Faculty Bibliography

Statement of Problem Or Question (One Sentence): Does actionable feedback on patient safety indicators and responses to disclosed social determinants of health (SDOH) impact clinical behavior? Objectives of Program/Intervention (No More Than Three Objectives): (1) Develop/disseminate quarterly audit-feedback reports on SDoH practice behavior, focusing on elicitation of patient information. (2) Enhance our understanding of factors related to disparities in safety/quality of care. (3) Increase rates of SDoH documentation and referral. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We sent Unannounced Standardized Patients (USPs) with SDoH-related needs to care teams in two urban, safety-net clinics. Data collected on practice behaviors were used for cycles of audit and feedback on the quality of electronic health record (EHR) documentation, team level information sharing, and appropriate service referral. Reports contained an evolving educational component (e.g. how to recognize, refer, and document SDoH). We disseminated reports to teams (doctors, nurses, physician's assistants, medical assistants, and staff) at routine meetings and via email. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): Three audit feedback reports have been distributed to date. Survey data was collected at two time points, 2017 (n=77) and 2018 (n=81), to assess provider attitude changes and integration of feedback into clinical practice. Measures included change in team knowledge and attitudes towards SDoH, and response to/documentation of presented SDoH (measured via post-visit checklist and EMR). Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): Preliminary data shows no change or improvement in documentation of SDoH and limited variation between firm-level responses. (1) Only 7% of providers reported feeling strongly confident in knowing how to make referrals for social needs in 2018; no improvement since 2017. (2) Despite regular report distribution, 58% of providers reported having received no formalized feedback on responding to SDoH. 24% reported maybe or not sure. (3) 86% of 2018 survey participants self-reported having referred a patient to appropriate services when a social need was identified. Our referral data says otherwise, referrals occur for less than 30% of visits with SDoH-related needs. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Results suggest disconnect between team data and individual reporting: most report they refer but data suggests few do. Deeper integration of reports into team processes, attachment of feedback to curricula, and increased frequency of regular feedback may be needed for accountability. These preliminary Results help refine audit feedback methodology but research is needed to understand motivation and systems barriers to referral and documentation. Future research will look at provider attitudes toward referral processes

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

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 /UNASSIGNED:Physicians across specialties need to be skilled at diagnosing and treating depression, yet studies show underrecognition and inadequate treatment. Understanding the reasons requires specifying the influence of patient presentation, screening, and physician competence. Objective /UNASSIGNED:We deployed an unannounced standardized patient (SP) case to assess clinic screening and internal medicine (IM) residents' practices in identifying, documenting, and treating depression. Methods /UNASSIGNED:The SP represented a new patient presenting to the outpatient clinic, complaining of fatigue, with positive Patient Health Questionnaire (PHQ) items 2 and 9 and a family history of depression. The SPs assessed clinic screening and IM resident practices; appropriate treatment was assessed through chart review and defined as the resident doing at least 1 of the following: prescribing a selective serotonin reuptake inhibitor (SSRI), making a referral, or scheduling a 2-week follow-up. Results /UNASSIGNED:< .001). Conclusions /UNASSIGNED:The use of unannounced SPs helps identify targets for training residents to provide evidence-based treatment of depression.