Lars Osterberg, MD, MPH

All Publications

• Developing institutional infrastructure for physician wellness: qualitative Insights from VA physicians. BMC health services research Schwartz, R., Shanafelt, T. D., Gimmler, C., Osterberg, L. 2020; 20 (1): 7

  Abstract

  The prevalence and detrimental effect of physician burnout requires new strategies for supporting physicians. In this project, we describe the development, and assessment, of a "Balint-like" physician support group that provided social cohesion and delivered novel didactic curricula for building resilience.The project began with a nine-month facilitated peer-support group for physicians that met every other week. Based on input from the first group, tailored content was developed to address physician wellness needs. These curricula were delivered to participants in the second nine-month Balint-like group. We then conducted semi-structured interviews with 7 hospitalists and 2 outpatient primary care physicians who participated in the Balint-like groups to explore the intervention's value and to identify remaining unmet physician wellness needs. Using an inductive thematic analysis approach, we identified a set of institutional-, community- and individual-level factors affecting physician wellness and corresponding intervention opportunities.Physicians spoke of systems-level factors that contributed to distress, and proposed infrastructure, both physical and procedural, that they felt could better support physician wellness. They highlighted the emotional challenges of daily work, and the need for a forum by which to process these interactions in order to maintain their own wellness. Participants reported that participation in Balint-like groups provided this forum and served to help the physicians normalize struggles, reduce isolation and provide new strategies for navigating challenging interactions.Institutional infrastructure, in the form of regular, psychologically-safe forums for processing with peers and learning relational strategies for preserving wellness, may mitigate physician distress. This project provides a model for how to develop and deliver a low-cost physician wellness program that can be tailored to the needs of individual clinical units.

  View details for DOI 10.1186/s12913-019-4783-9

  View details for PubMedID 31900137

• Revealing Novel IDEAS: A Fiduciary Framework for Team-Based Prescribing. Academic medicine : journal of the Association of American Medical Colleges Plowman, R. S., Peters, S. R., Brady, B. M., Osterberg, L. G. 2019

  Abstract

  The importance of safe, effective, and cost-effective prescribing habits can hardly be overstated in the current pay-for-value environment. The prescribing process taught in most medical curricula focuses primarily on accurate medical indications. While this may be of utmost importance from the clinician's perspective, it falls short of addressing the other key elements of highly effective prescribing. These other elements are often paramount in the minds of patients. A patient-centric framework that associates and incorporates the necessary components of optimal prescribing is overdue. Building this framework into medical curricula will foster increased teamwork among providers and enhance shared decision making between patients and clinicians. In addition to establishing accurate medical indications, prescribing teams need to assure every prescribed medication is desired, effective, affordable, and safe for patients who receive them. Prescription writing is an honorable prerogative and doing so safely, effectively, and cost-effectively requires both teamwork and technology. Highly effective prescribing teams can implement the IDEAS (Indicated, Desired, Effective, Affordable, Safe) framework through appropriate and deliberate delegation. By empowering members of the care team to support and educate patients, this framework will allow physicians to focus on ensuring appropriate indications and real-world effectiveness. This novel IDEAS framework serves as an important mental model for medical trainees and reinforces sound prescribing habits among seasoned clinicians. High-touch and high-tech partnerships have the potential to maximize the triple aim (i.e., improving the patient's experience of care, improving the health of populations, and reducing the per capita cost of health care). In an era when costs overwhelm quality, providing a fiduciary framework to instill responsibility for optimal prescribing, especially among young physician-leaders, is invaluable.

  View details for DOI 10.1097/ACM.0000000000003100

  View details for PubMedID 31789844

• Views of institutional leaders on maintaining humanism in today's practice. Patient education and counseling Gilligan, M. C., Osterberg, L. G., Rider, E. A., Derse, A. R., Weil, A. B., Litzelman, D. K., Dunne, D. W., Hafler, J. P., Plews-Ogan, M., Frankel, R. M., Branch, W. T. 2019

  Abstract

  OBJECTIVE: To explore leadership perspectives on how to maintain high quality efficient care that is also person-centered and humanistic.METHODS: The authors interviewed and collected narrative transcripts from a convenience sample of 32 institutional healthcare leaders at seven U.S. medical schools. The institutional leaders were asked to identify factors that either promoted or inhibited humanistic practice. A subset of authors used the constant comparative method to perform qualitative analysis of the interview transcripts. They reached thematic saturation by consensus on the major themes and illustrative examples after six conference calls.RESULTS: Institutional healthcare leaders supported vision statements, policies, organized educational and faculty development programs, role modeling including their own, and recognition of informal acts of kindness to promote and maintain humanistic patient-care. These measures were described individually rather than as components of a coordinated plan. Few healthcare leaders mentioned plans for organizational or systems changes to promote humanistic clinician-patient relationships.CONCLUSIONS: Institutional leaders assisted clinicians in dealing with stressful practices in beneficial ways but fell short of envisaging systems approaches that improve practice organization to encourage humanistic care.PRACTICE IMPLICATIONS: To preserve humanistic care requires system changes as well as programs to enhance skills and foster humanistic values and attitudes.

