Faculty Bibliography

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

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: Self-efficacy to manage chronic conditions affects patients' health-related behaviors and interactions with the healthcare system and therefore influences health outcomes. Few studies have explored the complex relationships between mental health, self-efficacy, and management of chronic disease. A greater understanding of these interactions could inform successful community programming for marginalized populations such as public housing residents. Harlem Health Advocacy Partners is a community health worker (CHW) program designed to close health and social outcomes gaps in residents living in New York City Housing Authority (NYCHA). This study uses survey data collected for this initiative to explore the relationship between mental health and self-efficacy to manage chronic conditions among NYCHA residents with asthma, diabetes, and/or hypertension, and assess whether key variables such as connectedness to health care, social isolation and general health influence this relationship.
Method(s): Five NYCHA housing developments were selected for the CHW intervention with five matched developments for comparison. Four-hundred adult residents with a chronic disease were recruited. Baseline intake interviews were conducted in person. Self-efficacy for managing chronic disease was measured with a 6-question scale. Depression was assessed using PHQ9 scores, a screen for the presence and severity of depression. Difficulty with mental health was assessed with questions on how difficult mental health problems made it to do work, take care of things at home, or get along with others. Bivariate analyses were conducted to assess the relationship between mental health and self-efficacy. A hierarchical linear regression model was run with mental health and other relevant variables (selected based on availability in the dataset and theoretical significance) as independent variables and self-efficacy as the outcome variable.
Result(s): Self-rated general health predicted the greatest amount of variance in self-efficacy (15.7%, p < 0.001). Mental health also contributed significantly; difficulty with mental health contributed 4.0% (p< 0.001) and depressive symptoms contributed 1.1% (p=0.03) to the variance in self-efficacy. Other variables, including demographics, type of insurance, connectedness to a primary care provider, and social isolation, were not associated with self-efficacy. Overall, the full model explained 22.5% of the variance in self-efficacy to manage chronic conditions.
Conclusion(s): NYCHA residents with mental health difficulty or depression represent a uniquely marginalized subpopulation of public housing residents, and were found to have lower self-efficacy than other residents, which may mean decreased ability to self-manage chronic medical conditions. Future research should explore relationships among mental health, self-management, and health care outcomes with the goal of augmenting targeted CHW interventions

BACKGROUND:Better research data management (RDM) provides the means to analyze data in new ways, effectively build on another researcher's results, and reproduce the results of an experiment. Librarians are recognized by many as a potential resource for assisting researchers in this area, however this potential has not been fully realized in the biomedical research community. While librarians possess the broad skill set needed to support RDM, they often lack specific knowledge and time to develop an appropriate curriculum for their research community. The goal of this project was to develop and pilot educational modules for librarians to learn RDM and a curriculum for them to subsequently use to train their own research communities. MATERIALS AND METHODS/METHODS:We created online modules for librarians that address RDM best practices, resources and regulations, as well as the culture and practice of biomedical research. Data was collected from librarians through questions embedded in the online modules on their self-reported changes in understanding of and comfort level with RDM using a retrospective pre-post design. We also developed a Teaching Toolkit which consists of slides, a script, and an evaluation form for librarians to use to teach an introductory RDM class to researchers at their own institutions. Researchers' satisfaction with the class and intent to use the material they had learned was collected. Actual changes in RDM practices by researchers who attended was assessed with a follow-up survey administered seven months after the class. RESULTS AND DISCUSSION/CONCLUSIONS:The online curriculum increased librarians' self-reported understanding of and comfort level with RDM. The Teaching Toolkit, when employed by librarians to teach researchers in person, resulted in improved RDM practices. This two-tiered curriculum provides concise training and a ready-made curriculum that allows working librarians to quickly gain an understanding of RDM, and translate this knowledge to researchers through training at their own institutions.

OBJECTIVE:To provide evidence for the validity of an Introductory Clinical Experience (ICE) that was implemented as a baseline assessment of medical students' clinical communication skills to support progression of skills over time. METHODS:In this longitudinal study of communication skills, medical students completed the ICE, then a Practice of Medicine (POM) Objective Structured Clinical Exam 8 months later, and the Comprehensive Clinical Skills Exam (CCSE) 25 months later. At each experience, trained Standardized Patients assessed students, using the same behaviorally anchored checklist in 3 domains: Information Gathering, Relationship Development, and Patient Education and Counseling (PEC) with good internal reliability (.70-.87). Skills development patterns were described. ICE as a predictor of later performance was explored. Students' perspectives were elicited. RESULTS: = .48, large effect), in 4 patterns. ICE and POM scores predicted future communication skills. Most students recognized the educational value of ICE. CONCLUSION/CONCLUSIONS:Entering medical students' clinical communication skills increase over time on average and may predict future performance. PRACTICE IMPLICATIONS/CONCLUSIONS:Implementing an ICE is likely a valid strategy for monitoring progress and facilitating communication skills development.

