Project description:Background and objectives: Although primary care clinicians provide >60% of U.S. asthma care, no nationally representative study has examined variation in adherence among primary care groups to four cornerstone domains of the Expert Panel Report-3 asthma guidelines: assessment/monitoring, patient education, environmental assessment, and medications. We used the 2012 National Asthma Survey of Physicians: National Ambulatory Medical Care Survey to compare adherence by family/general medicine practitioners (FM/GM), internists, pediatricians and Community Health Center mid-level clinicians (CHC). Methods: Adherence was self-reported (n = 1355 clinicians). Adjusted odds of almost always adhering to each recommendation (≥75% of the time) were estimated controlling for clinician/practice characteristics, and agreement and self-efficacy with guideline recommendations. Results: A higher percentage of pediatricians adhered to most assessment/monitoring recommendations compared to FM/GM and other groups (e.g. 71.6% [SE 4.0] almost always assessed daytime symptoms versus 50.6% [SE 5.1]-51.1% [SE 5.8], t-test p < 0.05) but low percentages from all groups almost always performed spirometry (6.8% [SE 2.0]-16.8% [SE 4.7]). Pediatricians were more likely to provide asthma action/treatment plans than FM/GM and internists. Internists were more likely to assess school/work triggers than pediatricians and CHC (environmental assessment). All groups prescribed inhaled corticosteroids for daily control (84.0% [SE 3.7]-90.7% [SE 2.5]) (medications). In adjusted analyses, pediatric specialty, high self-efficacy and frequent specialist referral were associated with high adherence. Conclusions: Pediatricians were more likely to report high adherence than other clinicians. Self- efficacy and frequent referral were also associated with adherence. Adherence was higher for history-taking recommendations and lower for recommendations involving patient education, equipment and expertise.

Project description:BackgroundIn 2018, the American College of Obstetricians and Gynecologists (ACOG) issued multiple recommendations to optimize care within the first 12 weeks postpartum. We explored the extent to which clinicians follow ACOG's recommendations at the first postpartum visit and identified factors associated with overall adherence to clinical recommendations.MethodsBetween September 2023 and February 2024, we collected data from an online survey about the care practices of 174 obstetric clinicians practicing in California. The response rate was 76%. Adherence was measured by asking the extent to which clinicians always complete care components drawn from a list of 26 of ACOG's clinical recommendations. We used descriptive statistics and ran linear regression models to quantify the association between adherence to guidelines and years of clinical practice, proportion of patients utilizing Medi-Cal, the method of reimbursement received by the provider, perceived organizational, financial and patient barriers, duration of the visit and number of collaborations with other providers.ResultsThe median percentage of components checked by clinicians was 62%. Significantly higher adherence was found among clinicians with at least 12 years of practice compared with those with approximately 5 years or less and among clinicians who collaborated with 5 or more multidisciplinary providers versus fewer than 3. Adherence was also higher among clinicians who on average spent at least 30 min vs. less than 20 min with their patients and those who perceived high financial barriers to care among their patients. In contrast, clinicians who served highly mixed practices of Medi-Cal and non-Medi-Cal recipients reported lower adherence.ConclusionWe sought to understand which clinicians were more able to align their practice with ACOG guidelines at the first postpartum visit. We found that more experienced clinicians, those who simplified their practices to either all Medi-Cal or few Medi-Cal recipients, and those who collaborated more with other providers from various disciplines were best able to provide the care recommended in the guidelines. Our findings highlight where policy, resources and training are needed to improve guideline adherence and whole person care.

Project description:ImportanceDespite published guidelines and a prevalence of pediatric hypertension of approximately 3%, less than 25% of affected children are identified, with 60% not receiving any intervention despite detection. Understanding the knowledge and perceptions of parents or caregivers and health care teams is crucial to identify factors that may contribute to these unacceptably low detection rates.ObjectiveTo examine the knowledge and perceptions of parents and health care teams regarding pediatric hypertension to identify common themes contributing to low hypertension detection.Design, setting, and participantsThis qualitative study, interviewed parents of children diagnosed with hypertension who did not follow up within 1 year after diagnosis and health care clinicians (medical assistants, nurses, managers, pediatricians, and nurse practitioners) across 10 clinics in Delaware and Pennsylvania between November 1, 2022, and March 31, 2023.Main outcomes and measuresWith the use of an inductive thematic approach, codes were developed and themes identified by multidisciplinary research investigators.ResultsA total of 38 stakeholders (mean [range] age, 43 [25-64] years; 33 [86%] female), including 13 parents and 25 health care clinicians, were interviewed. The parent sample was diverse based on race (5 [46%] Black, 5 [38%] White, and 3 [23%] other race), ethnicity (5 [38%] Hispanic and 8 [62%] non-Hispanic), and Child Opportunity Index (5 [38%] very low or low, 3 [23%] moderate, and 5 [38%] high or very high). Parents and clinicians demonstrated awareness of the significance of pediatric hypertension. Parents thought blood pressure checks were important; however, clinicians often had competing priorities during annual visits. Both groups expressed skepticism about high blood pressure readings, attributing them to situational factors or white coat syndrome. Parents and clinicians shared concerns about medication use and preferred lifestyle change. Parents advocated for further testing, whereas clinicians exhibited varying perspectives on additional diagnostics, emphasizing targeted testing strategies and cautious medication approaches.Conclusions and relevanceIn this qualitative study of parents and clinicians, both groups were skeptical of blood pressure readings and expressed concerns about medication use, with a preference for lifestyle changes over medication. Improving detection may require better measurement tools, reassurance about medications, and clear communication on the role of nonpharmacologic treatments, while future interventions should incorporate the perspectives of both parents and clinicians to develop practical strategies for managing pediatric hypertension.

