The Educational Needs of Clinicians Regarding Anticoagulation Therapy for Prevention of Thromboembolism and Stroke in Patients With Atrial Fibrillation.

The objective is to identify practice patterns and attitudes of and barriers faced by US physicians assessing thromboembolism/stroke risk and managing anticoagulation in atrial fibrillation (AF) to determine educational needs. Case-based surveys were used to assess practice patterns, guideline use, barriers, and attitudes; 51 cardiologists and 50 primary care physicians (PCPs) were surveyed. Most cardiologists use validated risk scoring systems to assess thromboembolism/stroke risk, and more than half of PCPs use clinical experience. Assessment of bleeding risk varied; more than half of respondents rely on clinical judgment or patient bleeding history. The most commonly used prophylactic agents are warfarin/another vitamin K antagonist (PCPs) or antiplatelet agents (cardiologists). Newer anticoagulants are used less frequently. Bleeding risk, need for frequent monitoring (vitamin K antagonists), and medication costs were the most significant barriers. Cardiologists and PCPs could benefit from education on validated scoring systems to assess risk of thromboembolism/stroke and bleeding in AF, on newly released AF guidelines, and on newer anticoagulants.

Physician knowledge about and perceptions of obesity management.

OBJECTIVE: Approximately 35% of US adults are obese. The purpose of this study was to assess the knowledge and practice patterns of primary care physicians (PCPs), endocrinologists (ENDOs), cardiologists (CARDs) and bariatricians (BARIs) regarding obesity. METHODS: A case vignette survey was distributed to 1625 US-based PCPs, ENDOs, CARDs, and BARIs via email and fax in February 2013. Results were analysed with PASW Statistics 18. RESULTS: Respondents included 100 PCPs, 100 ENDOs, 70 CARDs, and 30 BARIs. The majority agreed obesity is a disease as defined by the AMA, however, half of PCPs, ENDOs, and CARDs also agreed obesity results from a lack of self-control. Familiarity with select obesity guidelines was low. Nearly all respondents used body mass index for obesity screening. No consensus as to when to initiate weight-loss medication was observed. Many physicians expected a larger weight loss with pharmacotherapy than is realistic (∼ 30%) or were unsure (∼ 22%). A majority of PCPs, ENDOs and CARDs expected less excess weight loss with gastric bypass surgery than is realistic, BARIs had a more reasonable expectation. CONCLUSIONS: Overall, respondents demonstrated knowledge gaps for obesity guidelines and pathophysiology and generally lacked understanding of obesity medication efficacy, safety and MOA.

Health care provider management of patients with type 2 diabetes mellitus: analysis of trends in attitudes and practices.

OBJECTIVE: To identify attitudes and practices of endocrinologists (ENDOs), family practitioners (FPs), internists (IMs), primary care nurse practitioners (NPs), physician assistants (PAs), certified diabetes educators (CDEs), retail pharmacists (R-PHs), and hospital pharmacists (H-PHs) with respect to type 2 diabetes mellitus (T2DM) management; to compare current study data with results from a similar 2011 study. METHODS: A nominal group technique focus group identified barriers to optimal management of patients with T2DM. Five case-vignette surveys were created, 1 for each group of health care professionals (HCPs): ENDOs; FPs and IMs; NPs and PAs; CDEs; and R-PHs and H-PHs. Surveys were tailored to each group. Versions were as similar as possible to each other and to the 2011 surveys to facilitate comparisons. Questions assessed guideline familiarity; knowledge of insulin formulations, glucagon-like peptide-1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors; patterns of referral to ENDOs and CDEs; as well as cultural barriers and communication barriers. Surveys were distributed by e-mail/fax to a nationally representative, random sample of US HCPs during January and February 2013. RESULTS AND CONCLUSIONS: Notable shifts from 2011 included NPs' increased familiarity with American Diabetes Association (ADA) guidelines; FPs, IMs, NPs, and PAs continued comfort with prescribing long-acting basal insulin but less with basal-bolus, Neutral Protamine Hagedorn insulin alone, or human premixed insulin; increased pharmacists' comfort in discussing long-acting basal insulin; increased likelihood that FPs will refer patients with recurrent hypoglycemia unable to achieve target glycated hemoglobin level to an ENDO; and continued incorporation of insulin and incretins into treatment regimens. The trends suggest gaps in perception, knowledge, and management practices to be addressed by education. Most HCPs lack confidence in using insulin regimens more complex than long-acting insulin alone. All providers need education on T2DM management guidelines, differences between GLP-1 agonists and DPP-4 inhibitors, and how to intensify therapy for patients not reaching goal blood glycemic level with use of multiple agents. Pharmacists might benefit from education on glycemic treatment goals.

Current Practice Patterns and Educational Needs of Rheumatologists Who Manage Patients with Rheumatoid Arthritis.

