The AMA is urging states to create 'safe-haven' programs to encourage treatment for physicians suffering from burnout and mental health conditions.
The American Medical Association adopted several new policies during the organization's Annual Meeting this week.
The AMA is the largest national association representing physicians, convening more than 190 state and specialty medical societies as well as other key stakeholders. Activities of the AMA include advocacy in courts and legislatures, prevention of chronic disease, addressing public health crises, and training physician leaders.
Decisions made at this week's AMA Annual Meeting include the following 10 policy areas.
Poverty-level wages: A new AMA policy says poverty is detrimental to health, and it committed the organization to advocate for federal, state, and local policies regarding minimum wage that include adjusting the wage level to keep pace with inflation. The AMA also affirmed that minimum wage policies should be consistent with the AMA’s principle that the highest attainable standard of health is a basic human right and that optimizing the social determinants of health is an ethical obligation of a civil society.
Climate change: The AMA declared climate change a public health crisis that threatens the health and well-being of all people. Building on existing efforts to address the climate crisis, the new policy mobilizes the AMA to advocate for policies that limit global warming to no more than 1.5 degrees Celsius, reduce U.S. greenhouse gas emissions aimed at carbon neutrality by 2050, support rapid implementation and incentivization of clean energy solutions, and push for significant investments in climate resilience with climate justice in mind.
Addressing disinformation: With disinformation continuing to have a negative effect on efforts to deal with the coronavirus pandemic, the AMA adopted a policy to address health-related disinformation by health professionals. As part of a report developed by the AMA Board of Trustees, the new policy provides a comprehensive strategy aimed at stopping the spread of disinformation and protecting the health of the public, including actions that can be taken by the AMA, social media companies, publishers, state licensing bodies, credentialing boards, state and specialty health professional societies, and organizations that accredit continuing education.
Rural public health: With rural local health departments often limited by budgets, staffing, and capacity constraints that affect their ability to provide sufficient public health services, the AMA adopted a policy advocating for adequate and sustained funding for rural public health programs. The policy also supports equitable access to the 10 Essential Public Health Services and the Foundational Public Health Services to protect and promote the health of all people. The policy calls for more research to identify the unique needs and models for delivering public health and healthcare services in rural areas.
Combatting loneliness: The AMA adopted a policy identifying loneliness as a public health issue that impacts people of all ages. The new policy supports evidence-based efforts to combat loneliness. Studies show that loneliness is not only a significant predictor of functional decline and premature death similar to the risk from obesity, but loneliness in adolescence is associated with impaired sleep, symptoms of depression, and poorer health in general.
Criminalization of reproductive health: Responding to more policing and surveillance of reproductive health services, the AMA adopted a policy recognizing that it is a violation of human rights when government intrudes into medicine and impedes access to safe, evidence-based reproductive health services, including abortion and contraception. As part of the new policy, the AMA will seek expanded legal protections for patients and physicians against government efforts that criminalize reproductive health services.
Physician mental health: For physicians who seek care for burnout or other mental health-related issues, the AMA adopted a policy to urge states to create "safe-haven" programs to encourage counseling and treatment. The programs would complement Physician Health Programs to add additional, evidence-based options for physicians to receive care and enable them to continue practicing as long as public safety is not at risk.
Cannabis legal records: The AMA adopted a policy to call on states to expunge criminal records of people who were arrested or convicted of cannabis-related offenses that later were legalized or decriminalized. The policy aims to introduce equity and fairness into the fast-changing effort to legalize cannabis. "This affects young people aspiring to careers in medicine as well as many others who are denied housing, education, loans, and job opportunities. It simply isn't fair to ruin a life based on actions that result in convictions but are subsequently legalized or decriminalized," AMA Trustee Scott Ferguson, MD, said in a prepared statement.
Gun violence: The AMA adopted three policies related to firearms violence:
The AMA is advocating for school drills related to active shooter scenarios to be conducted in an evidence-based and trauma-informed way that takes children's physical and mental wellness into account, considers prior experiences that might affect children's response to a simulation, avoids creating additional traumatic experiences for children, and provides support for students who may be adversely affected.
The AMA called on state and federal lawmakers to subject homemade "ghost guns" to the same regulations and licensing requirements as traditional firearms.
The AMA committed to advocating for legislation requiring that packaging for ammunition carry a boxed warning. At a minimum, the AMA favors a warning with text-based statistics and/or graphic warning labels related to the risks, harms, and mortality associated with gun ownership and use.
Sexual assault examination kit backlog: The AMA called on state and federal officials to process all backlogged and new sexual assault examination kits upon patient consent and in a timely fashion. The kits have played a significant role in identifying and incarcerating perpetrators of violent sexual crimes. Even when a suspect cannot be instantly identified, the information can be uploaded to the Federal Bureau of Investigation's Combined DNA Index System and assist in the later identification of a criminal. The AMA also called for additional money to facilitate the immediate testing of the kits.
A new study compared the telehealth perceptions of mental health, primary care, and specialty care clinicians, as well as use of video versus phone telehealth.
Perceptions of telehealth vary between mental health (MH), primary care (PC), and specialty care (SC) clinicians, with an impact on remote care utilization rates, a new research article says.
Utilization of video and phone telehealth has expanded exponentially during the coronavirus pandemic as a way to limit patient and staff exposure to infection. Clinician perceptions about telehealth may affect utilization—a survey conducted early in the pandemic found Veterans Health Administration PC and SC clinicians were more likely to prefer phone over video care but MH clinicians were inclined to prefer video care.