Project description:OBJECTIVES:Although the American Academy of Pediatrics recommends screening for autism spectrum disorder (ASD) for all young children, disparities in ASD diagnosis and intervention in minority children persist. One potential contributor to disparities could be whether physicians take different actions after an initial positive screen based on patient demographics. This study estimated factors associated with physicians completing the follow-up interview for the Modified Checklist for Autism in Toddlers with Follow-up (M-CHAT-F), and referring children to diagnostic services, audiology, and Early Intervention (EI) immediately after a positive screen. METHODS:Children seen in a large primary care network that has implemented universal ASD screening were included if they screened positive on the M-CHAT parent questionnaire during a 16-30 month well child visit (N = 2882). Demographics, screening results, and referrals were extracted from the electronic health record. RESULTS:Children from lower-income families or on public insurance were more likely to have been administered the follow-up interview. Among children who screened positive, 26% were already in EI, 31% were newly referred to EI, 11% were referred each to audiology and for comprehensive ASD evaluation. 40.2% received at least one recommended referral; 3.7% received all recommended referrals. In adjusted multivariable models, male sex, white versus black race, living in an English-speaking household, and having public insurance were associated with new EI referral. Male sex, black versus white race, and lower household income were associated with referral to audiology. Being from an English-speaking family, white versus Asian race, and lower household income were associated with referral for ASD evaluation. A concurrent positive screen for general developmental concerns was associated with each referral. CONCLUSIONS:We found low rates of follow-up interview completion and referral after positive ASD screen, with variations in referral by sex, language, socio-economic status, and race. Understanding pediatrician decision-making about ASD screening is critical to improving care and reducing disparities.

Project description:BackgroundThe 2007 Guidelines for the Diagnosis and Management of Asthma provide evidence-based recommendations to improve asthma care. Limited national-level data are available about clinician agreement and adherence to these guidelines.ObjectiveTo assess clinician-reported adherence with specific guideline recommendations, as well as agreement with and self-efficacy to implement guidelines.MethodsWe analyzed 2012 National Asthma Survey of Physicians data for 1412 primary care clinicians and 233 asthma specialists about 4 cornerstone guideline domains: asthma control, patient education, environmental control, and pharmacologic treatment. Agreement and self-efficacy were measured using Likert scales; 2 overall indices of agreement and self-efficacy were compiled. Adherence was compared between primary care clinicians and asthma specialists. Logistic regression models assessed the association of agreement and self-efficacy indices with adherence.ResultsAsthma specialists expressed stronger agreement, higher self-efficacy, and greater adherence with guideline recommendations than did primary care clinicians. Adherence was low among both groups for specific core recommendations, including written asthma action plan (30.6% and 16.4%, respectively; P < .001); home peak flow monitoring, (12.8% and 11.2%; P = .34); spirometry testing (44.7% and 10.8%; P < .001); and repeated assessment of inhaler technique (39.7% and 16.8%; P < .001). Among primary care clinicians, greater self-efficacy was associated with greater adherence. For specialists, self-efficacy was associated only with increased odds of spirometry testing. Guideline agreement was generally not associated with adherence.ConclusionsAgreement with and adherence to asthma guidelines was higher for specialists than for primary care clinicians, but was low in both groups for several key recommendations. Self-efficacy was a good predictor of guideline adherence among primary care clinicians but not among specialists.

