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Biomedical subjects

Richard L Kravitz

Publications and source records attributed to Richard L Kravitz.

At least 19 recordsLinked to original sources
PubMed2006

Physicians' perceived knowledge of and responsibility for managing patients' out-of-pocket costs for prescription drugs.

BACKGROUND: Most insurers in the US have implemented incentive-based formularies that rely on out-of-pocket costs to influence prescription drug utilization. Medicare Part D plans have broadly adopted such benefit designs. OBJECTIVE: To evaluate physicians' perceptions of their knowledge of formularies and out-of-pocket costs, factors that influence knowledge of costs, physicians' perceived responsibility for helping patients manage their out-of-pocket costs for prescription drugs, and physicians' perceptions of the role of pharmacists in managing these costs. METHODS: A multiple-choice survey was mailed to a random sample of 1200 physician members of the California Medical Association; a phone survey of nonresponders was then conducted. RESULTS: Of 1027 surveys delivered to correct addresses, 509 (49.6%) responses were received. Thirty-three percent of physicians reported that they were usually or always aware of patients' formularies and 20% were usually or always aware of patients' out-of-pocket costs for medications. Surgeons, emergency department physicians, and physicians that prescribe from more formularies than other physicians are less likely to be aware of patients' out-of-pocket costs, while physicians in large practices and those who use computers to prescribe are more aware. While 91% of physicians agreed that it is important that patients' out-of-pocket costs be managed, 40% somewhat or strongly agreed that it is their responsibility to help. Sixty-five percent of physicians believed that it is the responsibility of the pharmacist to be familiar with patients' out-of-pocket costs. CONCLUSIONS: Physicians often lack the knowledge to assist patients in the management of their out-of-pocket costs for prescription drugs and they depend on pharmacists to help patients manage those costs. Computer order entry and resources available in large physician organizations improve physicians' awareness of out-of-pocket costs when prescribing.

Attitude of Health Personnel↗
PubMed2006

Mandating coverage of biologic therapies for rheumatic disease: where evidence and politics meet.

In this issue of Arthritis Care & Research, we inaugurate an occasional series of commentaries entitled Policy Matters. In all of clinical research, our goal is to improve patient outcomes. Usually, that means focusing on the medical, demographic, and socioeconomic factors at the level of individuals with rheumatic diseases; sometimes, our scope of inquiry expands to encompass the impact of the communities in which they live. However, increasingly, the welfare of persons with rheumatic conditions is also affected by health policies through such diverse mechanisms as reimbursement decisions for specific treatments, insurance coverage, manpower, and NIH budgets (the foregoing list is hardly exhaustive).Recently, a piece of legislation was introduced in California (SB913) that has the potential to alter the availability of biologic response modifying agents (BRMs) by mandating that health plans that provide coverage for one such agent include all on their formularies (a revised version would preclude a trial of another disease-modifying antirheumatic drug before use of a BRM). In this state, the California Health Benefits Review Program (CHBRP) provides evidence reviews of the medical effectiveness, cost, and public health impact of proposed health insurance mandates for the legislature. The analysts from the University of California who conducted the medical effectiveness review of SB913 for CHBRP provide a legislative history of the proposed law in this article. We hope that the readership of Arthritis Care & Research find this article informative as an exemplar of the policies that could dramatically alter the welfare of our patients.

Biological Therapy↗
PubMed2006

What are the public health effects of direct-to-consumer drug advertising?

BACKGROUND TO THE DEBATE: Only two industrialized countries, the United States and New Zealand, allow direct-to-consumer advertising (DTCA) of prescription medicines, although New Zealand is planning a ban. The challenge for these governments is ensuring that DTCA is more beneficial than harmful. Proponents of DTCA argue that it helps to inform the public about available treatments and stimulates appropriate use of drugs for high-priority illnesses (such as statin use in people with ischemic heart disease). Critics argue that the information in the adverts is often biased and misleading, and that DTCA raises prescribing costs without net evidence of health benefits.

Advertising↗
PubMed2006

What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms.