The new research article, which was published by JAMA Network Open, features survey data collected from more than 800 clinicians in the Department of Veterans Affairs New England Healthcare System, which serves about 260,000 veterans annually. The survey was conducted from August to September 2021.
The study generated several key data points.
Relative to PC and SC clinicians, MH clinicians gave video care the highest rating, and they had a greater preference for treating new and established patients remotely with video
PC and SC clinicians had a greater likelihood of rating the quality of phone care as at least equivalent to video care for new and established patients
PC and SC clinicians were more likely to note challenges of video care such as patient barriers and inability to have a physical examination
In providing remote care to established patients, the majority of PC and SC clinicians either had no preference for telehealth modality or preferred phone care
Utilization rates reflected clinician preferences and perceptions, with MH clinicians significantly more likely to conduct telehealth visits with video compared to PC and SC clinicians
"This survey study found significant specialty-level differences in clinician attitudes toward video and phone telehealth care, many of which aligned with observed differences in actual utilization of these modalities. Our findings suggest that in the absence of financial incentives, clinician beliefs, particularly regarding the quality and ease of use of telehealth, played an important role in the care modalities that were ultimately used with patients," the study's co-authors wrote.
Interpreting the data
MH clinicians conducted the highest proportion of video visits during the time of the survey. "MH clinicians were also more likely to report that their selection of care modalities was influenced by leadership guidance and data regarding the relative effectiveness of video, phone, and in-person care. Indeed, given that telehealth was being used for MH care well before the onset of the COVID-19 pandemic, there is a strong body of evidence demonstrating that video care is noninferior to in-person MH services, as well as an emerging literature suggesting that phone care may sometimes be inferior in quality to video care," the study's co-authors wrote.
PC and SC clinicians were less likely than MH clinicians to prefer video over phone telehealth visits, the study's co-authors wrote. "PC and SC clinicians, who conducted substantially less video care than MH, had multiple similarities in their responses across the survey. These clinicians were more likely to rate phone care as being at least equivalent in quality to video. They were also more likely to endorse challenges of video care, including patient barriers to use and the inability to conduct an adequate physical examination. Importantly, most PC and SC clinicians either had no preference or preferred phone for remote care of established patients."
PC clinicians provided the highest proportion of phone visits for established patients. "This could be owing, in part, to their increased likelihood of endorsing challenges of video care coupled with a tendency to believe that video and phone care are equivalent in quality, particularly for established patients. Indeed, most PC clinicians either preferred phone or had no preference between phone and video for the remote care of established patients. This finding underscores the importance of complexity in influencing adoption of new technologies; if PC clinicians believe that phone and video care are equivalent in quality, ease of use may then drive the choice of phone over video, particularly when treating patients whom they have already seen in-person," the study's co-authors wrote.
Most of the MH, PC, and SC clinicians reported that patient preference was a major contributor to selecting a telehealth modality. However, even though there is evidence that patients increasingly prefer video over phone visits, utilization data show that a significant proportion of telehealth visits are being conducted by phone. "It is unclear how often what we refer to as patient preference is instead a measure of patient readiness for telehealth (i.e., that the patient owns a video-enabled device or is comfortable navigating a telehealth platform). A patient without a smartphone may be viewed as preferring a phone appointment because they do not have access to the appropriate technologies. Indeed, COVID-19 has revealed a stark digital divide in which patients who are older and/or have lower income are less likely to be video-ready," the study's co-authors wrote.
The prevalence of high-risk pregnancies is on the rise in the United States.
Health systems, hospitals, and physician practices need to step up their efforts to provide care in cases of high-risk pregnancies, an expert at San Diego-based Scripps Health says.
A national study of women aged 18 to 44 showed that complicated pregnancies are growing more prevalent in the United States—they rose by 16.4% from 2014 to 2018. The same study, which looked at 1.8 million pregnancies, revealed that childbirth complications increased by about 14% from 2014 to 2018.
These are high numbers in the span of just four years, says Sean Daneshmand, MD, medical director of the Maternal-Fetal Medicine Program at Scripps Clinic. "The study also found a significant increase in chronic health conditions in women before becoming pregnant—issues such as high blood pressure and obesity have become much more common, which can make pregnancy a challenge to manage. Also on the rise are conditions that begin during pregnancy such as hypertensive-related crises, which are better known as pre-eclampsia, and gestational diabetes. These conditions increased by 19% and 16%, respectively."
A significant percentage of pregnancies involve medical challenges, he says. "While 80% of women have healthy pregnancies and deliveries, the others have one or more risk factors that can cause serious complications. These could be stemming from heart disease, hypertensive-related crises, diabetes, obesity, and depression and anxiety. For babies, there can be genetic or chromosomal abnormalities, structural defects such as heart or spine defects, and pre-term birth."
Health systems and hospitals should have integrated care teams to provide services for women with high-risk pregnancies, Daneshmand says. "One of the major failings of our country's healthcare system is, too often, we do not have the right team in place to provide the best care for high-risk pregnancies. We need to make sure that the physical and mental health of pregnant women are addressed. A major problem in caring for high-risk patients is inadequate access to mental health services. There was a recent report from USAFacts, which is a clearinghouse for U.S. government data, that showed 37% of Americans live in areas with shortages of mental health professionals. The nation needs nearly 6,400 mental health professionals to fill in the gaps."