PURPOSE/OBJECTIVE:To determine practices and opinions among study investigators in the Zoster Eye Disease Study (ZEDS) regarding suppressive valacyclovir treatment for recent-onset and chronic herpes zoster ophthalmicus (HZO). METHODS:An Internet-based survey was distributed to 170 ZEDS study investigators with questions regarding treatment practices for stromal keratitis in HZO and opinions regarding the efficacy of prolonged antiviral prophylaxis. RESULTS:The response rate was 72.4% (123/170). Topical steroids and oral antivirals were used by the majority of respondents for stromal keratitis in both recent-onset (69.1%, 85/123) and chronic HZO (63.4%, 78/123) (P = 0.86). The duration of treatment was similar in both recent-onset and chronic HZO (P = 0.58) with 50.4% (124/246) of ZEDS investigators using prolonged treatment for stromal keratitis due to recent-onset or chronic HZO. The majority of ZEDS respondents believe that oral antivirals are effective during treatment (70.7%, 87/123). CONCLUSIONS:Approximately half of ZEDS investigators treat HZO with prolonged oral antivirals, in addition to topical steroids, and two-thirds believe that it is effective. Completion of ZEDS is feasible and necessary to determine whether or not these practices are effective. Participation in this study is necessary to obtain evidence to support treatment that many ophthalmologists use and believe is effective.

Background/UNASSIGNED:Despite evidence that biological and genetic factors contribute strongly to obesity, many healthcare providers still attribute obesity more to controllable behavioral issues rather than factors outside a person's control. We evaluated whether medical school students' beliefs about obesity correlate with ability to effectively counsel patients with obesity. Methods/UNASSIGNED:Clerkship-year medical students at NYU School of Medicine completed an Objective Structured Clinical Experience (OSCE) that tests ability to effectively counsel standardized actor-patients with obesity. We surveyed these students to evaluate their beliefs about the causes of obesity and their attitudes towards people with obesity. We analyzed correlations between student beliefs, negative obesity attitudes, and OSCE performance. Results/UNASSIGNED: < 0.05). Conclusions/UNASSIGNED:Attribution of obesity to external factors correlated with greater ability to counsel patients with obesity, suggesting that educating providers on the biological causes of obesity could help reduce bias and improve provider care.

Introduction: Veterans with mental health disorders smoke at high rates, but encounter low rates of tobacco treatment. We sought to understand barriers and facilitators to treating tobacco use in VA mental health clinics. Methods: This qualitative study was part of a trial evaluating a telephone care coordination program for smokers using mental health services at 6 VA facilities. We conducted semi-structured interviews with 14 staff: 12 mental health clinic staff working at the parent study's intervention sites (n=6 psychiatrists, 3 psychologists, 2 social workers, 1 NP), as well as one psychiatrist and one psychologist on the VA's national tobacco advisory committee. Interviews were transcribed and inductively coded to identify themes. Results: Five "barriers" themes emerged: 1) competing priorities, 2) patient challenges/resistance, 3) complex staffing/challenging cross-discipline coordination, 4) mixed perceptions about whether tobacco is a mental health care responsibility, and 5) limited staff training/comfort in treating tobacco. Five "facilitators" themes emerged: 1) reminding mental health staff about tobacco, 2) staff belief in the importance of addressing tobacco, 3) designating a cessation medication prescriber, 4) linking tobacco to mental health outcomes and norms, and 5) limiting mental health staff burden. Conclusions: VA mental health staff struggle with knowing that tobacco use is important, but they face competing priorities, encounter patient resistance, are conflicted on their role in addressing tobacco, and lack tobacco training. They suggested strategies at multiple levels that would help overcome those barriers that can be used to design interventions that improve tobacco treatment delivery for mental health patients. IMPLICATIONS: This study builds upon the existing literature on the high rates of smoking, but low rates of treatment, in people with mental health diagnoses. This study is one of the few qualitative evaluations of mental health clinic staff perceptions of barriers and facilitators to treating tobacco. The study results provide a multi-level framework for developing strategies to improve the implementation of tobacco treatment programs in mental health clinics.

PURPOSE/OBJECTIVE:To investigate the knowledge, attitudes, and practice patterns of primary care physicians regarding administration of the herpes zoster (HZ) vaccine at NYU Langone Health (NYULH). METHODS:A cross-sectional online survey was distributed from January to March 2017 to all physicians in the Division of General Internal Medicine and Clinical Innovation at NYULH across 5 different practice settings. RESULTS:The response rate was 26% (138 of 530). Of the surveyed physicians, 76% (100/132) agreed that the HZ vaccine was an important clinical priority, compared with 93% and 94% for influenza and pneumococcal vaccination, respectively (P < 0.001). Only 35% (47/132) strongly agreed that it was important, compared with 68% (90/132) and 74% (98/132) who strongly agreed that pneumococcal and influenza vaccines, respectively, were important. Respondents estimated that 43% of their immunocompetent patients aged 60 or older received the HZ vaccine, whereas only 11% of patients aged 50 to 59 received the HZ vaccine (P < 0.001). The rate of HZ vaccination was lower in public hospitals (26%) than in the NYULH faculty group practice (46%) (P = 0.007). A greater percent (67% and 72%) of their patients have received influenza and pneumococcal vaccines, respectively (P < 0.001). Almost all doctors (99%, 131/132) consider the Centers for Disease Control and Prevention recommendations important in determining vaccination practices. CONCLUSIONS:HZ vaccination rates remain relatively low compared with rates of influenza and pneumonia vaccination. The recommendation for vaccination against zoster by the Centers for Disease Control and Prevention for individuals aged 50 years and older and stronger recommendations by primary care physicians for administration of zoster vaccines are needed to increase HZ vaccination rates.