INTRODUCTION: As the therapeutic landscape for rheumatoid arthritis (RA) continues to change, it is relevant to examine current treatment patterns among rheumatologists. The purpose of this study was to identify attitudes and practices of US rheumatologists with respect to RA. METHODS: Nine-hundred and one US-practicing rheumatologists were sent electronic invites (via email or fax) to participate in a case-vignette survey in April 2013. All respondents were currently practicing rheumatology and seeing at least one RA patient per week. The survey examined current attitudes, existing knowledge, management choices and perceived barriers in the management of RA. Data collection stopped once 125 responses were received. RESULTS: Approximately half of the 125 respondents were very familiar with current clinical practice guidelines for RA diagnosis and management. There was no consensus on which validated tools to use when assessing RA severity, with 54% using Physician Global Assessment and 34% using Disease Activity Score 28 at initial assessment. Most respondents (74%) used methotrexate (MTX) as initial therapy for a newly diagnosed RA patient. Eighty-six percent of respondents would add a tumor necrosis factor inhibitor (TNFi) when MTX alone could not control RA. There was no consensus on which treatment should be used when a TNFi is ineffective. The majority of respondents (66% of respondents) would prescribe TNFis indefinitely in patients with continued response. If a patient was in stable remission on MTX and a TNFi, respondents were most likely to maintain this regimen (53% of respondents); a notable minority (43%) would lower the MTX dose. When prescribing biologics, respondents were most concerned with infection; infection was considered a very significant barrier to biologic use. Although 98% of respondents indicated that they personally educate patients about RA, only 42% provide written material. CONCLUSIONS: The lack of consistency in responses suggests that rheumatologists may benefit from continuing medical education on; clinical practice guidelines; the most recent evidence for management of patients in remission; the use of biologic agents after infection; and management of patients with RA and comorbidities.

Current pathology practices in and barriers to MDS diagnosis.

Myelodysplastic syndromes (MDS) are a heterogeneous group of hematopoietic stem cell malignancies that represent a diagnostic challenge for pathologists. Accurate classification and prognostic scoring are essential to treating MDS. To understand factors that affect MDS management, a case-based survey was distributed to hematopathologists (n=53) and general pathologists (n=72) to identify perceived barriers, attitudes, and practices in MDS diagnosis. Results demonstrated confidence and practice gaps. Only 33% of general pathologists are confident in diagnosing MDS. Neither general pathologists nor hematopathologists are comfortable using the International Prognostic Scoring System to characterize risk. Thirty percent of general pathologists and 22% of hematopathologists would not include bone marrow aspirate and cytogenetics in initial testing of a neutropenic patient. Most practitioners tested appropriately for disease classification and prognosis; discrepancies were identified in testing to differentiate MDS from acute myeloid leukemia and testing in post treatment specimens. These results have implications in the management of MDS.

Assessing the effectiveness of a Grand Rounds CME activity for health-care professionals.

The Lymphoma Research Foundation offers Grand Rounds continuing medical education (CME) activities on specific issues related to advances in the management of patients with lymphoma. The 2012 activity comprised interactive case studies presented by local lymphoma experts. A case-based survey was designed to assess whether the management choices of program participants are consistent with the evidence-based content of the CME activity. This survey was administered to participants 1 month after completion of the CME activity and also to a control group who did not participate in the educational program. Participants were more aware of the epidemiology of CD20-positive tumors than were controls and were more likely to appropriately diagnose primary mediastinal large B cell lymphoma (PMBCL), use evidence-based second-line therapy for PMBCL, and properly manage a patient with classic Hodgkin lymphoma that did not respond to standard therapy. Participants were also more confident than controls in their ability to interpret histology and cytogenetic testing for selecting an optimal treatment.

Identifying psychiatrists' practice patterns when managing depression in patients with bipolar I disorder: a descriptive study to inform education needs.

OBJECTIVE: The purpose of this study was to describe practice patterns of US psychiatrists with regard to the diagnosis and management of depression in adults with bipolar I disorder and to identify relevant gaps in clinical knowledge and competence. METHODS: Two focus groups were conducted using nominal group technique via a web interface and teleconference to elicit barriers that psychiatrists face in managing depression in patients with bipolar I disorder. These results framed a case-based survey that was administered to 200 US-based psychiatrists to explore and quantitatively assess their knowledge and practice patterns with respect to the diagnosis and management of depression in patients with bipolar I disorder. We completed all statistical analyses with PASW Statistics 18 and used descriptive statistics to summarize survey responses. RESULTS: To identify previously undiagnosed mania, 67% of clinician respondents said that they asked depressed patients if they had previously experienced all Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision mania-defining symptoms. To treat a patient with symptoms of depression and no other risk factors for bipolar I disorder, 85% of the respondents said that they would use an antidepressant; 55% of respondents were not concerned that their choice of treatment would lead to a manic episode; 5% thought that there was no greater risk of treatment-emergent mood disorder when treating depression in patients with bipolar I disorder compared with major depressive disorder. If the patient had depression and risk factors for bipolar I disorder, 54% of the respondents said that they would still prescribe an antidepressant as monotherapy. CONCLUSION: The clinician responses were not adherent to evidence-based practice based on clinical trial results or current guideline recommendations. There is an unmet need for education to enable psychiatrists to differentiate between unipolar and bipolar depression, to identify the risk of treatment-emergent mood disorders with the use of antidepressants, and to effectively manage patients at risk for bipolar I disorder.