  View details for DOI 10.1016/j.pec.2019.04.025

  View details for PubMedID 31097330

• Too Many Hats? Conflicts of Interest in Learning Community Faculty Roles JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT Gliatto, P., Colbert-Getz, J. M., Bhutiani, M., Cutrer, W. B., Edwards, S., Fleming, A., Keeley, M., Osterberg, L., Pilla, M. A., Moynahan, K. 2019; 6: 2382120519827890

  Abstract

  Many US medical schools have adopted learning communities to provide a framework for advising and teaching functions. Faculty who participate in learning communities often have additional educator roles. Defining potential conflicts of interest (COIs) among these roles is an important consideration for schools with existing learning communities and those looking to develop them, both for transparency with students and also to comply with regulatory requirements.A survey was sent to the institutional contact for each of the 42 Learning Communities Institute (LCI) member medical schools to assess faculty opinions about what roles potentially conflict. The survey asked the role of learning community faculty in summative and formative assessment of students and whether schools had existing policies around COIs in medical education.In all, 35 (85%) LCI representatives responded; 30 (86%) respondents agreed or strongly agreed that learning community faculty should be permitted to evaluate their students for formative purposes, while 19 (54%) strongly agreed or agreed that learning community faculty should be permitted to evaluate their students in a way that contributes to a grade; 31 (89%) reported awareness of the accreditation standard ensuring "that medical students can obtain academic counseling from individuals who have no role in making assessment or promotion decisions about them," but only 10 (29%) had a school policy about COIs in education. There was a wide range of responses about what roles potentially conflict with being a learning community faculty.The potential for COIs between learning community faculty and other educator roles concerns faculty at schools with learning communities, but most schools have not formally addressed these concerns.

  View details for PubMedID 30923748

• Preclinical curriculum of prospective case-based teaching with faculty- and student-blinded approach. BMC medical education Waliany, S., Caceres, W., Merrell, S. B., Thadaney, S., Johnstone, N., Osterberg, L. 2019; 19 (1): 31

  Abstract

  BACKGROUND: Case-based teaching with real patient cases provides benefit of simulating real-world cognition. However, while clinical practice involves a prospective approach to cases, preclinical instruction typically involves full disclosure of case content to faculty, introducing hindsight bias into faculty teaching in medical curricula.METHODS: During 2015-2018, we piloted an optional medical school curriculum involving 6-7 one-hour sessions over a 3-month period each year. New groups enrolled each year from first- and second-year classes. A facilitator provided a blinded physician discussant and blinded students with case information during and not in advance of each session, allowing prospective case-based discussions. Cases were based on real patients treated in the Department of Medicine. Clinical material was presented in the chronologic sequence encountered by treating physicians. Content covered a median of 5 patient visits/case (range: 2-10) spanning over months. A 14-item survey addressing components of the reporter-interpreter-manager-educator (RIME) scheme was developed and used to compare self-reported clinical skills between course participants and non-participant controls during the 2016 course iteration.RESULTS: This elective curriculum at Stanford School of Medicine involved 170 preclinical students (22.7% of 750 eligible). During the 2016 course iteration, a quasi-experimental study compared self-reported clinical skills between 29 course participants (response rate: 29/49 [59.2%]) and 35 non-participant controls (response rate: 35/132 [26.5%]); students self-assessed clinical skills via the RIME-based survey developed for the course. Two-sample t-tests compared the change in pre- and post-course skills between course participants and non-participants. Of 15 Department of Medicine faculty members invited as discussants, 12 (80%) consented to participate. Compared with controls, first-year participants self-assessed significantly greater improvement in understanding how clinicians reason through cases step-by-step to arrive at diagnoses (P=0.049), work through cases in longitudinal settings (P=0.049), and share information with patients (P=0.047). Compared with controls, second-year participants self-assessed significantly greater improvement (P=0.040) in understanding how clinicians reason through cases step-by-step to arrive at diagnoses.CONCLUSIONS: Prospective case-based discussions with blinding offaculty and students to clinical content circumvents hindsight bias and may impart real-world cognitive skills as determined by student self-report.

  View details for PubMedID 30674302

• Healthcare at the Crossroads: The Need to Shape an Organizational Culture of Humanistic Teaching and Practice JOURNAL OF GENERAL INTERNAL MEDICINE Rider, E. A., Gilligan, M. C., Osterberg, L. G., Litzelman, D. K., Plews-Ogan, M., Weil, A. B., Dunne, D. W., Hafler, J. P., May, N. B., Derse, A. R., Frankel, R. M., Branch, W. T. 2018; 33 (7): 1092–99

  Abstract

  Changes in the organization of medical practice have impeded humanistic practice and resulted in widespread physician burnout and dissatisfaction.To identify organizational factors that promote or inhibit humanistic practice of medicine by faculty physicians.From January 1, 2015, through December 31, 2016, faculty from eight US medical schools were asked to write reflectively on two open-ended questions regarding institutional-level motivators and impediments to humanistic practice and teaching within their organizations.Sixty eight of the 92 (74%) study participants who received the survey provided written responses. All subjects who were sent the survey had participated in a year-long small-group faculty development program to enhance humanistic practice and teaching. As humanistic leaders, subjects should have insights into motivating and inhibiting factors.Participants' responses were analyzed using the constant comparative method.Motivators included an organizational culture that enhances humanism, which we judged to be the overarching theme. Related themes included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities that promote humanism, and practice structures that facilitate humanism. Impediments included top down organizational culture that inhibits humanism, along with related themes of non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures.While healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus.