Depression and anxiety among women during and after their pregnancies can have a negative impact on their babies, he says. "There was a recent study published in JAMA Pediatrics that suggested maternal depression and anxiety during the perinatal stage spanning from conception to the baby's first year of life is associated with negative developmental outcomes in the offspring through adolescence, including deficits in language and motor development. What happens during pregnancy can impact a child in a positive or a negative way."
Scripps' approach to high-risk pregnancies
Daneshmand says Scripps Health has several key elements in place for care of high-risk pregnancies, including helping patients manage health issues before they become pregnant, close collaboration between various subspecialties such as cardiology and endocrinology, and pre-conception counseling. The health system has recently taken two vital steps, he says.
"One is creating a complex care coordinator—better known as a patient navigator—to help keep patients from falling into dangerous spirals. Scripps added this new role to our Maternal-Fetal Medicine Program in October 2021. The complex care coordinator role is seen more commonly in cancer and organ transplant clinics. We also have expanded access to mental health therapists. Scripps recently began a unique collaboration with a local nonprofit organization to expand access to mental health therapists for high-risk moms, with the goal of identifying these new mothers and delivering care to them within a 72-hour period after diagnosis. We can screen these patients but getting them help in a timely fashion is a challenge for most healthcare professionals."
The two recent initiatives are adding value to Scripps' high-risk pregnancy care, Daneshmand says. "By embedding a complex care coordinator inside our clinic and teaming with a community partner for additional mental health resources, we are building a bridge to connect vulnerable patients to more of the care they need."
Complex care coordinator
Adding a complex care coordinator to the Maternal-Fetal Medicine Program has improved care for high-risk pregnancies, he says. "With our complex care coordinator, we have someone who has clinical experience who is emotionally intelligent and compassionate. We have embedded this role within the clinic, so that when the patient sees me and has an abnormal finding, they can have a consult with the complex care coordinator and follow-up visits with the complex care coordinator."
The complex care coordinator has become a crucial care team member, Daneshmand says. "The complex care coordinator is available for every one of our high-risk patients, making sure they are receiving necessary testing and follow-up care as well as answering questions. She plays a critical role in determining which patients need additional help. She keeps an eye out for warning signs that may emerge between screenings because early intervention is important for issues such as depression and anxiety."
The complex care coordinator is like a consultant, he says.
"For example, a woman could come in at 20 weeks of her pregnancy, have an ultrasound, and we suspect the baby has a heart defect. This patient is then referred to pediatric cardiology to get a fetal echocardiogram and referred to our complex care coordinator. The complex care coordinator either sees the patient immediately or within 48 hours. The patient is also scheduled for an appointment within a week for mental health screenings to assess whether they are exhibiting any signs of depression or anxiety. From that point forward, care depends on the diagnosis and whether the complex care coordinator feels the patient should be seen more frequently. If the patient exhibits any signs of depression or anxiety, the complex care coordinator refers the patient to a program called My Brain & My Baby."
Improving care for high-risk pregnancies
Daneshmand offered advice for other health systems seeking to improve care for high-risk pregnancies. "First, we need to recognize that complicated pregnancies are becoming more common. Secondly, we need to move beyond the status quo and find ways to improve care for these vulnerable moms and their children. Putting an integrated care team in place to surround and support these patients is important. For example, this can ensure that mothers-to-be who need mental health services receive care in a timely fashion—this is one of the main challenges in our country."
The stakes are high, he says. "We have a responsibility to provide the care that is desperately needed by these moms and their babies. This impacts entire families—it is not just the mother who struggles with depression or other complications. The fetus can be impacted, as well as other children, the woman's partner, and the workplace. Their future hangs in the balance."
The Wisconsin-based physician was on the AMA Board of Trustees from 2014 to 2020, including serving as chair of the board.
The American Medical Association has voted a Wisconsin anesthesiologist to serve as the organization's president-elect.
Jesse Ehrenfeld, MD, MPH, was elected at the Annual Meeting of the AMA House of Delegates. He will become president of the AMA in June 2023.
"I am honored to be elected by my peers to represent the nation's physicians and the patients we serve. It is a pivotal and challenging time for medicine, physicians and our health system, and as president-elect, I am committed to advancing the AMA's immediate goals around the Recovery Plan for America's Physicians, as well as the longer-term advocacy efforts aimed at shaping the future of medicine and improving the health of the nation," Ehrenfeld said in a prepared statement.
He is the first openly gay individual to serve as AMA president-elect and is an inaugural recipient of the National Institutes of Health Sexual and Gender Minority Research Investigator Award.
Ehrenfeld has served in several AMA leadership roles. He was elected to the AMA Board of Trustees in 2014 and served as chair of the board from 2019 to 2020. He has served as a member of the governing councils of the AMA Young Physicians Section and the AMA Resident and Fellow Section.
Ehrenfeld is a practicing anesthesiologist, senior associate dean, and tenured professor of anesthesiology at the Medical College of Wisconsin. He is also an adjunct professor of anesthesiology and health policy at Vanderbilt University and adjunct professor of surgery at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Ehrenfeld is the co-author of 18 clinical textbooks and more than 200 peer-reviewed articles. His areas of research include using digital technology to improve surgical safety, patient outcomes, and health equity.
He is a graduate of Haverford College, the University of Chicago Pritzker School of Medicine, and the Harvard School of Public Health. He conducted his post-graduate work including a residency in anesthesiology at Massachusetts General Hospital in Boston.
