Droughting a megadrought: Ecological consequences of a decade of experimental drought atop aridification on the Colorado Plateau.

Global dryland vegetation communities will likely change as ongoing drought conditions shift regional climates towards a more arid future. Additional aridification of drylands can impact plant and ground cover, biogeochemical cycles, and plant-soil feedbacks, yet how and when these crucial ecosystem components will respond to drought intensification requires further investigation. Using a long-term precipitation reduction experiment (35% reduction) conducted across the Colorado Plateau and spanning 10 years into a 20+ year regional megadrought, we explored how vegetation cover, soil conditions, and growing season nitrogen (N) availability are impacted by drying climate conditions. We observed large declines for all dominant plant functional types (C3 and C4 grasses and C3 and C4 shrubs) across measurement period, both in the drought treatment and control plots, likely due to ongoing regional megadrought conditions. In experimental drought plots, we observed less plant cover, less biological soil crust cover, warmer and drier soil conditions, and more soil resin-extractable N compared to the control plots. Observed increases in soil N availability were best explained by a negative correlation with plant cover regardless of treatment, suggesting that declines in vegetation N uptake may be driving increases in available soil N. However, in ecosystems experiencing long-term aridification, increased N availability may ultimately result in N losses if soil moisture is consistently too dry to support plant and microbial N immobilization and ecosystem recovery. These results show dramatic, worrisome declines in plant cover with long-term drought. Additionally, this study highlights that more plant cover losses are possible with further drought intensification and underscore that, in addition to large drought effects on aboveground communities, drying trends drive significant changes to critical soil resources such as N availability, all of which could have long-term ecosystem impacts for drylands.

Fire, rodent herbivory, and plant competition: implications for invasion and altered fire regimes in the Mojave Desert.

Biological invasions are responsive to changing wildfire regimes related to human activities that are altering biological communities. Our objective was to investigate how fire, rodent activity, and competition among plant species modify plant community structure, invasion patterns, and vulnerability to altered fire regimes. We imposed experimental fires, and reduced rodent density using fencing in a full factorial design and quantified competitive interactions among plant species in the northeast Mojave Desert that has experienced dramatic increases in plant invasion and fire in recent years. Vegetation surveys were conducted in the experimental plots to determine plant density, cover, and biomass of herbaceous plants over a 5-year period. Rodent exclusion increased the density, cover, and biomass of Bromus rubens, an invasive annual grass, and density of forb species. In contrast, rodent exclusion decreased the density, cover, and biomass of Schismus spp. another dominant annual invader. Fire increased Schismus spp. and forb species density, cover, and biomass but decreased B. rubens density. Negative spatial correlation between B. rubens and Schismus spp., and forbs indicated interspecific competition among the dominant plant species. Fire reduced rodent community diversity (Shannon's) 2.5-fold, which was correlated with increases in B. rubens cover and biomass, and native forb diversity. Fire, high rodent diversity, and competition from the other plant species may decrease fire potential in our study system by reducing the density and biomass of B. rubens, which because of its taller growth form tends to ignite and carry fire better than Schismus spp. and forbs.

Creosote growth rate and reproduction increase in postfire environments.

Human activities are changing patterns of ecological disturbance globally. In North American deserts, wildfire is increasing in size and frequency due to fuel characteristics of invasive annual grasses. Fire reduces the abundance and cover of native vegetation in desert ecosystems. In this study, we sought to characterize stem growth and reproductive output of a dominant native shrub in the Mojave Desert, creosote bush (Larrea tridentata (DC.) Coville) following wildfires that occurred in 2005. We sampled 55 shrubs along burned and unburned transects 12 years after the fires (2017) and quantified age, stem diameter, stem number, radial and vertical growth rates, and fruit production for each shrub. The shrubs on the burn transects were most likely postfire resprouts based on stem age while stems from unburn transects dated from before the fire. Stem and vertical growth rates for shrubs on burned transects were 2.6 and 1.7 times higher than that observed for shrubs on unburned transects. Fruit production of shrubs along burned transects was 4.7-fold more than shrubs along paired unburned transects. Growth rates and fruit production of shrubs in burned areas did not differ with increasing distance from the burn perimeter. Positive growth and reproduction responses of creosote following wildfires could be critical for soil stabilization and re-establishment of native plant communities in this desert system. Additional research is needed to assess if repeat fires that are characteristic of invasive grass-fire cycles may limit these benefits.

Niche opportunities for invasive annual plants in dryland ecosystems are controlled by disturbance, trophic interactions, and rainfall.