  View details for PubMedID 29740787

• A daily skincare regimen with a unique ceramide and filaggrin formulation rapidly improves chronic xerosis, pruritus, and quality of life in older adults GERIATRIC NURSING Chang, A. S., Chen, S. C., Osterberg, L., Brandt, S., von Grote, E. C., Meckfessel, M. H. 2018; 39 (1): 24–28

  Abstract

  A skin care regimen which significantly improved atopic dermatitis and pruritus was evaluated for its efficacy and acceptability in senior subjects diagnosed with xerosis who also suffer from pruritus. This was an open-label, single-center study, designed to evaluate the daily use of a skin care regimen for 15 days. Assessments were made at baseline, day 8 and day 15 for visual skin dryness, transepidermal water loss (TEWL), hydration, desquamation, subject-perceived itch and quality of life (QoL). Twenty-five subjects, ages 60-73 years, had significantly improved skin visual dryness, hydration, desquamation, itch and QoL at days 8 and 15, relative to baseline (P < .05). TEWL was improved, though not significantly. Subjects expressed a high degree of satisfaction with the results. This regimen provides geriatric patients with an easily incorporated skin routine to help improve a common symptom of aging skin which negatively affects QoL.

  View details for PubMedID 28600081

• A Multi-Institutional Longitudinal Faculty Development Program in Humanism Supports the Professional Development of Faculty Teachers ACADEMIC MEDICINE Branch, W. T., Frankel, R. M., Hafler, J. P., Weil, A. B., Gilligan, M. C., Litzelman, D. K., Plews-Ogan, M., Rider, E. A., Osterberg, L. G., Dunne, D., May, N. B., Derse, A. R. 2017; 92 (12): 1680–86

  Abstract

  The authors describe the first 11 academic years (2005-2006 through 2016-2017) of a longitudinal, small-group faculty development program for strengthening humanistic teaching and role modeling at 30 U.S. and Canadian medical schools that continues today. During the yearlong program, small groups of participating faculty met twice monthly with a local facilitator for exercises in humanistic teaching, role modeling, and related topics that combined narrative reflection with skills training using experiential learning techniques. The program focused on the professional development of its participants. Thirty schools participated; 993 faculty, including some residents, completed the program.In evaluations, participating faculty at 13 of the schools scored significantly more positively as rated by learners on all dimensions of medical humanism than did matched controls. Qualitative analyses from several cohorts suggest many participants had progressed to more advanced stages of professional identity formation after completing the program. Strong engagement and attendance by faculty participants as well as the multimodal evaluation suggest that the program may serve as a model for others. Recently, most schools adopting the program have offered the curriculum annually to two or more groups of faculty participants to create sufficient numbers of trained faculty to positively influence humanistic teaching at the institution.The authors discuss the program's learning theory, outline its curriculum, reflect on the program's accomplishments and plans for the future, and state how faculty trained in such programs could lead institutional initiatives and foster positive change in humanistic professional development at all levels of medical education.

  View details for PubMedID 28991846

  View details for PubMedCentralID PMC5704738

• Ready for independent practice ... or not? MEDICAL EDUCATION Osterberg, L. G., Branch, W. T. 2017; 51 (6): 570–72

  View details for DOI 10.1111/medu.13325

  View details for Web of Science ID 000400977800003

  View details for PubMedID 28488301

• The Five-Minute Moment. American journal of medicine Chi, J., Artandi, M., Kugler, J., Ozdalga, E., Hosamani, P., Koehler, E., Osterberg, L., Zaman, J., Thadaney, S., Elder, A., Verghese, A. 2016; 129 (8): 792-795

  Abstract

  In today's hospital and clinic environment, the obstacles to bedside teaching both for faculty and trainees are considerable. As Electronic Health Records (EHR) systems become increasingly prevalent, trainees are spending more time performing patient care tasks from computer workstations, limiting opportunities to learn at the bedside. Physical examination skills are rarely emphasized and low confidence levels, especially in junior faculty, pose additional barriers to teaching the bedside exam.

  View details for DOI 10.1016/j.amjmed.2016.02.020

  View details for PubMedID 26972793

• Back to the Future: What Learning Communities Offer to Medical Education Journal of Medical Education and Curricular Development Osterberg, L., Goldstein, E., Hatem, D. S., Moynahan, K., Shochet, R. 2016: 67-70

  View details for DOI 10.4137/JMECD.S39420

• The highly influential teacher: recognising our unsung heroes. Medical education Osterberg, L., Swigris, R., Weil, A., Branch, W. T. 2015; 49 (11): 1117-1123

  View details for DOI 10.1111/medu.12808

  View details for PubMedID 26494064

• Screen of Drug Use: Diagnostic Accuracy of a New Brief Tool for Primary Care. JAMA internal medicine Tiet, Q. Q., Leyva, Y. E., Moos, R. H., Frayne, S. M., Osterberg, L., Smith, B. 2015; 175 (8): 1371-1377

