An Inpatient Treatment and Discharge Planning Protocol for Alcohol Dependence: Efficacy in Reducing 30-Day Readmissions and Emergency Department Visits

BACKGROUND

Alcohol dependence results in multiple hospital readmissions, but no discharge planning protocol has been studied to improve outcomes. The inpatient setting is a frequently missed opportunity to discuss treatment of alcohol dependence and initiate medication-assisted treatment, which is effective yet rarely utilized.

AIM

Our aim was to implement and evaluate a discharge planning protocol for patients admitted with alcohol dependence.

SETTING

The study took place at the San Francisco General Hospital (SFGH), a university-affiliated, large urban county hospital.

PARTICIPANTS

Learner participants included Internal Medicine residents at the University of California, San Francisco (UCSF) who staff the teaching service at SFGH. Patient participants included inpatients with alcohol dependence admitted to the Internal Medicine teaching service.

PROGRAM DESCRIPTION

We developed and implemented a discharge planning protocol for patients admitted with alcohol dependence that included eligibility assessment and initiation of medication-assisted treatment.

PROGRAM EVALUATION

Rates of medication-assisted treatment increased from 0 % to 64 % (p value < 0.001). All-cause 30-day readmission rates to SFGH decreased from 23.4 % to 8.2 % (p value = 0.042). All-cause emergency department visits to SFGH within 30 days of discharge decreased from 18.8 % to 6.1 % (p value = 0.056).

DISCUSSION

Through implementation of a discharge planning protocol by Internal Medicine residents for patients admitted with alcohol dependence, there was a statistically significant increase in medication-assisted treatment and a statistically significant decrease in both 30-day readmission rates and emergency department visits.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-2968-9) contains supplementary material, which is available to authorized users.KEY WORDS: alcoholism and addictive behavior, care transitions, medical student and residency education, substance abuse, medical education-clinical skills training     

Working with Patients with Alcohol Problems: A Controlled Trial of the Impact of a Rich Media Web Module on Medical Student Performance

INTRODUCTION/AIMS

We designed an interactive web module to improve medical student competence in screening and interventions for hazardous drinking. We assessed its impact on performance with a standardized patient (SP) vs. traditional lecture.

SETTING

First year medical school curriculum.

PROGRAM DESCRIPTION

The web module included pre/posttests, Flash©, and text didactics. It centered on videos of two alcohol cases, each contrasting a novice with an experienced physician interviewer. The learner free-text critiqued each clip then reviewed expert analysis.

PROGRAM EVALUATION

First year medical students conveniently assigned to voluntarily complete a web module (N = 82) or lecture (N = 81) were rated by a SP in a later alcohol case. Participation trended higher (82% vs. 72%, p < .07) among web students, with an additional 4 lecture-assigned students crossing to the web module. The web group had higher mean scores on scales of individual components of brief intervention (assessment and decisional balance) and a brief intervention composite score (1–13 pt.; 9 vs. 7.8, p < .02) and self-reported as better prepared for the SP case.

CONCLUSIONS

A web module for alcohol use interview skills reached a greater proportion of voluntary learners and was associated with equivalent overall performance scores and higher brief intervention skills scores on a standardized patient encounter.KEY WORDS: health education, alcohol use disorders/alcoholism, Internet, multimedia learning     

US Medical Student Performance on the NBME Subject Examination in Internal Medicine: Do Clerkship Sequence and Clerkship Length Matter?

BACKGROUND

Prior to graduation, US medical students are required to complete clinical clerkship rotations, most commonly in the specialty areas of family medicine, internal medicine, obstetrics and gynecology (ob/gyn), pediatrics, psychiatry, and surgery. Within a school, the sequence in which students complete these clerkships varies. In addition, the length of these rotations varies, both within a school for different clerkships and between schools for the same clerkship.

OBJECTIVE

The present study investigated the effects of clerkship sequence and length on performance on the National Board of Medical Examiner’s subject examination in internal medicine.

PARTICIPANTS

The study sample included 16,091 students from 67 US Liaison Committee on Medical Education (LCME)-accredited medical schools who graduated in 2012 or 2013.