Resource availability and biotic interactions control opportunities for the establishment and expansion of invasive species. Studies on biotic resistance to plant invasions have typically focused on competition and occasionally on herbivory, while resource-oriented studies have focused on water or nutrient pulses. Through synthesizing these approaches, we identify conditions that create invasion opportunities. In a nested fully factorial experiment, we examined how chronic alterations in water availability and rodent density influenced the density of invasive species in both the Mojave Desert and the Great Basin Desert after fire. We used structural equation modeling to examine the direct and mediated effects controlling the density of invasives in both deserts. In the first 2 years after our controlled burn in the Great Basin, we observed that fire had a direct effect on increasing the invasive forb Halogeton glomeratus as well as a mediated effect through reducing rodent densities and herbivory. 4 years after the burn, the invasive annual grass Bromus tectorum was suppressing Halogeton glomeratus in mammal exclusion plots. There was a clear transition from years where invasives were controlled by disturbance and trophic interactions to years were resource availability and competition controlled invasive density. Similarly, in the Mojave Desert we observed a strong early influence of trophic processes on invasives, with Schismus arabicus benefitted by rodents and Bromus rubens negatively influenced by rodents. In the Mojave Desert, post-fire conditions became less important in controlling the abundance of invasives over time, while Bromus rubens was consistently benefitted by increases in fall rainfall.

The Effects of Malpractice Non-Economic Damage Caps on the Supply of Physician Labor: Heterogeneity by Physician Age and Risk.

We explore the impact of malpractice caps on non-economic damages that were enacted between 2003 and 2006 on the supply of physician labor, separately for high-malpractice risk and low-malpractice risk physician specialty types, and separately by young and old physicians. We use physician data from the Area Resource File for 2000-2011 and malpractice policy data from the Database of State Tort Law Reforms. We study the impact of these caps using a reverse natural experiment, comparing physician supply in nine states enacting new caps to physician supply in ten states that had malpractice caps in place throughout the full time period. We use an event study to evaluate changes in physician labor compared to the prior year. We find evidence that non-economic damage caps increased the supply of high-risk physicians <35 years of age by 0.93 physicians per 100,000 people in the year after the caps were enacted. Non-economic damage caps were cumulatively associated with an increase of 2.1 high-risk physicians <35 years of age per 100,000 people. Stronger non-economic damage caps generally had a larger impact on physical supply.

Academic physicians' views on low-value services and the choosing wisely campaign: A qualitative study.

BACKGROUND: In 2012, the American Board of Internal Medicine (ABIM) Foundation launched a campaign called Choosing Wisely which was intended to start a national dialogue on services that are not medically necessary. More research is needed on the in-depth reasons why doctors overuse low-value services, their views on Choosing Wisely specifically, and ways to help them change their practice patterns. METHODS: We performed a qualitative study of focus groups with physicians to explore their views on the problem of overuse of low-value services, the reasons why they overuse, and ways that they think could be effective at curbing overuse. Participants were attendings in the fields of emergency medicine, internal medicine, hospital medicine, and cardiology. RESULTS: All physicians felt that overuse of low-value services was a significant problem. Physicians frequently cited that patient expectations drove the use of low-value services and lack of time was the most cited reason why behavior change was difficult. Facilitators that could promote behavior change included decision support through the electronic medical record, motivation to maintain their reputation among their colleagues, internal motivation to be a good doctor, objective data showing their rates of overuse, alignment of institutional goals, and forums to discuss evidence and new research. CONCLUSIONS AND IMPLICATIONS: In focus groups with physicians, we found that physicians perceived that overuse of low-value services was a problem. Participants cited many barriers to behavior change. Methods that help address patient expectations, physician time, and social norms may help physicians reduce their use of low-value services.

The Use of Social Media in Graduate Medical Education: A Systematic Review.

PURPOSE: Despite the growing presence of social media in graduate medical education (GME), few studies have attempted to characterize their effect on residents and their training. The authors conducted a systematic review of the peer-reviewed literature to understand the effect of social media on resident (1) education, (2) recruitment, and (3) professionalism. METHOD: The authors identified English-language peer-reviewed articles published through November 2015 using Medline, Embase, Cochrane, PubMed, Scopus, and ERIC. They extracted and synthesized data from articles that met inclusion criteria. They assessed study quality for quantitative and qualitative studies through, respectively, the Medical Education Research Study Quality Instrument and the Consolidated Criteria for Reporting Qualitative Studies. RESULTS: Twenty-nine studies met inclusion criteria. Thirteen (44.8%) pertained to residency education. Twitter, podcasts, and blogs were frequently used to engage learners and enhance education. YouTube and wikis were more commonly used to teach technical skills and promote self-efficacy. Six studies (20.7%) pertained to the recruitment process; these suggest that GME programs are transitioning information to social media to attract applicants. Ten studies (34.5%) pertained to resident professionalism. Most were exploratory, highlighting patient and resident privacy, particularly with respect to Facebook. Four of these studies surveyed residents about their social network behavior with respect to their patients, while the rest explored how program directors use it to monitor residents' unprofessional online behavior. CONCLUSIONS: The effect of social media platforms on residency education, recruitment, and professionalism is mixed, and the quality of existing studies is modest at best.