  Abstract

  Illicit drug use is prevalent, and primary care provides an ideal setting in which to screen for drug use disorders (DUDs) and negative consequences of drug use (NCDU). Comprehensive reviews have concluded that existing drug use screening instruments are not appropriate for routine use in primary care.To develop and validate a screening instrument for drug use.We revised items drawn from existing screening instruments and conducted signal detection analyses to develop the new instrument. We approached 3173 patients at 2 primary care clinics in a US Department of Veterans Affairs health care system from February 1, 2012, through April 30, 2014. A total of 1300 (41.0%) patients consented to the study, of whom 1283 adults were eligible (mean [SD] age, 62.2 [12.6] years). In the last 12 months, 241 (18.8%) participants reported using illicit drugs or prescription medication for a nonmedical purpose, and 189 (14.7%) reported 1 or more NCDU. A total of 133 (10.4%) patients met DSM-IV criteria for a DUD. The sample was randomly divided first to develop the measure and then to validate it.The Mini-International Diagnostic Interview was used as the criterion for DUDs, and the Inventory of Drug Use Consequences was used as the criterion for NCDU.The screening instrument has 2 questions. The first is, "How many days in the past 12 months have you used drugs other than alcohol?" Patients meet that criterion with a response of 7 or more days. The second question asks, "How many days in the past 12 months have you used drugs more than you meant to?" A response of 2 or more days meets that criterion. The screening instrument was 100% sensitive and 93.73% specific for DUDs (643 patients); when replicated in the second half of the sample (640 patients), it was 92.31% sensitive and 92.87% specific. The screening instrument was 93.18% sensitive and 96.03% specific for NCDU (643 patients); when replicated in the second half of the sample (640 patients), it was 83.17% sensitive and 96.85% specific.The 2-item screen of drug use has excellent statistical properties and is a brief screening instrument for DUDs and problems suitable for busy US Department of Veterans Affairs primary care clinics.

  View details for DOI 10.1001/jamainternmed.2015.2438

  View details for PubMedID 26075352

• Antiretroviral therapy adherence and predictors to adherence in Albania: a cross-sectional study. Journal of infection in developing countries Morrison, S. D., Rashidi, V., Sarnquist, C., Banushi, V. H., Hole, M. K., Barbhaiya, N. J., Gashi, V. H., Osterberg, L., Maldonado, Y., Harxhi, A. 2014; 8 (7): 853-862

  Abstract

  The possibility of an HIV/AIDS epidemic in southeastern Europe (SEE) is not improbable. Thus, an understanding of the current issues surrounding HIV/AIDS care, specifically antiretroviral therapy (ART) adherence, in countries within SEE is critical. This study was conducted to determine the ART adherence characteristics of Albania's HIV-positive population.This cross-sectional study reports initial demographic and adherence characteristics of patients receiving HIV/AIDS treatment in Albania. Retrospective review of pharmacy medications dispensed supplemented reported adherence behavior. Further, an adherence index was utilized to explore adherence more thoroughly.Patient-reported adherence and pharmacy review showed adherence levels of 98.9±4.4% and 97.7±4.7%, respectively. Assessment by adherence index revealed an index level of 91.7±6.7. Factors associated with a score of < 95 on the adherence index were: being partnered (OR = 0.29, 95% CI = 0.09 - 0.98), history of depression (OR = 0.24, 95% CI = 0.08 - 0.76), increased number of barriers to care (OR = 0.80, 95% CI = 0.66 - 0.97), and increased number of current social and medical needs (OR = 0.72, 95% CI = 0.58 - 0.91).Interventions aimed at reducing barriers to care, addressing current medical and social needs, and treating mental health issues may help improve adherence to ART in patients with HIV/AIDS in Albania. With little known about HIV/AIDS in SEE, this study provides guidance on how SEE countries can help prevent a possible rise in the prevalence of HIV given the close link of ART adherence and spread of HIV.

  View details for DOI 10.3855/jidc.3563

  View details for PubMedID 25022295

• From High School to Medical School: The Importance of Community in Education Med Sci Educ Osterberg, L. G., Gilbert, J., Lotan, R. 2014; 24:253-256
• Strategies to Predict, Measure, and Improve Psychosocial Treatment Adherence HARVARD REVIEW OF PSYCHIATRY Gearing, R. E., Townsend, L., Elkins, J., El-Bassel, N., Osterberg, L. 2014; 22 (1): 31-45

  Abstract

  Nonadherence to psychosocial and behavioral treatment is a significant public health problem that presents a barrier to recovery and effective treatment. An estimated 20% to 70% of individuals who initiate psychosocial mental health services discontinue treatment prior to clinicians' recommendations. Empirically supported, evidence-based, stand-alone or adjunctive psychosocial interventions treat an increasingly wide range of mental health conditions. A core assumption of most, if not all, interventions is that clients will fully and actively engage in the treatment protocol. Adherence to psychosocial treatment has received much less scientific attention, however, than adherence to medical treatment. Drawing extensively from existing research, this comprehensive review conceptualizes several types of psychosocial and behavioral treatment adherence, examines predictors of adherence to psychosocial treatment, summarizes measures of adherence, and describes existing interventions to enhance psychosocial treatment adherence.

  View details for DOI 10.1097/HRP.0000000000000005

  View details for Web of Science ID 000329612100003

  View details for PubMedID 24394220

• Strategies to Predict, Measure, and Improve Psychosocial Treatment Adherence. Harvard review of psychiatry Gearing, R. E., Townsend, L., Elkins, J., El-Bassel, N., Osterberg, L. 2013: -?

  Abstract

  Nonadherence to psychosocial and behavioral treatment is a significant public health problem that presents a barrier to recovery and effective treatment. An estimated 20% to 70% of individuals who initiate psychosocial mental health services discontinue treatment prior to clinicians' recommendations. Empirically supported, evidence-based, stand-alone or adjunctive psychosocial interventions treat an increasingly wide range of mental health conditions. A core assumption of most, if not all, interventions is that clients will fully and actively engage in the treatment protocol. Adherence to psychosocial treatment has received much less scientific attention, however, than adherence to medical treatment. Drawing extensively from existing research, this comprehensive review conceptualizes several types of psychosocial and behavioral treatment adherence, examines predictors of adherence to psychosocial treatment, summarizes measures of adherence, and describes existing interventions to enhance psychosocial treatment adherence.