A combat veteran, Ehrenfeld served in Afghanistan during Operation Enduring Freedom and Resolute Support Mission. He lives in Milwaukee with his husband, Judd Taback, and their son, Ethan.
Before the coronavirus pandemic, physician burnout was a national concern, and the pandemic has driven physician burnout to crisis proportions. The Association of American Medical Colleges projects there will be a shortage of physicians between 37,800 and 124,000 clinicians by 2034.
In comments before the AMA House of Delegates, AMA President Gerald Harmon, MD, said the need for action is urgent. "America's doctors are a precious, and irreplaceable, resource. Physician shortages, already projected to be severe before COVID, have almost become a public health emergency. If we aren't successful with this Recovery Plan, it'll be even more challenging to bring talented young people into medicine and fill that expected shortage."
The Recovery Plan has five key elements:
Supporting telehealth services including insurance coverage
Reforming the way Medicare pays for physician services
Stopping "scope creep" that expands the scope of practice of non-physicians such as nurse practitioners
Reforming prior authorization of medical services to reduce administrative burden on physician practices and to avoid care delays for patients
Tackling physician burnout and reducing stigma around physician mental health
Expanding telehealth
The pandemic spurred unprecedented growth in telehealth, with 90% of physicians shifting to telehealth to provide patient care, and a continuation of telehealth services is in the best interest of physicians and patients, Harmon said.
"[The Centers for Medicare & Medicaid Services] made changes to ensure that telehealth payment rates were equivalent to in-person services including audio-only visits—meaning a telephone call! And then a funny thing happened: doctors and patients discovered that this wasn't such a bad idea in many circumstances. It's safe, convenient, and certainly for patients, less time consuming than a visit to the office. In my rural community, patients have substantial geographic barriers like rivers, swamps, and islands that contribute to long travel delays. Digital health is a godsend to these patients," he said.
Telehealth gains achieved during the pandemic must be preserved, Harmon said. "We know the vast majority of patients and physicians want this type of care to continue after the declared Public Health Emergency is over. Telehealth is here to stay, and we are fighting to update our laws and regulations to reflect that fact."
Reforming Medicare physician payment
Medicare reimbursement for physician services has been inadequate for years, and annual uncertainty about Medicare physician payment is crippling for physician practices, he said.
"Medicare physician payments are the only component of healthcare delivery subject to budget neutrality and have fallen 20%, adjusted for inflation, since 2001—an average of about 1% a year. As a result of various legislative and regulatory provisions implemented prior to and during the COVID pandemic, we were threatened with a 10% cut in Medicare payments this past January. Thanks to the pressure of the AMA and others in organized medicine, Congress acted at the last minute to avert the cuts. This was a major victory. But we should not have to suffer this annual cliffhanger. We need a permanent solution to end the annual battles that threaten the economic survival of physician practices."
The need for payment reform is undeniable, Harmon said. "We must be able to predict financial returns with some reliability in order to invest in costly infrastructure like new technologies and treatments. In short—we're done with short-term patches and looming cuts."
Stopping 'scope creep'
Physicians are better equipped to play leading roles in care teams than other clinicians, he said.
"Quality, affordable healthcare is only possible with teamwork. We rely on nurses, physician assistants, and office workers to do the invaluable work they are trained to do. My practice, for example, has a superb team of staff delivering this team-based care. We currently have physicians, [advanced practice registered nurses], physician assistants, licensed social workers, dedicated office staff, and others under one roof. But patients need to trust that a physician is leading their care and leading the team. We have years' more education, and thousands of hours' more clinical training than other members of the team, and are better prepared to treat complex cases and complications."
Reforming prior authorization
Prior authorization for medical services by payers places an unnecessary administrative burden on physician practices and is bad for patients, Harmon said.
"In a recent AMA survey, 93 percent of physicians reported that hurdles imposed by prior authorization for medication, tests, and procedures resulted in care delays for their patients. Four out of five doctors said these processes have led patients to abandon their treatment! Can you believe it? And navigating these hurdles is also a burden for physicians and staff, who must spend valuable patient care time doing this. I have personally done this more times than I can count, to ensure that my patients get the care they need. Four years ago, the AMA developed a Consensus Statement on Improving the Prior Authorization Process together with other national organizations representing health plans and providers. Unfortunately, since then, insurers have done precious little to implement agreed-upon improvements."
Physician burnout and mental health stigma
Physician well-being needs to be a top priority, he said.
"The final element of our Recovery Plan—and potentially the most important—is to develop a health system that retains existing physicians, attracts new physicians, and reduces burnout. For over a decade, the AMA has worked to remove administrative barriers like prior authorization to care that can lead to burnout. But we know solutions must go even further. We must find ways for physicians to address their mental health needs without fear of negative repercussions, and to practice their skills without threats of hostility or violence. This March, we took a great step forward with the passage of the Dr. Lorna Breen Health Care Provider Protection Act. This new law—named after a young physician who took her own life early in the pandemic—will direct more funding and resources to support the mental health needs of physicians."
Reducing mental health care stigma for physicians is essential, Harmon said. "The AMA is working at the state and national levels to reform outdated language on medical licensing applications and employment and credentialing applications that may be stigmatizing. We are also supporting legislation to create confidential physician wellness programs so that physicians and medical students will have somewhere to go when they need help."
A physician involved in the move to seek union representation says the main reason for the effort is to gain influence on administrative decision-making.