Trends in Ambulatory Management of Urinary Incontinence in Women in the United States.

OBJECTIVES: Urinary incontinence (UI) is a common condition, but despite the availability of guidelines, variations exist in the care of patients. We sought to assess the changes in assessment and management of women with UI over time in the United States. METHODS: The National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey are annual surveys from a nationally representative sample of visits to physicians. From 1999 through 2010, we identified visits by women to physicians where the chief complaint was UI using reason-for-visit and International Classification of Diseases, Ninth Revision codes. RESULTS: Using 2-year intervals between 1999-2000 and 2009-2010, the number of visits by women with UI to physicians increased (5.3 million to 6.8 million). There was no difference in patient age, race/ethnicity, or physician specialty (primary care, urology, gynecology). The majority did not have their incontinence characterized (42.4%-47.4%). The use of urinalysis significantly decreased (53%-37.2%, P = 0.02), whereas antimuscarinic use significantly increased (16.7%-35%, P = 0.006). There was an overall increased trend in number of referrals to another physician (5.8%-14.7%, P = 0.06). Urologists had a significant increase in antimuscarinic use (23.5%-44.2%, P = 0.003). All physician specialties demonstrated a decreased trend in use of urinalysis between 1999 and 2010. Although imaging rates were low, they were at highest rates among urologists. CONCLUSIONS: The majority of women do not have the type of UI characterized, whereas there is underutilization of urinalysis. Given the widespread prevalence of UI and its implications on quality of life, greater adherence to guidelines is warranted.

Population Of US Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access To Mental Health Care.

A large proportion of the US population suffers from mental illness. Limited access to psychiatrists may be a contributor to the underuse of mental health services. We studied changes in the supply of psychiatrists from 2003 to 2013, compared to changes in the supply of primary care physicians and neurologists. During this period the number of practicing psychiatrists declined from 37,968 to 37,889, which represented a 10.2 percent reduction in the median number of psychiatrists per 100,000 residents in hospital referral regions. In contrast, the numbers of primary care physicians and neurologists grew during the study period. These findings may help explain why patients report poor access to mental health care. Future research should explore the impact of the declining psychiatrist supply on patients and investigate new models of care that seek to integrate mental health and primary care or use team-based care that combines the services of psychiatrists and nonphysician providers for individuals with severe mental illnesses.

A Cross-Sectional Assessment of the Quality of Physician Quality Reporting System Measures.

BACKGROUND: Starting in 2015, the Center for Medicare and Medicaid Services (CMS) requires all Medicare providers to report quality measures through Physician Quality Reporting System (PQRS) or incur a 1.5 % financial penalty. Research indicates that physicians believe this reporting does not lead to high quality care; however, little research has examined what PQRS actually measures, which is reflective of the physicians and patient disease populations being assessed. OBJECTIVES: (1) Identify the proportion of measures that apply to different medical specialties, types of quality measurement, and National Quality Strategy (NQS) priorities. (2) Identify how different specialties are required to measure quality and NQS priorities. (3) Compare the 2011 and 2015 measures. DESIGN AND MAIN MEASURES: This was a categorical qualitative analysis of 2011 and 2015 PQRS measures. One hundred and ninety-eight and 254 individual measures, respectively, were analyzed by three domains: medical specialty measured, type of measure, and NQS priority category. KEY RESULTS: Between 2011 and 2015, the type of measures changed significantly, with fewer processes (85.4 % vs. 66.5 %, p < 0.001) and more outcomes (12.6 % vs. 29.1 %, p < 0.001). The measures showed no significant specialty or NQS category differences. For subcategories within each specialty in 2015, differences in measure type were statistically significant: surgery had the highest percentage of outcomes (61.1 %) compared to 21.7 % of internal medicine and 5.9 % of obstetrics/gynecology. For NQS categories, internal medicine had the highest percentage of effective clinical care measures (68.5 %), compared to 22.2 % in surgery. Surgery had the highest percentage of patient safety (31.9 %) and communication and care coordination measures (27.8 %) compared with internal medicine (5.4 % and 6.5 %). CONCLUSIONS: Our study shows that PQRS measures include many medical specialties and significantly more outcomes in recent years, particularly for surgery. PQRS still lacks sufficient measures for half of NQS priorities and sufficient outcomes to assess internal medicine and obstetrics/gynecology. CMS must continue to improve PQRS measures to better assess and encourage high-quality care for all Americans.