  View details for PubMedID 24335513

• Revolutionizing volunteer interpreter services: an evaluation of an innovative medical interpreter education program. Journal of general internal medicine Hasbún Avalos, O., Pennington, K., Osterberg, L. 2013; 28 (12): 1589-1595

  Abstract

  In our ever-increasingly multicultural, multilingual society, medical interpreters serve an important role in the provision of care. Though it is known that using untrained interpreters leads to decreased quality of care for limited English proficiency patients, because of a short supply of professionals and a lack of formalized, feasible education programs for volunteers, community health centers and internal medicine practices continue to rely on untrained interpreters.To develop and formally evaluate a novel medical interpreter education program that encompasses major tenets of interpretation, tailored to the needs of volunteer medical interpreters.One-armed, quasi-experimental retro-pre-post study using survey ratings and feedback correlated by assessment scores to determine educational intervention effects.Thirty-eight students; 24 Spanish, nine Mandarin, and five Vietnamese. The majority had prior interpreting experience but no formal medical interpreter training.Students completed retrospective pre-test and post-test surveys measuring confidence in and perceived knowledge of key skills of interpretation. Primary outcome measures were a 10-point Likert scale for survey questions of knowledge, skills, and confidence, written and oral assessments of interpreter skills, and qualitative evidence of newfound knowledge in written reflections.Analyses showed a statistically significant (P <0.001) change of about two points in mean self-ratings on knowledge, skills, and confidence, with large effect sizes (d > 0.8). The second half of the program was also quantitatively and qualitatively shown to be a vital learning experience, resulting in 18 % more students passing the oral assessments; a 19 % increase in mean scores for written assessments; and a newfound understanding of interpreter roles and ways to navigate them.This innovative program was successful in increasing volunteer interpreters' skills and knowledge of interpretation, as well as confidence in own abilities. Additionally, the program effectively taught how to navigate the roles of the interpreter to maintain clear communication.

  View details for DOI 10.1007/s11606-013-2502-5

  View details for PubMedID 23739810

  View details for PubMedCentralID PMC3832724

• Revolutionizing Volunteer Interpreter Services: An Evaluation of an Innovative Medical Interpreter Education Program JOURNAL OF GENERAL INTERNAL MEDICINE Avalos, O. H., Pennington, K., Osterberg, L. 2013; 28 (12): 1589-1595

  View details for DOI 10.1007/s11606-013-2502-5

  View details for Web of Science ID 000327127700013

• Adherence to Medications: Insights Arising from Studies on the Unreliable Link Between Prescribed and Actual Drug Dosing Histories ANNUAL REVIEW OF PHARMACOLOGY AND TOXICOLOGY, VOL 52 Blaschke, T. F., Osterberg, L., Vrijens, B., Urquhart, J. 2012; 52: 275-?

  Abstract

  Satisfactory adherence to aptly prescribed medications is essential for good outcomes of patient care and reliable evaluation of competing modes of drug treatment. The measure of satisfactory adherence is a dosing history that includes timely initiation of dosing plus punctual and persistent execution of the dosing regimen throughout the specified duration of treatment. Standardized terminology for initiation, execution, and persistence of drug dosing is essential for clarity of communication and scientific progress. Electronic methods for compiling drug dosing histories are now the recognized standard for quantifying adherence, the parameters of which support model-based, continuous projections of drug actions and concentrations in plasma that are confirmable by intermittent, direct measurements at single time points. The frequency of inadequate adherence is usually underestimated by pre-electronic methods and thus is clinically unrecognized as a frequent cause of failed treatment or underestimated effectiveness. Intermittent lapses in dosing are potential sources of toxicity through hazardous rebound effects or recurrent first-dose effects.

  View details for DOI 10.1146/annurev-pharmtox-011711-113247

  View details for Web of Science ID 000301839600014

  View details for PubMedID 21942628

• Levels of self-reported depression and anxiety among HIV-positive patients in Albania: a cross-sectional study CROATIAN MEDICAL JOURNAL Morrison, S. D., Banushi, V. H., Sarnquist, C., Gashi, V. H., Osterberg, L., Maldonado, Y., Harxhi, A. 2011; 52 (5): 622-628

  Abstract

  To gain an initial perspective of mental health issues facing the Human Immunodeficiency Virus (HIV)-positive population at the University Hospital Center of Tirana (UHCT) HIV/AIDS Ambulatory Clinic.From June-August 2009, we conducted semi-structured interviews with 79 patients (93% response rate) at the UHCT HIV/AIDS Ambulatory Clinic. The interviews assessed patient-reported histories of mental health diagnoses, patients' demographics, and current emotional health status.The percentage of patients who reported a history of diagnosis of depression or anxiety was high - 62.3% and 82.3%, respectively. Factors associated with a history of depression included having been diagnosed with anxiety (P<0.001), having a higher number of barriers to care (P<0.001), having a higher number of current medical and social needs (P<0.001), or having not obtained antiretroviral therapy (ART) abroad (P=0.004). Factors associated with a history of anxiety included having been on first-line ART (P=0.008), having been diagnosed with HIV for shorter periods of time (P=0.043), having been diagnosed with depression (P<0.001), having a higher number of current medical and social needs (P=0.035), or having not obtained ART abroad (P=0.003).Mental health problems are widespread among the known HIV-positive patient population in Albania. The high prevalences of anxiety and depression and of dual diagnoses of these conditions suggest the need for more mental health care for HIV-positive patients in Albania.