BACKGROUND: Referral from primary care to the mental health specialty sector is important but poorly understood. OBJECTIVE: Identify physician characteristics influencing mental health referral. DESIGN: Randomized controlled trial using Standardized Patients (SPs). SETTING: Offices of primary care physicians in 3 cities. PARTICIPANTS: One hundred fifty-two family physicians and general internists recruited from 4 broad practice settings; 18 middle aged Caucasian female actors. INTERVENTION: Two hundred and ninety-eight unannounced SP visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. MEASUREMENTS: Mental health referrals via SP written reports; physician and system characteristics through a self-administered physician questionnaire. RESULTS: Among 298 SP visits, 107 (36%) resulted in mental health referral. Referrals were less likely among physicians with greater self-confidence in their ability to manage antidepressant therapy (adjusted odds ratio [AOR] 0.39, 95% confidence interval [CI] 0.17 to 0.86) and were more likely if physicians typically spent > or =10% of professional time on nonclinical activities (AOR 3.42, 95% CI 1.45 to 8.07), had personal life experience with psychotherapy for depression (AOR 2.74, 95% CI 1.15 to 6.52), or usually had access to mental health consultation within 2 weeks (AOR 2.94, 95% CI 1.26 to 6.92). LIMITATION: The roles portrayed by SPs may not reflect the experience of a typical panel of primary care patients. CONCLUSIONS: Controlling for patient and health system factors, physicians' therapeutic confidence and personal experience were important influences on mental health referral. Research is needed to determine if addressing these factors can facilitate more appropriate care.

Adult↗
PubMed2006

Providing health care services to the formerly homeless: a quasi-experimental evaluation.

We performed a quasi-experiment to assess the effects of a focused health care intervention delivered in transitional housing facilities in Sacramento, California. Four transitional housing facilities (THFs) receiving the intervention were compared with 2 THFs that did not receive it. A multidisciplinary team provided a diverse package of services to residents at the intervention sites. Residents at comparison sites received usual care. Survey and physical examination data were collected in repeated cross-sectional surveys at baseline (pre-intervention) and after 6 and 18 months of follow-up (post-intervention). Using analysis of covariance techniques, our statistical models showed improved odds of receiving recommended gynecologic preventive care and decreased odds of frequent Emergency Department use at 18 months among residents at the intervention sites. At 6 months, residents at the intervention sites also experienced improved blood pressure control. There was no intervention effect on residents' access to specialists or on physical functioning, mental health, or dental health.

Adult↗
PubMed2006

Physicians' perceptions of relevant prescription drug costs: do costs to the individual patient or to the population matter most?

OBJECTIVES: Physicians may be aware of at least 2 types of costs when prescribing: patient's out-of-pocket costs and the actual costs of the medication. We evaluated physicians' perceptions about relevant costs for prescription drugs and the importance of communication about these costs. STUDY DESIGN: Mailed survey to a random sample of 1200 physician members of the California Medical Association, and a phone survey of a sample of nonresponders. METHODS: Descriptive statistics of survey items, McNemar's test to compare survey item responses, and logistic regression to evaluate the relationship between physician, practice, and system variables and physicians' perceptions of relevant medication costs. RESULTS: Of respondents with correct addresses, 49.6% responded to the survey; 13% of nonresponders were contacted by phone. Approximately 91% and 80% of physicians reported that it is important to manage patients' out-of-pocket costs and total medication costs, respectively. When comparing the relative importance of managing the 2 types of costs, 59% of physicians agreed that managing patients' out-of-pocket costs was more important than managing the total medication costs and only 16% disagreed. Physicians believed it was more important to discuss out-of-pocket costs than total costs with patients (P < .0001), but only 15% of physicians reported discussing out-of-pocket costs frequently and 5% reported talking about total medication costs frequently. Physicians who managed more Medicare patients had a greater likelihood than physicians managing fewer Medicare patients of prioritizing out-of-pocket cost rather than total cost management (P = .038), and generalists had a greater likelihood than medical subspecialists (P = .046). CONCLUSIONS: Physicians prioritize managing out-of-pocket costs over total medication costs. Pharmacy benefit designs that use patient out-of-pocket cost incentives to influence utilization are addressing the costs to which physicians may be most responsive. When physicians face conflicts between managing patients' out-of-pocket costs and total costs, they will likely try to protect the patients' resources at the expense of the insurer or society. Efforts to align patients', insurers', and societies' incentives will simplify prescribing decisions and result in better value in prescribing.

Adult↗
PubMed2005

Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial.

CONTEXT: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. OBJECTIVE: To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms. DESIGN: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). SETTING: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. PARTICIPANTS: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. INTERVENTIONS: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. MAIN OUTCOME MEASURES: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. RESULTS: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001). CONCLUSIONS: Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.