Project description:ImportancePromotion of clinician adherence to stroke guidelines can improve stroke outcomes.ObjectiveTo investigate the outcomes of a multilevel system program on clinician adherence to guidelines for treatment of patients with acute ischemic stroke (AIS).Design, setting, and participantsThis quality improvement study used a prospective interrupted time series (ITS) and difference-in-difference (DID) design, from August 1, 2018, to January 31, 2020, divided into preprogram term and short and long postprogram terms; each term had 6 months. Data were collected during hospitalization and at discharge with an automated medical record data capture system in 58 public hospitals in Zhejiang province, China. Data were analyzed from August 2018 to January 2020.ExposuresThe multilevel system program included a modularized standard template for medical records, centrally supported continuing education, continuous monitoring and feedback, and collaborative workshops.Main outcomes and measuresThe primary outcome was adherence to 12 key performance indicators (KPIs), expressed as (1) percentage of patient-applicable KPIs achieved in each participant and (2) percentage of participants among whom all applicable KPIs were achieved (dichotomous all-or-none measure). The secondary outcome was severe disability or death (modified Rankin Scale 5-6) at discharge.ResultsAmong 45 091 patients (mean [SD] age, 69 [12] years; 18 347 female [40.7%]), 28 721 from 30 hospitals received the program and 16 370 from 28 hospitals continued routine care. In adjusted DID analysis, the program was associated with an increase in the absolute percentage of KPIs achieved per patient (6.46%; 95% CI, 5.49% to 7.43%), absolute rate of all-or-none success (8.29%; 95% CI, 6.99% to 9.60%), and decreased rate of severe disability or death at discharge (-1.68%; 95% CI, -2.99% to -0.38%). The ITS result showed the program was associated with an increase in KPIs achieved per patient per week (slope change in short-term period, 0.36%; 95% CI, 0.20% to 0.52%; level change in long-term period, (9.64%; 95% CI, 4.58% to 14.69%) and in all-or-none success (slope change in short-term period 0.34%; 95% CI, 0.23% to 0.46%; level change in long-term period 5.89%; 95% CI, 0.19% to 11.59%).Conclusions and relevanceThe centrally supported program was associated with increases in clinician adherence to guidelines and reduced the proportion of severely disabled or deceased patients with AIS at discharge, providing support for its wider implementation.

Project description:BackgroundCancer screening guidelines reflect the costs and benefits of population-based screening based on evidence from clinical trials. While most of the existing literature on compliance with cancer screening guidelines only measures raw screening rates in the target age groups, we used a novel approach to estimate degree of guideline compliance across Canadian provinces for breast, colorectal and prostate cancer screening. Measuring compliance as the change in age-specific screening rates at the guideline-recommended initiation age (50), we generally found screening patterns across Canadian provinces that were not consistent with guideline compliance.MethodsWe calculated age-cancer-specific screening rates for ages 40-60 using the Canadian Community Health Survey (2003 and 2005), a cross-sectional, nationally representative survey of health status, health care utilization and health determinants in the Canadian population. We estimated the degree of compliance using logistic regression to measure the change in adjusted screening rates at the guideline-recommended initiation age for each province in the sample.ResultsFor breast cancer, after adjusting for age trends and other covariates, being above age 50 in Quebec increased the probability of being screened by 19 percentage points, from an average screening rate of 24% among 40-49 year olds. None of the other regions exhibited a statistically significant change in screening rates at age 50. Additional analyses indicated that these patterns reflect asymptomatic screening and that Quebec's breast cancer screening program enhanced the degree of guideline compliance in that province. Colorectal cancer screening practice was consistent with guidelines only in Saskatchewan, as screening rates increased at age 50 by 12 percentage points, from an average rate of 6% among 40-49 year olds. For prostate cancer, the regions examined here are not compliant with Canadian guidelines since screening rates were quite high, and there was not a discrete increase at any particular age.ConclusionsScreening practice for breast, colorectal and prostate cancer was generally not consistent with Canadian clinical guidelines. Quebec (breast) and Saskatchewan (colorectal) were exceptions to this, and the impact of Quebec's breast cancer screening program suggests a role for policy in improving screening guideline compliance.

Project description:ObjectiveThe aim of the study was to survey obstetrician-gynecologists' cervical cancer screening practices and management of cervical abnormalities to ascertain adherence to guidelines.MethodsFrom January to July 2019, obstetrician-gynecologists at 5 St. Louis area hospitals were surveyed online about cervical cancer screening and management practices through 13 clinical vignettes. Survey scores and the American Society of Colposcopy and Cervical Pathology (ASCCP) app use were compared using Mann-Whitney tests.ResultsWhen screening 30- to 65-year-old participants, 114 (98%) of the 116 total participants used co-testing, but only 71 (61%) screened at 5-year intervals. None used primary human papillomavirus (HPV) testing. For 21- to 29-year-old participants, 17 (15%) screened with annual cytology, whereas 14 (12%) used annual or every 3-year co-testing. Forty eight (41%) screened younger than 21 years, regardless of risk factors or only if immunocompromised. Eleven (9%) continued screening after total hysterectomy for benign indications. Only 2 (2%) responded to all clinical vignettes in adherence to guidelines. More than 30% of participants would pursue unnecessary HPV testing and/or loop electrosurgical excision procedure for persistent low-grade cytology. Fifty eight (48%) incorrectly reported hysterectomy as management for adenocarcinoma in situ on biopsy. Participants would undertreat young women with high-grade abnormalities including high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 3 (48, 41%) and high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 1 (65, 56%). Forty one (35%) reported exiting women from screening prematurely. The median score for participants using the ASCCP app was significantly greater than those who did not (79% vs 71%, p = .002).ConclusionsMidwestern obstetrician-gynecologists' adherence to the guidelines for cervical cancer screening and management of abnormal results is suboptimal. Although co-testing for women aged 30-65 years has been broadly adopted, primary HPV testing has not. Physicians overscreen, overtreat low-grade lesions, and undertreat high-grade lesions in young women.

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Clinician Adherence to Hypertension Screening and Care Guidelines.

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Clinician Adherence to Hypertension Screening and Care Guidelines.

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