Physicians and other healthcare workers at Bend, Oregon-based St. Charles Medical Group have filed for union representation from the American Federation of Teachers.
Union representation of physicians is relatively rare. Several factors are contributing to efforts to unionize physicians, including burnout, the growing physician as employee model, and desire among physicians to have a stronger voice in healthcare organization administration.
St. Charles Medical Group is affiliated with St. Charles Health System, which features four acute-care hospitals in central Oregon. In addition to physicians, the union effort at St. Charles Medical Group includes nurse practitioners, physician assistants, behavioral health clinicians, licensed clinical social workers, and other healthcare workers.
The American Federation of Teachers is a national union with 1.7 million members, including about 200,000 healthcare workers.
A physician involved in the move to seek union representation at St. Charles Medical Group says the primary impetus of the effort is to gain decision-making authority at the medical group and St. Charles Health System.
"It is mainly concern about bad administrative decisions. It has gone from bad decisions to frustration and concern about the healthcare that we are providing. The term union tends to make people think about things like pay and strikes, and that is not a major part of the discussion. It is concern about patient care," Lester Dixon, MD, an emergency room physician at St. Charles Medical Group, told HealthLeaders.
A recent event cemented the move to unionize, he said. "There is a group called the Medical Governance Board that is about 10 providers that St. Charles Health System has supported, theoretically. The Medical Governance Board is supposed to provide guidance in monthly meetings with the administration to help steer the St. Charles Health System and St. Charles Medical Group. About three months ago, when things were starting to get heated up regarding finances, the leader of the Medical Governance Board, Dr. Richard Freeman, did not show up to a meeting. The health system CEO and chief medical officer said they had fired him. Members of the Medical Governance Board said they should be part of that decision, and they were essentially told they had no power."
Forming a union will boost the voice of physicians and other healthcare workers, Dixon said. "The expectation is that if you have a union, the administration cannot make unilateral changes because there is a contract. A union gives you a guaranteed decision-making position that would be much more powerful than what we have had in the past."
Clinicians have also been frustrated by the health system administration's handling of COVID-19 patients, he said. "They closed the main hospital to everything except COVID patients, which completely eliminated elective surgery in the operating rooms of the main hospital. That put us behind on surgeries and affected patient care, when we had three other hospitals that could have absorbed some of the COVID patients."
Health system's response
Jeff Absalon, MD, chief physician executive at St. Charles Health System, responded to the union effort in a prepared statement.
"As always, we want to reassure our community that patient care is and will continue to be our top priority. We greatly value our employed providers and respect their right to take this step, although we'd far prefer to work directly with them in partnership while navigating these unprecedented times. We know many healthcare workers are frustrated and exhausted after the past two years of the COVID-19 pandemic. Our focus as individuals and a health system needs to be on healing and recovering from the pandemic and stabilizing our finances so that we can preserve and strengthen the vital healthcare services that we provide to our community," he said.
Other union benefits
Forming a union will benefit physicians and other healthcare workers in three areas beyond the ability to have more influence on administrative decisions, Dixon said.
"It will give us assurances that we can staff adequately. The administration has just announced that as part of their cost-cutting measures, they are going to go from two to one provider at some of the facilities. That is obviously not patient-focused."
"There has also been talk that compensation is going to be related to productivity in the clinics, where you will be required to see a certain number of patients per hour or per shift. There are huge concerns about how that is going to work, especially if the administration is cutting back other staffing."
"Forming the union will also open the accounting book. The administration has made a lot of claims—sometimes stepping on their own prior claims—about how money is being spent. By opening the accounting book, we should be able to make sure that financial claims are addressed directly."
A new study found that nearly three-quarters of primary care clinicians would prescribe antibiotics for bacteria in urine against established guidelines.
In a survey study of primary care clinicians, a majority of survey respondents said they would prescribe antibiotics for asymptomatic bacteriuria, which does not bode well for antibiotic stewardship, a new research article found.
Even if testing shows bacteria in a patient's urine, treating asymptomatic bacteriuria is against guidelines set by the Infectious Diseases Society of America. Prescribing antibiotics for asymptomatic bacteriuria can lead to negative outcomes, including the development of Clostridium difficile infection.
The new research article, which was published in JAMA Network Open, examines survey data collected from more than 500 primary care clinicians. The survey included a clinical scenario of asymptomatic bacteriuria: a 65-year-old man who reported foul-smelling urine but no pain or difficulty with urination.
The study includes several key data points:
Among 551 primary care clinicians surveyed, 71% said they would prescribe antibiotics in the asymptomatic bacteriuria scenario
Clinicians with a background in family medicine were more likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 2.93)
Clinicians with a high score on the Medical Maximizer-Minimizer Scale, which indicated a tendency toward high utilization of medical services, were more likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 2.06)
Resident physicians were less likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 0.57)
Pacific Northwest clinicians were less likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 0.49)
Survey respondents who would prescribe antibiotics in the asymptomatic bacteriuria scenario estimated a 90% likelihood of a urinary tract infection (UTI), and survey respondents who would not prescribe antibiotics estimated a 15% likelihood of a UTI
"The findings of this survey study suggest that most primary care clinicians prescribe inappropriate antibiotic treatment for asymptomatic bacteriuria in the absence of risk factors. This tendency is more pronounced among family medicine physicians and medical maximizers and is less common among resident physicians and clinicians in the U.S. Pacific Northwest. Clinician characteristics should be considered when designing antibiotic stewardship interventions," the study's co-authors wrote.