MAIN MEASURES

Student-level measures included first-attempt internal medicine subject examination scores, first-attempt USMLE Step 1 scores, and five dichotomous variables capturing whether or not students completed rotations in family medicine, ob/gyn, pediatrics, psychiatry, and surgery prior to taking the internal medicine rotation. School-level measures included clerkship length and average Step 1 score.

DESIGN

Multilevel models with students nested in schools were estimated with internal medicine subject examination scores as the dependent measure. Step 1 scores and the five dichotomous variables were treated as student-level predictors. Internal medicine clerkship length and average Step 1 score were used to predict school-to-school variation in average internal medicine subject examination scores.

KEY RESULTS

Completion of rotations in surgery, pediatrics and family medicine prior to taking the internal medicine examination significantly improved scores, with the largest benefit observed for surgery (coefficient = 1.58 points; p value < 0.01); completion of rotations in ob/gyn and psychiatry were unrelated to internal medicine subject examination performance. At the school level, longer internal medicine clerkships were associated with higher scores on the internal medicine examination (coefficient = 0.23 points/week; p value < 0.01).

CONCLUSIONS

The order in which students complete clinical clerkships and the length of the internal medicine clerkship are associated with their internal medicine subject examination scores. Findings may have implications for curriculum re-design.KEY WORDS: clinical education, internal medicine clerkship performance, clerkship sequence, clerkship length, NBME subject examinations     

Medical Student Perceptions of Cost-Conscious Care in an Internal Medicine Clerkship: A Thematic Analysis

Background

Although as much as 87 % of all healthcare spending is directed by physicians, studies have demonstrated that they lack knowledge about the costs of medical care. Similarly, learners have not traditionally received instruction on cost-conscious care.

Objective

To examine medical students'' perceptions of healthcare delivery as it relates to cost consciousness

Design

Retrospective qualitative analysis of medical student narratives

Participants

Third-year medical students during their inpatient internal medicine clerkship

Main Measures

Students completed a reflective exercise wherein they were asked to describe a scenario in which a patient experienced lack of attention to cost-conscious care, and were asked to identify solutions and barriers. We analyzed these reflections to learn more about students’ awareness and perceptions regarding the practice of cost-conscious care within our medical center.

Key Results

Eighty students submitted the assignment between July and December 2012. The most common problems identified included unnecessary tests and treatments (n = 69) and duplicative tests and treatments (n = 20.) With regards to solutions, students described 82 scenarios, with 125 potential solutions identified. Students most commonly used discussion with the team (speak up, ask why) as the process they would use (n = 28) and most often wanted to focus lab testing (n = 38) as the intervention. The most common barriers to high-value care included increased time and effort (n = 19), ingrained practices (n = 17), and defensive medicine or fear of missing something (n = 18.)

Conclusions

Even with minimal clinical experience, medical students were able to identify instances of lack of attention to cost-conscious care as well as potential solutions. Although students identified the hierarchy in healthcare teams as a potential barrier to improving high value care, most students stated they would feel comfortable engaging the team in discussion. Future efforts to empower learners at all levels to question value decisions and to develop and implement solutions may result in improved healthcare.     

Effect of Extrinsic and Intrinsic Stressors on Clinical Skills Performance in Third-Year Medical Students

Background

Both enhancements and impairments of clinical performance due to acute stress have been reported, often as a function of the intensity of an individual’s response. According to the broader stress literature, peripheral or extrinsic stressors (ES) and task-contingent or intrinsic stressors (IS) can be distinguished within a stressful situation. The objective of this study was to assess the impact of IS and ES on clinical performance.

Method

A prospective randomized crossover study was undertaken with third-year medical students conducting two medical experiences with simulated patients. The effects of severity of the disease (IS) and the patient’s aggressiveness (ES) were studied. A total of 109 students were assigned to four groups according to the presence of ES and IS. Subjective stress and anxiety responses were assessed before and after each experience. The students’ clinical skills, diagnostic accuracy and argumentation were assessed as clinical performance measures. Sex and student-perceived cognitive difficulty of the task were considered as adjustment variables.