Adjustment Disorders↗
PubMed2005

Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues.

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.

Communication↗
PubMed2005

Patient participation in medical consultations: why some patients are more involved than others.

BACKGROUND: Patients vary in their willingness and ability to actively participate in medical consultations. Because more active patient participation contributes to improved health outcomes and quality of care, it is important to understand factors affecting the way patients communicate with healthcare providers. OBJECTIVES: The objectives of this study were to examine the extent to which patient participation in medical interactions is influenced by 1) the patient's personal characteristics (age, gender, education, ethnicity); 2) the physician's communication style (eg, use of partnership-building and supportive talk); and 3) the clinical setting (eg, the health condition, medical specialty). RESEARCH DESIGN AND SUBJECTS: The authors conducted a post hoc cross-sectional analysis of 279 physician-patient interactions from 3 clinical sites: 1) primary care patients in Sacramento, California, 2) patients with systemic lupus erythematosus (SLE) from the San Francisco Bay area, and 3) patients with lung cancer from a VA hospital in Texas. MAIN OUTCOME MEASURES: The outcome measures included the degree to which patients asked questions, were assertive, and expressed concerns and the degree to which physicians used partnership-building and supportive talk (praise, reassurance, empathy) in their consultations. RESULTS: The majority of active participation behaviors were patient-initiated (84%) rather than prompted by physician partnership-building or supportive talk. Patients who were more active participants received more facilitative communication from physicians, were more educated, and were more likely to be white than of another ethnicity. Women more willingly expressed negative feelings and concerns. There was considerable variability in patient participation across the 3 clinical settings. Female physicians were more likely to use supportive talk than males, and physicians generally used less supportive talk with nonwhite compared with white patients. CONCLUSIONS: Patient participation in medical encounters depends on a complex interplay of personal, physician, and contextual factors. Although more educated and white patients tended to be more active participants than their counterparts, the strongest predictors of patient participation were situation-specific, namely the clinical setting and the physician's communicative style. Physicians could more effectively facilitate patient involvement by more frequently using partnership-building and supportive communication. Future research should investigate how the nuances of individual clinical settings (eg, the health condition, time allotted for the visit) impose constraints or opportunities for more effective patient involvement in care.

Adult↗
PubMed2005

Do the incentives in 3-tier pharmaceutical benefit plans operate as intended? Results from a physician leadership survey.

BACKGROUND: Three-tier pharmaceutical benefit systems use graded co-payments to steer patients toward "preferred" formulary medications. OBJECTIVES: To evaluate physicians' knowledge of formularies and out-of-pocket costs in such systems, as well as their perceived responsibility for helping patients manage out-of-pocket costs. STUDY DESIGN: Self-administered written survey. METHODS: Physician leaders participating in the California Medical Association Leadership Conference were surveyed. RESULTS: A total of 133 responses were received from 205 participants (65% response rate). Physicians reported that they were often unaware of patients' out-of-pocket costs at the time of prescribing. Fifty-nine percent of physicians reported that they never or seldom were aware of patients' "preferred" (lower cost) formulary options when prescribing, and 70% never or seldom were aware of patients' out-of-pocket costs when prescribing. Although 88% of physicians agreed that it is important that patients' out-of-pocket costs for prescription drugs are managed, only 25% strongly or somewhat agreed that it is their "responsibility" to help. Instead, 69% of physicians believed that it is the responsibility of the pharmacist to be familiar with patients' out-of-pocket costs. Physicians reported that they receive phone calls from pharmacists concerning formulary issues after 18.6% of the prescriptions they write. CONCLUSIONS: Physician leaders reported that they often do not possess the knowledge to assist patients in managing out-of-pocket costs for prescription drugs and they depend on pharmacists to communicate patient preferences in making prescribing decisions. As a result, price preferences are communicated indirectly, likely less efficiently, rather than intentionally when prescribing decisions are made.

Data Collection↗
PubMed2004

Combined use of rapid D-dimer testing and estimation of clinical probability in the diagnosis of deep vein thrombosis: systematic review.