Interpreting the data
The findings related to the likelihood of a UTI probably indicate a knowledge gap, the study's co-authors wrote. "Overwhelmingly, clinicians who indicated they would prescribe antibiotics estimated that the patient had a high probability of having a UTI, although the case details did not support this diagnosis. We suspect that many clinicians in our sample were not aware of what constitutes UTI symptoms or were not aware that symptoms are required to substantiate a UTI diagnosis."
The study's findings indicate that resident physicians have less of a knowledge gap than attending physicians, many of whom do not have the benefit of better education about bacteriuria, the co-authors wrote. "Given that current residents were less likely than attending physicians to prescribe antibiotics, greater clarity in the recent literature on what constitutes a symptom and evolving graduate medical education on appropriate management of asymptomatic bacteriuria may mean that knowledge gaps will be less of an issue moving forward."
Regarding cultural impact, the study says a culture of high-value care in the Pacific Northwest likely led to better prescribing practices in that region of the country. The lead author of the study told HealthLeaders that fostering an effective antibiotic stewardship culture can be achieved while clinicians are training or early in their careers.
"Clinicians tend to model their behaviors on what they observe from their peers. One way to encourage the development of good habits would be to encourage trainees and early career clinicians to practice in different parts of the country or different settings, such as safety net hospitals or Veterans Affairs facilities. That way, clinicians are exposed to different ways to practice before bad habits can become too ingrained," said Jonathan Baghdadi, MD, PhD, an assistant professor in the Department of Epidemiology and Public Health at University of Maryland School of Medicine.
The survey data shows clinician attributes can impact their clinical decisions, study co-author Daniel Morgan, MD, MS, told HealthLeaders. "Our study demonstrates that doctors are human and not always rational. Human aspects like personality and culture can change how we treat patients," said Morgan, who is a professor of epidemiology and public health and medicine at University of Maryland School of Medicine.
The finding that clinicians who were medical maximizers were more inclined to prescribe antibiotics for asymptomatic bacteriuria was not surprising, Baghdadi said. "I suspect that inappropriate antibiotic prescribing for asymptomatic bacteriuria is driven by the common but potentially harmful attitude that doing more is better, even when doing more is not supported by evidence, known as 'action bias' or by others as the 'Yes, Prime Minister' effect. When facing a patient and not being sure what to do, many clinicians will opt to do something, even if it's not clear that doing that thing will be beneficial."
Antibiotic stewardship implications
"It is highly problematic that the majority of clinicians would give antibiotics when a patient is healthy, and antibiotics are unnecessary," Morgan said.
The study's findings are "shocking," Baghdadi said. "It is widely recognized that outpatient antibiotics for suspected urinary infections are commonly prescribed in situations not recommended by guidelines, using agents not recommended by guidelines, for durations not recommended by guidelines. The findings from our study are shocking because we present a case patient in which there is no ambiguity, and yet clinicians prescribed inappropriate antibiotics anyway."
For clinicians who face asymptomatic bacteriuria cases, clinical decision support is needed to encourage antibiotic stewardship, Baghdadi said. "Education alone is not the answer. Asymptomatic bacteriuria is poorly understood by clinicians, and efforts to improve awareness of who will benefit from antibiotics do not consistently or sustainably change behavior. To change antibiotic prescribing, solutions need to be hard-wired into electronic health systems that guide clinicians toward making the right choice."
After the first year of interventions at Emory Saint Joseph's Hospital, there was a 63% decrease in hospital-onset C. diff cases as compared to the two years prior.
Through a series of interventions since 2016, Emory Saint Joseph's Hospital in Atlanta has been able to significantly reduce hospital-onset Clostridioides difficile.
Clostridioides difficile (C. diff) is a bacterium that causes severe diarrhea and colitis, with nearly half a million infections in the United States annually, according to theCenters for Disease Control and Prevention. One in 11 patients over age 65 with a healthcare-associated C. diff infection die within one month, the CDC says.
Timing is crucial in determining whether a C. diff infection in the inpatient setting is categorized as a hospital-onset C. diff case. If a patient tests positive for C. diff in the first three days of a hospital admission, the case is categorized as community acquired. If a patient tests positive for C. diff after four days or more of a hospital admission, the case is categorized as hospital-onset C. diff. High rates of hospital-onset C. diff draw financial penalties from the Centers for Medicare & Medicaid Services.
Increasing the testing of patients for C. diff in the first three days of hospital admission was a key intervention at Emory Saint Joseph's Hospital, saysCherith Walter, RN, MSN, APRN, a clinical nurse specialist at the facility who led an interdisciplinary team formed in 2016 to tackle hospital-onset C. diff. "A lot of our hospital-onset C. diff cases were being erroneously categorized as hospital-onset infections because we were not testing in the first three days. So, we wanted to make sure we were accurately capturing and reporting community-acquired C. diff.”
The interdisciplinary C. diff reduction team had several stakeholders on the panel's roster.