  View details for DOI 10.3325/cmj.2011.52.622

  View details for PubMedID 21990080

• BARRIERS TO CARE AND CURRENT MEDICAL AND SOCIAL NEEDS OF HIV-POSITIVE PATIENTS IN ALBANIA CENTRAL EUROPEAN JOURNAL OF PUBLIC HEALTH Morrison, S. D., Banushi, V. H., Sarnquist, C., Gashi, V. H., Osterberg, L., Maldonado, Y., Harxhi, A. 2011; 19 (2): 91-97

  Abstract

  As HIV/AIDS prevalence rises in Eastern Europe, assessment of local epidemics in the bordering Central European region, especially South Eastern Europe, is vital in order to meet treatment and prevention needs. Understanding current medical and social needs and barriers to care experienced by HIV-positive patients in these regions may provide insight into how to best respond to the local epidemics, increase patients' access to treatment, and reduce loss to follow-up.This study assesses the patient characteristics, barriers to care, and current medical and social needs of HIV-positive patients in Albania. Semi-structured interviews were used in this cross-sectional study.We interviewed 79 of 85 patients (93% response rate) followed at the University Hospital Center of Tirana (UHCT) HIV/AIDS Ambulatory Clinic, which represented the majority of patients under HIV care in Albania during 2009.The local HIV epidemic seems to be comprised mainly of heterosexual men who have spent an average of 3.6 years abroad. The vast majority of patients under care at UHCT HIV/AIDS Ambulatory Clinic had experienced barriers to care associated with social stigma (97.4%), lack of knowledge of HIV medical care (76.6%), and medical provider's lack of knowledge of HIV (70.9%). Social needs of the patients were also overwhelmingly unmet (90.0-95.7%).In addressing HIV/AIDS in Albania, it will be crucial to educate the healthcare sector in ways to identify and address barriers to care and current medical and social needs of HIV-positive patients.

  View details for PubMedID 21739899

• Medical Student Wellness: An Essential Role for Mentors. Med Sci Educ 2011; Adams, P. J., Osterberg, L. G., Basaviah, P. 2011; 21(4):382-384
• Understanding Forgiveness: Minding and Mining the Gaps Between Pharmacokinetics and Therapeutics CLINICAL PHARMACOLOGY & THERAPEUTICS Osterberg, L. G., Urquhart, J., Blaschke, T. F. 2010; 88 (4): 457-459

  Abstract

  The usual objective during long-term pharmacotherapy is, in large part, to maintain continuity of action of the prescribed drug(s). Continuity of action arises from the continuity of execution of a prescribed dosing regimen that is pharmacologically sound in dose quantity and interval between successive doses. Interruptions in dosing can interrupt drug action, but the consequences vary according to length of interruption, drug, drug formulation, length of the patient's prior exposure to the drug, and the disease being treated.

  View details for DOI 10.1038/clpt.2010.171

  View details for Web of Science ID 000282064000013

  View details for PubMedID 20856243

• Electronic monitors of drug adherence: tools to make rational therapeutic decisions Reply JOURNAL OF HYPERTENSION Christensen, A., Osterberg, L. G., Hansen, E. H. 2009; 27 (11): 2295-2295

  View details for DOI 10.1097/HJH.0b013e328332a511

  View details for Web of Science ID 000271614800012

• Electronic monitoring of patient adherence to oral antihypertensive medical treatment: a systematic review JOURNAL OF HYPERTENSION Christensen, A., Osterberg, L. G., Hansen, E. H. 2009; 27 (8): 1540-1551

  Abstract

  Poor patient adherence is often the reason for suboptimal blood pressure control. Electronic monitoring is one method of assessing adherence. The aim was to systematically review the literature on electronic monitoring of patient adherence to self-administered oral antihypertensive medications. We searched the Pubmed, Embase, Cinahl and Psychinfo databases and websites of suppliers of electronic monitoring devices. The quality of the studies was assessed according to the quality criteria proposed by Haynes et al. Sixty-two articles were included; three met the criteria proposed by Haynes et al. and nine reported the use of electronic adherence monitoring for feedback interventions. Adherence rates were generally high, whereas average study quality was low with a recent tendency towards improved quality. One study detected investigator fraud based on electronic monitoring data. Use of electronic monitoring of patient adherence according to the quality criteria proposed by Haynes et al. has been rather limited during the past two decades. Electronic monitoring has mainly been used as a measurement tool, but it seems to have the potential to significantly improve blood pressure control as well and should be used more widely.

  View details for DOI 10.1097/HJH.0b013e32832d50ef

  View details for Web of Science ID 000268803900008

  View details for PubMedID 19474761

• Planning services for the homeless in the San Francisco Peninsula JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Osterberg, L. G., Barr, D. A. 2007; 18 (4): 749-756

  Abstract

  A survey of clients seeking homeless services at agencies in the SF Peninsula, indicates that a disproportionate percentage are minority group members (African American and Hispanic) and veterans, and points to the need for integrated housing, social services, and health care for this vulnerable population.