OBJECTIVE: To summarise the evidence supporting the use of rapid d-dimer testing combined with estimation of clinical probability to exclude the diagnosis of deep venous thrombosis among outpatients. DATA SOURCES: Medline (June 1993 to December 2003), the Database of Abstracts and Reviews (DARE), and reference lists of studies in English. SELECTION OF STUDIES: We selected 12 studies from among 84 reviewed. The selected studies included more than 5000 patients and used a rapid D-dimer assay and explicit criteria to classify cases as having low, intermediate, or high clinical probability of deep vein thrombosis of the lower extremity among consecutive outpatients. REVIEW METHODS: Diagnosis required objective confirmation, and untreated patients had to have at least three months of follow up. The outcome was objectively documented venous thromboembolism. Two authors independently abstracted data by using a data collection form. RESULTS: When the less sensitive SimpliRED D-dimer assay was used the three month incidence of venous thromboembolism was 0.5% (95% confidence interval 0.07% to 1.1%) among patients with a low clinical probability of deep vein thrombosis and normal D-dimer concentrations. When a highly sensitive D-dimer assay was used, the three month incidence of venous thromboembolism was 0.4% (0.04% to 1.1%) among outpatients with low or moderate clinical probability of deep vein thrombosis and a normal D-dimer concentration. CONCLUSIONS: The combination of low clinical probability for deep vein thrombosis and a normal result from the SimpliRED D-dimer test safely excludes a diagnosis of acute venous thrombosis A normal result from a highly sensitive D-dimer test effectively rules out deep vein thrombosis among patients classified as having either low or moderate clinical probability of deep vein thrombosis.

Biomarkers↗
PubMed2004

A new instrument to measure appropriateness of services in primary care.

OBJECTIVE: To develop a new instrument for judging the appropriateness of three key services (new prescription, diagnostic test, and referral) as delivered in primary care outpatient visits. DESIGN: Candidate items were generated by a seven-member expert panel, using a five-step nominal technique, for each of three service categories in primary care: new prescriptions, diagnostic tests, and referrals. Expert panelists and a convenience sample of 95 community-based primary care physicians ranked items for (i) importance and (ii) feasibility of ascertaining from a typical office chart record. Resulting items were used to construct a measure of appropriateness using principals of structured implicit review. Two physician reviewers used this measure to judge the appropriateness of 421 services from 160 outpatient visits. SETTING: Primary care practices in a staff model health maintenance organization and a large preferred provider network. MEASURES: Inter-rater agreement was measured using intraclass correlation coefficient (ICC) and kappa statistic. RESULTS: For overall appropriateness, the ICC and kappa were 0.52 and 0.44 for new medication, 0.35 and 0.32 for diagnostic test, and 0.40 and 0.41 for referral, respectively. Only 3% of services were judged to be inappropriate by either reviewer. The proportion of services judged to be less than definitely appropriate by one or both reviewers was 56% for new medication, 31% for diagnostic test, and 22% for referral. CONCLUSIONS: This new measure of appropriateness of primary care services has fair inter-rater agreement for new medications and referrals, similar to appropriateness measures of other general services, but poor agreement for diagnostic tests. It may be useful as a tool to assess the appropriateness of common primary care services in studies of health care quality, but is not suitable for evaluating performance of individual physicians.

Adult↗
PubMed2004

Licensed caregiver characteristics and staffing in California acute care hospital units.

PURPOSE: Concerns about declining quality of care and nurse staffing shortages led to legislation mandating minimum nurse-to-patient ratios in the state of California. Although research finds that better registered nurse (RN) staffing results in higher quality of care, little evidence exists on which to base specific nurse-patient ratios. The authors describe the results of a California survey characterizing licensed caregivers, identifying staffing levels by unit type, and describing how staffing levels vary across hospital types. METHODS: A stratified random sample of general acute care hospitals was surveyed to collect cross-sectional data on hospitals' nursing workforce and staffing practices and to assess the impact of potential patient-to-nurse staffing ratios. All academic medical centers; rural, private, and city/county hospitals; and hospitals affiliated with a large group-model health maintenance organization (HMO) were eligible for inclusion. RESULTS: Eighty hospitals were surveyed, representing all major metropolitan areas in the state. Acute care hospitals in California have diverse nursing staffs with variations in education, experience, and employment status. Considerable variations in skill mix were identified, with the proportion of RNs ranging from 30% to 84%, depending on the unit type surveyed. CONCLUSIONS: As states struggle with an anticipated critical shortage of RNs, these results have several implications for health and education policy. Future studies of this type will be needed to evaluate the impact of anticipated changes in the regulation of nurse staffing.