As a clinical nurse specialist, Walter was chosen to lead the team because a major part of her role at the hospital is to improve outcomes for patients and the organization
Inpatient unit nurse champions helped with education efforts and the rollout of interventions
An infection preventionist brought C. diff expertise in areas such as diagnosis and testing
A physician champion and the hospital epidemiologist helped to make sure clinicians were engaged in C. diff interventions
A clinical microbiologist helped in areas such as setting testing criteria
An environmental services representative helped make changes in how patient rooms were cleaned
An antimicrobial stewardship pharmacist helped to make sure antibiotics were used appropriately and to reduce usage of fluoroquinolone antibiotics, which are a risk factor for the development of C. diff
The primary C. diff reduction interventions included a new testing protocol, enhanced environmental cleaning, antimicrobial stewardship, and education efforts. The ongoing initiative is detailed in a research article published recently by American Journal of Infection Control.
New testing protocol
The interdisciplinary team developed a "diarrhea decision tree algorithm" to increase the testing of patients for C. diff in the first three days of a hospital admission, Walter says. "In the first three days of a patient's admission, nurses have the autonomy to test any unformed stool for C. diff. They do not have to get a provider order. As soon as they recognize that a patient has an unformed stool, nurses can go ahead and put an order into the electronic medical record themselves and get the stool tested. At that time, the patient is placed on contact enteric isolation until we receive a negative result."
Contact enteric isolation includes requiring staff members to wear gloves and gowns in a patient's room. In addition, staff members must conduct hand hygiene with soap and water rather than hand sanitizer.
Increasing C. diff testing in the first three days of a patient's admission benefits the hospital and the patient, she says. "When we looked back at our hospital-onset C. diff cases and found that many of the cases that we were testing were in Day 4 and after, we identified that was one of our greatest opportunities—increasing testing during the community-acquired window in the first three days of an admission. We not only wanted to appropriately categorize cases as community onset but also wanted to get early diagnosis to improve patient outcomes and infection prevention. If a patient has C. diff, we want to get it diagnosed early, we want to get it treated early, and we want to get the patient in isolation to avoid the spread of infection to other patients and staff members."
Enhanced environmental cleaning
Environmental services workers made changes to how they cleaned patient rooms, Walter says. "For the enhanced environmental cleaning, we changed the type of sporicidal products that we were using. Previously, they were using a sporicidal disinfectant in the isolation rooms. In 2018, they moved to a more effective sporicidal disinfectant and started using that in all patient rooms regardless of isolation status. We became more proactive with our cleaning."
In patient rooms that were placed under contact enteric isolation for a C. diff infection, cleaning was intensified, she says. "For patients who were on C. diff isolation, at discharge we did a terminal cleaning with disinfectant and UV light disinfection. Any equipment was cleaned with bleach wipes."
Antimicrobial stewardship
Antimicrobial stewardship focused on reducing the use of fluoroquinolones, Walter says.
"They put protocols in place to make sure providers could not order fluoroquinolones as standalone orders—they had to order them as part of an order set and they had to use clinical decision support that was built in to the electronic medical record. We also added some Food and Drug Administration warnings that popped up in the electronic medical record. So, we made it more difficult for providers to order fluoroquinolones because they are associated with the development of C. diff. Fluoroquinolones are a risk factor for C. diff because they disrupt the gut flora."
C. diff education
The interdisciplinary team has introduced several educational initiatives for the hospital staff, she says.
"When the protocols first rolled out, our nurses were heavily involved in getting the protocols out to the inpatient units. We did educational emails, flyers, and huddles. We added new protocols to the orientation that we do for new hires. We designated a 'C. diff Day,' where we set up prizes and games in our cafeteria, and we had roving carts that went into all of the inpatient units to conduct quizzes and provide teaching opportunities for the nurses about C. diff and the new protocols."
Impact and lessons learned
The interventions have generated impressive results. After the first year, there was a 63% decrease in hospital-onset C. diff cases as compared to the two years prior. C. diff testing for appropriate patients within the first three days of hospital admission increased from 54% in 2014 to 81% in late 2019.
Walter has several suggestions for other hospitals seeking to decrease hospital-onset C. diff infections.
"First, I would recommend gathering an interdisciplinary team. We could not have done this work without the support and collaboration of each discipline working together because each discipline brought their own expertise and the ability to make sure that interventions were rolled out in their department. Our interdisciplinary team allowed us to do a robust project with multiple interventions. It is also important to focus on diagnostic stewardship and appropriate ordering as well as evidence-based interventions. Another thing that our team has done that is important is to continuously look for opportunities for improvement. Even after the submission of the American Journal of Infection Control manuscript, we continued to find opportunities for improvement."
Eight healthcare organizations are participating in a year-long program called the Advancing Equity Through Quality and Safety Peer Network.
A health equity initiative launched by the American Medical Association, Brigham & Women's Hospital, and The Joint Commission is designed to capitalize on peer learning at health systems and hospitals, the president of the AMA says.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
The Peer Network has lofty goals, says Gerald Harmon, MD, president of the AMA. "What we are trying to do is to eliminate as many of the inequities that we can in the current healthcare delivery system. We would like to embed this focus on improving health equity and lowering health disparities in the structural DNA of hospital operations and health system delivery. We want to improve the public discourse on health equity and make it a national priority."
The Peer Network will identify health equity interventions through a shared framework, he says. "This type of networking will generate actionable items. We are focusing on a framework of equity, quality, and safety. This framework was designed by the Institute for Healthcare Improvement and Brigham & Women's Hospital. The framework features a couple of things: the critical role of healthcare organizations when we address inequity by incorporating equity into the DNA of the operational, day-to-day, and everything we do, as well as promoting high-quality, safe, and equitable outcomes for every patient."