Trends in hospital ownership of physician practices and the effect on processes to improve quality.

OBJECTIVES: Reports suggest a trend for physician practices to change ownership from physicians to hospitals. It remains unclear how this change affects quality of patient care. We report the effect of a change to hospital ownership on the use of care management processes (CMPs) and health information technology (IT) among practices in the United States. STUDY DESIGN: Trend analyses of 3 large national surveys of physician practices. METHODS: We included 2 cohorts of practices: large practices with 20 or more physicians and small/medium practices with fewer than 20 physicians. The main outcomes were the changes in CMP and health IT indices among practices that were acquired by hospitals. We used multivariate logistic regression to assess these changes. RESULTS: Large practices acquired by hospitals had larger increases in their CMP index than those that remained physician-owned (11.0-point increase vs 7.0-point decrease; adjusted P = .03). Small/medium practices acquired by hospitals had smaller but significantly higher increases in their CMP score (3.8 points vs 2.6 points; adjusted P = .04). Among all practices, there were no significant differences in the change of the health IT index. CONCLUSIONS: We found a significant increase in the use of CMPs among practices that were acquired by hospitals and no difference in health IT use. These findings suggest that a trend for hospitals to own physician practices may have a positive effect on chronic disease management and quality of care.

Care Management Processes Used Less Often For Depression Than For Other Chronic Conditions In US Primary Care Practices.

Primary care physicians play an important role in the diagnosis and management of depression. Yet little is known about their use of care management processes for depression. Using national survey data for the period 2006-13, we assessed the use of five care management processes for depression and other chronic illnesses among primary care practices in the United States. We found significantly less use for depression than for asthma, congestive heart failure, or diabetes in 2012-13. On average, practices used fewer than one care management process for depression, and this level of use has not changed since 2006-07, regardless of practice size. In contrast, use of diabetes care management processes has increased significantly among larger practices. These findings may indicate that US primary care practices are not well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide. Policies that incentivize depression care management, including additional quality metrics, should be considered.

US Physician Practices Spend More Than $15.4 Billion Annually To Report Quality Measures.

Each year US physician practices in four common specialties spend, on average, 785 hours per physician and more than $15.4 billion dealing with the reporting of quality measures. While much is to be gained from quality measurement, the current system is unnecessarily costly, and greater effort is needed to standardize measures and make them easier to report.

A Randomized, Controlled Trial of a Shared Panel Management Program for Small Practices.

OBJECTIVES: To determine whether a shared panel management program was effective at improving quality of care for patients with uncontrolled chronic disease. DATA SOURCES: Data were extracted from electronic health records. STUDY DESIGN: Randomized controlled trial of a panel management program initiated by New York City Department of Health and Mental Hygiene. Patients from 20 practices with an uncontrolled chronic disease and a lapse in care were assigned to the intervention (a phone call requesting that the patient schedule a physician appointment) or usual care. Outcomes were visits to physician practices, body mass index measurement, blood pressure measurement and control, use of antithrombotics, and low-density lipoprotein measurement and control. PRINCIPAL FINDINGS: Panel managers were able to successfully speak with 1,676 patients (14.7 percent of the intervention group). There were no significant differences in outcomes between the intervention and usual care groups. Successfully contacted patients were more likely to have an office visit within 1 year of randomization (45.6 percent [95 percent CI: 22.8, 26.9] vs. 38.1 percent [95 percent CI: 36.8, 39.3]) and more likely to be on antithrombotics (24.4 percent [95 percent CI: 17.7, 31.0]) versus those in the usual care group (17.0 percent [95 percent CI: 13.9, 20.0]) but had no other difference in quality. CONCLUSIONS: A shared, low-intensity panel management program run by a city health department did not improve quality of care for patients with chronic illnesses and lapses in care.

Effect of Attending Practice Style on Generic Medication Prescribing by Residents in the Clinic Setting: An Observational Study.

