64 identified as high-cost and high-risk for readmission in the following 12 months by a validated predictive case-finding algorithm. Principal Findings: Over the past year, 19 patients have enrolled. 100% are male. 17/19 were chronic substance users at enrollment. 5/19 were lost to follow-up. Of the remaining patients, 8 met criteria for chronic homelessness that would facilitate expedited placement into permanent housing. Of these 8, 2 were placed in nursing homes and 2 died. The remaining 4 chronically homeless patients are now in transitional or permanent housing. Hospitalizations and ED visits have decreased, while establishment of an outpatient medical home has increased. Comparing the 9-12 months after the intervention to the 12 months before intervention revealed a decrease in average monthly inpatient Medicaid costs per patient ranging from $1205-$2881. This resulted in an average annual inpatient cost reduction from $14,464 to $34,568.52. Prior research indicates without intervention, Medicaid costs for these patients in the following 12 months will increase. Conclusion: A pilot intervention to improve care for medically, socially complex high-cost Medicaid patients shows savings to Medicaid and decreased hospitalizations and ED visits by addressing issues that are challenging for the traditional health care system to manage. Implications for Policy, Delivery or Practice: Our model will be expanded to serve a greater number of patients across additional hospitals to determine if the success of our pilot can be replicated, and will include a more detailed cost analysis. Funding Source(s): The United Hospital Fund