  View details for Web of Science ID 000252211100005

  View details for PubMedID 17982204

• Adherence to medication - Reply NEW ENGLAND JOURNAL OF MEDICINE Osterberg, L., Blaschke, T. 2005; 353 (18): 1973-1974

  View details for Web of Science ID 000232972800024

• Adherence to medication. New England journal of medicine Osterberg, L., Blaschke, T. 2005; 353 (5): 487-497

  View details for PubMedID 16079372

• Drug therapy - Adherence to medication NEW ENGLAND JOURNAL OF MEDICINE Osterberg, L., Blaschke, T. 2005; 353 (5): 487-497

  View details for Web of Science ID 000230939000008

• Missed opportunities for patient education and social worker consultation at the arbor free clinic JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Soller, M., Osterberg, L. 2004; 15 (4): 538-546

  Abstract

  We conducted a cross-sectional survey of 210 patients who came to a free medical clinic for health care over an 8-month period. We (1) measured their satisfaction with care, (2) determined the frequency of missed opportunities for providing health education and social work consultation, and (3) assessed whether patient-specific factors drive the frequency of these missed opportunities. Of the 210 patients surveyed, a total of 168 (80.0%) completed the entire survey. The mean satisfaction rating was high (4.6 on a scale of 1 to 5). A significant number of missed opportunities occurred, with only 28% of patients receiving patient education material, and 32% of patients visiting the social worker. No particular patient groups emerged as most susceptible to these missed opportunities. This study shows both the high degree of patient satisfaction at this free clinic and the many opportunities for improving patient education and social services. Adding health education and social work consultation to the patient encounter could improve the health of these patients.

  View details for Web of Science ID 000225119700006

  View details for PubMedID 15531813

• A Web Based Course in Clinical Pharmacology Academic Exchange Quarterly Osterberg LG, Stiller C-O, Tornqvist E, Ayers M, Youngblood P, Bastholm P, Gardner P, Gustafsson LG 2003; 7 (Spring): 29-33
• Comparison of treadmill scores with physician estimates of diagnosis and prognosis in patients with coronary artery disease AMERICAN HEART JOURNAL Lipinski, M., Froelicher, V., Atwood, E., Tseitlin, A., Franklin, B., Osterberg, L., Do, D., Myers, J. 2002; 143 (4): 650-658

  Abstract

  Our purpose was to compare exercise test scores and ST measurements with a physician's estimation of the probability of the presence and severity of angiographic disease and the risk of death. The American College of Cardiology/American Heart Association exercise testing guidelines provide equations to calculate treadmill scores and recommend their use to improve the predictive accuracy of the standard exercise test. However, if physicians can estimate the probability of coronary artery disease and prognosis as well as the scores, there is no reason to add this complexity to test interpretation.A clinical exercise test was performed and an angiographic database was used to print patient summaries and treadmill reports. The clinical/treadmill test reports were sent to expert cardiologists and to 2 other groups, including randomly selected cardiologists and internists. They classified the patients summarized in the reports as having a high, low, or intermediate probability for the presence of any severe angiographic disease and estimated a numerical probability from 0% to 100%. The Social Security Death Index was used to determine survival status of the patients.Twenty-six percent of the patients had severe angiographic disease, and the annual mortality rate for the population was 2%. Forty-five expert cardiologists returned estimates on 473 patients, 37 randomly chosen practicing cardiologists returned estimates on 202 patients, 29 randomly chosen practicing internists returned estimates on 162 patients, 13 academic cardiologists returned estimates on 145 patients, and 27 academic internists returned estimates on 272 patients. When probability estimates for presence and severity of angiographic disease were compared, in general, the treadmill scores were superior to physicians' and ST analysis at predicting severe angiographic disease. When prognosis was estimated, treadmill prognostic scores did as well as expert cardiologists and better than most other physician groups.Estimates of the presence of clinically significant and severe angiographic coronary artery disease provided by scores were superior to physician estimates and ST analysis alone. Estimates of prognosis provided by scores were similar to the estimates made by expert cardiologists and more accurate than the estimates made by most other physician groups.

  View details for DOI 10.1067/mhj.2002.120967

  View details for PubMedID 11923802

• Comparison of exercise test scores and physician estimation in determining disease probability 72nd Annual Scientific Session of the American-Heart-Association Lipinski, M., Do, D., Froelicher, V., Osterberg, L., Franklin, B., West, J., Atwood, E. AMER MEDICAL ASSOC. 2001: 2239–44

  Abstract

  The recent American College of Cardiology/American Heart Association exercise testing guidelines provided equations to calculate treadmill scores and recommended their use to improve the predictive accuracy of the standard exercise test. However, if physicians can estimate the probability of coronary artery disease as well as the scores can, there would be no reason to add this complexity to test interpretation. To compare the exercise test scores with physician's estimation of disease probability, we used clinical, exercise test, and coronary angiographic data to compute the recommended scores and print patient summaries and treadmill reports.To determine whether exercise test scores can be as effective as expert cardiologists in diagnosing coronary disease.Five hundred ninety-nine consecutive male patients without previous myocardial infarction with a mean +/- SD age of 59 +/- 11 years were considered for this analysis. With angiographic disease defined as any coronary lumen occlusion of 50% or more, 58% had disease. The clinical/treadmill test reports were sent to expert cardiologists and to 2 other groups, including randomly selected cardiologists and internists, who classified the patients as having high, low, or intermediate probability of disease and estimated a numerical probability from 0% to 100%.Forty-five expert cardiologists returned estimates on 336 patients, 37 randomly chosen practicing cardiologists returned estimates on 129 patients, 29 randomly chosen practicing internists returned estimates on 106 patients, 13 academic cardiologists returned estimates on 102 patients, and 27 academic internists returned estimates on 174 patients. When probability estimates were compared, the scores were superior to all physician groups (0.76 area under the receiver operating characteristic curve to 0.70 for experts [P=.046], 0.73 to 0.58 for cardiologists [P=.003], and 0.76 to 0.61 for internists [P=.006]). Using a probability cut point of greater than 70% for abnormal, predictive accuracy was 69% for scores compared with 64% for experts, 63% to 62% for cardiologists, and 70% to 57% for internists.Although most similar to the disease estimates of the presence of clinically significant angiographic coronary artery disease provided by the expert cardiologists, the scores outperformed the nonexpert physicians.