BACKGROUND: Despite increased emphasis on cost-consciousness in graduate medical training, there is little empirical evidence of the role of attending physician supervision on resident practice in this area. OBJECTIVE: To study whether the prescribing practices of attendings influence residents' prescribing of brand-name statin medications in the ambulatory clinic setting. DESIGN AND PARTICIPANTS: A retrospective study of statin prescriptions by residents at two internal medicine residency programs, using electronic medical record data from July 2007 through November 2011. MAIN MEASURES: We estimated multivariable hierarchical logistic regression models to assess the independent effect of the supervising attending's rate of brand-name prescribing in the preceding quarter on the likelihood of a resident prescribing a brand-name statin. KEY RESULTS: The sample included 342 residents and 58 attendings, accounting for 10,151 initial statin prescriptions, including 3,942 by residents. Brand-name statins were prescribed in about one-fourth of encounters. After adjusting for patient-, physician-, and practice-level factors, the supervising attendings' brand-name prescribing rate in the quarter preceding the encounter was positively associated with a postgraduate year (PGY)-1 resident's prescribing a brand-name statin, but not for PGY-2 or PGY-3 residents. For PGY-1 residents, the adjusted probability of a resident prescribing a brand-name statin ranged from 22.6 % (95 % CI 17.3-28.0 %, p < 0.001) for residents supervised by an attending who prescribed < 20 % brand-name statins in the previous quarter to 41.6 % (95 % CI 24.6-58.5 %, p < 0.001) for residents supervised by an attending who prescribed at least 80 % brand-name statins in the previous quarter. A higher PGY level was associated with brand-name prescribing (aOR 2.07, 95 % CI 1.28-3.35, p = 0.003 for PGY-2; aOR 2.15, 95 % CI 1.31-3.55, p = 0.003 for PGY-3, vs. PGY-1). CONCLUSIONS: Supervising attendings' prescribing of brand-name medications may have a significant influence on PGY-1 residents' prescribing of brand-name medications, but not on prescribing by more senior residents.

Do provider attitudes about electronic health records predict future electronic health record use?

INTRODUCTION: Prior research has shown that provider attitudes about EHRs are associated with successful adoption. There is no evidence on whether comfort with technology and more positive attitudes about EHRs affect use of EHR functions once they are adopted. METHODS: We used data from a survey of providers in the Primary Care Information Project, a bureau of the New York City Department of Health and Mental Hygiene and measures of use from their EHRs. The main predictor variables were scores on three indices: comfort with computers, positive attitudes about EHRs, and negative attitudes about EHRs. The main outcome measures were four measures of use of EHR functions. We used linear regression models to test the association between the three indices and measures of EHR use. RESULTS: The mean comfort with computers score was 2.37 (SD0.53) on a scale of 1-3 with 3 being the most comfortable. The mean positive attitude score was 2.74 (SD 0.40) on a scale of 1-3 with 3 being more positive. The mean negative attitude score was 1.81 (SD 0.54) on a scale of 1-3 with 3 being more negative. Within the first twelve months of having the EHR, 59.5% of visits had allergy information entered into a structured field, 64.8% had medications reviewed, and 74.3% had blood pressured entered. Among visits with a prescription generated, 24.5% had prescriptions electronically. In multivariate regression analysis, we found no significant correlations between comfort with computers, positive attitudes about EHRs, or negative attitudes about EHRs and any of the measures of use. DISCUSSION: Comfort with computers and attitudes about EHRs did not predict future use of the EHR functions. Our findings suggest that meaningful use of the EHR may not be affected by providers' prior attitudes about EHRs.

The effect of charge display on cost of care and physician practice behaviors: a systematic review.

BACKGROUND: While studies have been published in the last 30 years that examine the effect of charge display during physician decision-making, no analysis or synthesis of these studies has been conducted. OBJECTIVE: We aimed to determine the type and quality of charge display studies that have been published; to synthesize this information in the form of a literature review. METHODS: English-language articles published between 1982 and 2013 were identified using MEDLINE, Web of Knowledge, ABI-Inform, and Academic Search Premier. Article titles, abstracts, and text were reviewed for relevancy by two authors. Data were then extracted and subsequently synthesized and analyzed. RESULTS: Seventeen articles were identified that fell into two topic categories: the effect of charge display on radiology and laboratory test ordering versus on medication choice. Seven articles were randomized controlled trials, eight were pre-intervention vs. post-intervention studies, and two interventions had a concurrent control and intervention groups, but were not randomized. Twelve studies were conducted in a clinical environment, whereas five were survey studies. Of the nine clinically based interventions that examined test ordering, seven had statistically significant reductions in cost and/or the number of tests ordered. Two of the three clinical studies looking at medication expenditures found significant reductions in cost. In the survey studies, physicians consistently chose fewer tests or lower cost options in the theoretical scenarios presented. CONCLUSIONS: In the majority of studies, charge information changed ordering and prescribing behavior.