The eight early adopters of the Peer Network started their work by conducting a self-assessment, Harmon says. "The Peer Network participants provide a self-assessment outlining where they hope equity can be integrated into their current quality and safety practices. Each of the eight early adopters are going to have their own internal metrics and strategic plans. We are giving the early adopters a target outcome and letting them come up with initiatives on their own over a year."
Peer learning is an essential part of the initiative, he says. "We are going to have monthly calls for foundational learning and to facilitate the sharing of scalable solutions and opportunities. We also will have asynchronous meetings among the early adopters with subgroups to share what is happening at the institutions and to share metrics. I'm also hoping that the participants will be able to report on wins and scale them to the larger group."
The Peer Network will also develop health equity leaders, Harmon says. "Hopefully, what we will get is a pipeline of leaders who are capable of designing equitable healthcare systems going forward. We are going to have a learning pod of leaders who can find out what is available in their internal systems, then scale this out to other health systems and hospitals, which are desperately in need of improving equity within their own systems."
Getting to root causes
Harmon says he has had experience with delays in diagnostic testing that have impacted marginalized communities. "For example, we would order a CT scan or an X-ray that you could not get at the point of service—you had to get follow-up on it. Then there was a delay, which could happen for several reasons such as prior authorization or other insurance concerns, and there were issues with marginalized patients such as transportation or communication. These delays seemed to happen more often with marginalized communities."
The Peer Network is designed to get at the root causes of these kinds of health inequities, he says. "We need to find the root causes of these delays when they involve marginalized communities. Is it because of transportation? Is it because of communication? Is it because of health literacy? Whatever it is, these communities tend to have longer delays in diagnostic imaging, diagnosis, and reporting of laboratory results. When there are inherent delays, there can be inherent inequities."
The Peer Network is going to have to craft sophisticated solutions to health equity problems, Harmon says. "If this were easy, we would not have to have things such as the Peer Network. It is an incredibly complex situation. I have been dealing with inequities for 40 years and have tried to find workarounds such as electronic medical records and other ticklers, but when you are dealing with hundreds or thousands of patients, there are several opportunities for data to slip through the cracks. You do everything you can within your skillset to improve the interaction with the patient, but if we had an easy answer for equity challenges, we would have already applied it."
Researchers show that pulse oximetry, which is a gatekeeper in treatment decisions for COVID-19 patients, overestimates blood oxygen levels in people of color.
In a new study involving more than 7,000 COVID-19 patients, pulse oximeter devices overestimated blood oxygen levels in Asian, Black, and non-Black Hispanic patients, which could have affected their eligibility for treatment.
Pulse oximetry, which measures blood oxygen saturation levels based on blood pulse and the relative absorbance of two wavelengths of light, is used for triage and treatment decisions in the care of COVID-19 patients. Low blood oxygen saturation levels prompt interventions for COVID-19 patients.
Earlier research has shown that pulse oximetry overestimates blood oxygen saturation in people with skin of darker pigmentation compared to people with lighter pigmentation.
COVID-19 has had a disproportionate impact on people of color, including Black, Hispanic, American Indian, Alaskan Native, and Native Hawaiian and other Pacific Islander people, according to the Centers for Disease Control and Prevention.
The new study, which was published by JAMA Internal Medicine, examined data from five referral centers and community hospitals in the Johns Hopkins Health System.
The analysis included reviewing data from more than 1,200 COVID-19 patients who had their blood oxygen saturation levels measure by both pulse oximetry and arterial blood gas testing. That review showed pulse oximetry overestimated arterial oxygen saturation among Asian, Black, and non-Black Hispanic patients compared with White patients.
The analysis also included reviewing data from more than 6,500 other COVID-19 patients with pulse oximetry measurements, with predicted overestimation of arterial oxygen saturation levels for 1,900 patients associated with failure to identify many Black and non-Black Hispanic patients who were eligible to receive COVID-19 treatment.
The study includes two key data points.
When compared to White COVID-19 patients, pulse oximetry overestimated blood oxygen levels by 1.7% for Asian patients, 1.2% for Black patients, and 1.1% for non-Black Hispanic patients.
Compared to White COVID-19 patients, Black patients were 29% less likely to have their treatment eligibility recognized by pulse oximetry and non-Black Hispanic patients were 23% less likely to have their treatment eligibility recognized by pulse oximetry.
Bias in pulse oximetry could contribute to health disparity in care for COVID-19 and other respiratory conditions, the study's co-authors wrote. "We found statistically significant and persistent overestimation of arterial oxygen saturation by pulse oximetry among Asian, Black, and Hispanic patients compared with non-Hispanic White patients. Black and Hispanic patients were more likely to experience unrecognized and delayed recognition of eligibility to receive COVID-19 therapy. Differential inaccuracies in pulse oximetry should be examined as a potential explanation for disparities in COVID-19 outcomes and may have implications for the monitoring and treatment of other respiratory illnesses."
Pulse oximetry inaccuracy can impact treatment for COVID-19, particularly for people of color, study co-author Tianshi David Wu, MD, MHS, an assistant professor of medicine at Baylor College of Medicine, said in a prepared statement. "Because eligibility for many COVID-19 medications depends on oxygen levels, pulse oximeter tools have become de facto gatekeepers for how we treat patients with this condition. We've shown that biases in pulse oximeter accuracy can mean the difference between receiving a necessary medication and not—and, critically, we were able to quantify how much this disproportionately affects minority communities."