  View details for Web of Science ID 000171237800009

  View details for PubMedID 11575981

• Images in clinical medicine. Constrictive pericarditis. New England journal of medicine Atwood, J. E., Osterberg, L. 2000; 343 (2): 106-?

  View details for PubMedID 10891518

• Constrictive pericarditis NEW ENGLAND JOURNAL OF MEDICINE Atwood, J. E., Osterberg, L. 2000; 343 (2): 106-106

  View details for Web of Science ID 000088116500005

• Case in point - Discoloration due to "chest pen" HOSPITAL PRACTICE Osterberg, L. 1999; 34 (3): 37-37

  View details for Web of Science ID 000079058300004

  View details for PubMedID 10089925

• Case presentation and review: Constrictive pericarditis WESTERN JOURNAL OF MEDICINE Osterberg, L., Vagelos, R., Atwood, J. E. 1998; 169 (4): 232-239

  View details for Web of Science ID 000076401200015

  View details for PubMedID 9795593

  View details for PubMedCentralID PMC1305302

• PULMONARY MELIOIDOSIS CHEST Ip, M., Osterberg, L. G., Chau, P. Y., Raffin, T. A. 1995; 108 (5): 1420-1424

  Abstract

  Melioidosis is the name given to all diseases caused by the bacterium Pseudomonas pseudomallei. Melioidosis is a tropical disease and prevails in parts of Southeast Asia, northern Australia, and Central and South America. However, in recent years, cases of melioidosis have been reported in the United States and other areas. The organism can infect any organ system, although the lung is the most common organ affected. Pulmonary melioidosis presents either as an acute fulminant pneumonia or as an indolent cavitary disease. In northeastern Thailand, the incidence of P pseudomallei infection is extremely high with significant mortality. One of the key problems with treating melioidosis is its recalcitrance to therapy and high relapse rate. In addition, this Gram-negative rod is resistant to aminoglycosides. In nonendemic regions, patients with melioidosis more typically present with reactivation disease occurring months to years after initial exposure to the organism. The pulmonary disease is mainly in the apices and resembles tuberculosis. With the increasing mobility of people throughout the world and the influx of immigrants from endemic to nonendemic areas, it is important that clinicians be aware of this disease. This article will review the epidemiology, clinical presentations, diagnosis, and treatment of pulmonary melioidosis.

  View details for Web of Science ID A1995TD70800046

  View details for PubMedID 7587451

• [Rotavirus diarrhea in a health center and a hospital of Managua, Nicaragua]. Revista cubana de medicina tropical López Cruz, S., Osterberg, L. 1992; 44 (1): 7-11

  Abstract

  Diarrhoea has been considered by WHO as a major problem of morbidity and mortality in children under 5 years. Rotavirus has been reported as one of the main causal agents, although its frequency as causal agent of diarrhoea in Nicaragua is not known. A study was carried out on 206 samples from an equal number of children under 5 years, who presented at a health center and a pediatric hospital in Managua during 9 months in 1987. In order to detect the presence of Rotavirus in faeces, the ELISA technique was used. It was proved that Rotavirus is not a significant cause of diarrhoea in children under 5 years in the places studied.

  View details for PubMedID 1344693

• PURIFICATION OF A PROTEIN HISTIDINE KINASE FROM THE YEAST SACCHAROMYCES-CEREVISIAE - THE 1ST MEMBER OF THIS CLASS OF PROTEIN-KINASES JOURNAL OF BIOLOGICAL CHEMISTRY Huang, J. M., Wei, Y. F., Kim, Y. H., Osterberg, L., Matthews, H. R. 1991; 266 (14): 9023-9031

  Abstract

  An enzyme of molecular weight 32,000 comprising a single subunit has been isolated from whole cell extracts of the yeast Saccharomyces cerevisiae. In vitro, the enzyme transfers the gamma phosphate of ATP to a protein substrate, histone H4, to produce an alkali-stable phosphorylation. Modification of the substrate histidine with diethylpyrocarbonate prevented phosphorylation. Phosphoamino acid analysis of the phosphorylated substrate showed the presence of 1-phosphohistidine. Hence, the isolated enzyme is a protein histidine kinase. A novel assay for acid-labile alkali-stable protein phosphorylation was used in the purification of the kinase activity to a final specific activity of 2,700 nmol/15 min/mg. The purified enzyme phosphorylates specifically histidine 75 in histone H4 and does not phosphorylate histidine 18 nor histidine residues in any other core histone. Steady state kinetic data are consistent with an ordered sequential reaction with Km values for Mg-ATP and histone H4 of 60 and 17 microM, respectively. The protein histidine kinase requires a divalent cation such as Mg2+, Co2+, or Mn2+ but will not use Ca2+, Zn2+, Cu2+, Fe2+, spermine, or spermidine. This is the first purification of an enzyme that catalyzes N-linked phosphorylation in proteins.

  View details for Web of Science ID A1991FM03800057

  View details for PubMedID 2026610