California↗
PubMed2004

Evidence-based medicine, heterogeneity of treatment effects, and the trouble with averages.

Evidence-based medicine is the application of scientific evidence to clinical practice. This article discusses the difficulties of applying global evidence ("average effects" measured as population means) to local problems (individual patients or groups who might depart from the population average). It argues that the benefit or harm of most treatments in clinical trials can be misleading and fail to reveal the potentially complex mixture of substantial benefits for some, little benefit for many, and harm for a few. Heterogeneity of treatment effects reflects patient diversity in risk of disease, responsiveness to treatment, vulnerability to adverse effects, and utility for different outcomes. Recognizing these factors, researchers can design studies that better characterize who will benefit from medical treatments, and clinicians and policymakers can make better use of the results.

Drug Approval↗
PubMed2003

Neurologists' assessment of their ability to provide high quality care.

OBJECTIVE: S: To assess levels of professional satisfaction and distress in a national sample of neurologists and to compare neurologists with other physicians. METHODS: The authors used data from the 1996 through 1997 and 1998 through 1999 Community Tracking Study Physician Survey and analyzed responses in the two time frames to measures of career satisfaction, physician autonomy and communication, and ability to obtain needed services for patients. RESULTS: Most physicians, including neurologists, are satisfied with careers in medicine. Neurologists feel they have more time to spend with patients than do other physicians but are more concerned than are other physicians about their ability to obtain needed services and to provide high-quality care for patients. One-third of all physicians feel that they cannot maintain the kind of continuing relationships with patients over time that are necessary for delivering high-quality care. CONCLUSION: The majority of physicians, including neurologists, are satisfied with medical practice today. Because some neurologists are experiencing significant professional distress, those factors that will enhance physician satisfaction, prevent burnout, and encourage high-quality interpersonal care need to be carefully examined and modified.

Attitude of Health Personnel↗
PubMed2003

How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA.

BACKGROUND: Direct-to-consumer advertising (DTCA) of prescription drugs has increased rapidly in the United States during the last decade, yet little is known about its effects on prescribing decisions in primary care. We compared prescribing decisions in a US setting with legal DTCA and a Canadian setting where DTCA of prescription drugs is illegal, but some cross-border exposure occurs. METHODS: We recruited primary care physicians working in Sacramento, California, and Vancouver, British Columbia, and their group practice partners to participate in the study. On pre- selected days, patients aged 18 years or more completed a questionnaire before seeing their physician. We asked these patients' physicians to complete a brief questionnaire immediately following the selected patient visit. By pairing individual patient and physician responses, we determined how many patients had been exposed to some form of DTCA, the frequency of patients' requests for prescriptions for advertised medicines and the frequency of prescriptions that were stimulated by the patients' requests. We measured physicians' confidence in treatment choice for each new prescription by asking them whether they would prescribe this drug to a patient with the same condition. RESULTS: Seventy-eight physicians (Sacramento n = 38, Vancouver n = 40) and 1431 adult patients (Sacramento n = 683, Vancouver n = 748), or 61% of patients who consulted participating physicians on pre-set days, participated in the survey. Exposure to DTCA was higher in Sacramento, although 87.4% of Vancouver patients had seen prescription drug advertisements. Of the Sacramento patients, 7.2% requested advertised drugs as opposed to 3.3% in Vancouver (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.2-4.1). Patients with higher self- reported exposure to advertising, conditions that were potentially treatable by advertised drugs, and/or greater reliance on advertising requested more advertised medicines. Physicians fulfilled most requests for DTCA drugs (for 72% of patients in Vancouver and 78% in Sacramento); this difference was not statistically significant. Patients who requested DTCA drugs were much more likely to receive 1 or more new prescriptions (for requested drugs or alternatives) than those who did not request DTCA drugs (OR 16.9, 95% CI 7.5-38.2). Physicians judged 50.0% of new prescriptions for requested DTCA drugs to be only "possible" or "unlikely" choices for other similar patients, as compared with 12.4% of new prescriptions not requested by patients (p < 0.001). INTERPRETATION: Our results suggest that more advertising leads to more requests for advertised medicines, and more prescriptions. If DTCA opens a conversation between patients and physicians, that conversation is highly likely to end with a prescription, often despite physician ambivalence about treatment choice.

Adult↗