Results

Both types of stressors improved clinical performance. IS improved diagnostic accuracy (regression parameter β = 9.7, p = 0.004) and differential argumentation (β = 5.9, p = 0.02), whereas ES improved clinical examination (β = 12.3, p < 0.001) and communication skills (β = 15.4, p < 0.001). The student-perceived cognitive difficulty of the task was a strong deleterious factor on both stress and performance.

Conclusion

In simulated consultation, extrinsic and intrinsic stressors both have a positive but different effect on clinical performance.KEY WORDS: Stress, Clinical reasoning assessment, Medical students, Performance, Medical education research     

Moving Forward in GME Reform: A 4 + 1 Model of Resident Ambulatory Training

BACKGROUND

Traditional ambulatory training models have limitations in important domains, including opportunities for residents to learn, fragmentation of care delivery experience, and satisfaction with ambulatory experiences. New models of ambulatory training are needed.

AIM

To compare the impact of a traditional ambulatory training model with a templated 4 + 1 model.

SETTING

A large university-based internal medicine residency using three different training sites: a patient-centered medical home, a hospital-based ambulatory clinic, and community private practices.

PARTICIPANTS

Residents, faculty, and administrative staff.

PROGRAM DESCRIPTION

Development of a templated 4 + 1 model of residency where trainees do not attend to inpatient and outpatient responsibilities simultaneously.

PROGRAM EVALUATION

A mixed-methods analysis of survey and nominal group data measuring three primary outcomes: 1) Perception of learning opportunities and quality of faculty teaching; 2) Reported fragmentation of care delivery experience; 3) Satisfaction with ambulatory experiences. Self-reported empanelment was a secondary outcome. Residents’ learning opportunities increased (p = 0.007) but quality of faculty teaching was unchanged. Participants reported less fragmentation in the care residents provide patients in the inpatient and outpatient setting (p < 0.0001). Satisfaction with ambulatory training improved (p < 0.0001). Self-reported empanelment also increased (p < 0.0001). Results held true for residents, faculty, and staff at all three ambulatory training sites (p < 0.0001).

DISCUSSION

A 4 + 1 model increased resident time in ambulatory continuity clinic, enhanced learning opportunities, reduced fragmentation of care residents provide, and improved satisfaction with ambulatory experiences. More studies of similar models are needed to evaluate effects on additional trainee and patient outcomes.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-013-2387-3) contains supplementary material, which is available to authorized users.KEY WORDS: ambulatory training, 4 + 1 model     

Medical Students’ Views and Knowledge of the Affordable Care Act: A Survey of Eight U.S. Medical Schools

BACKGROUND

It is not known whether medical students support the Affordable Care Act (ACA) or possess the knowledge or will to engage in its implementation as part of their professional obligations.

OBJECTIVE

To characterize medical students’ views and knowledge of the ACA and to assess correlates of these views.

DESIGN

Cross-sectional email survey.

PARTICIPANTS

All 5,340 medical students enrolled at eight geographically diverse U.S. medical schools (overall response rate 52 % [2,761/5,340]).

MAIN MEASURES

Level of agreement with four questions regarding views of the ACA and responses to nine knowledge-based questions.

KEY RESULTS

The majority of respondents indicated an understanding of (75.3 %) and support for (62.8 %) the ACA and a professional obligation to assist with its implementation (56.1 %). The mean knowledge score from nine knowledge-based questions was 6.9 ± 1.3. Students anticipating a surgical specialty or procedural specialty compared to those anticipating a medical specialty were less likely to support the legislation (OR = 0.6 [0.4–0.7], OR = 0.4 [0.3–0.6], respectively), less likely to indicate a professional obligation to implement the ACA (OR = 0.7 [0.6–0.9], OR = 0.7 [0.5–0.96], respectively), and more likely to have negative expectations (OR = 1.9 [1.5–2.6], OR = 2.3 [1.6–3.5], respectively). Moderates, liberals, and those with an above-average knowledge score were more likely to indicate support for the ACA (OR = 5.7 [4.1–7.9], OR = 35.1 [25.4–48.5], OR = 1.7 [1.4–2.1], respectively) and a professional obligation toward its implementation (OR = 1.9 [1.4–2.5], OR = 4.7 [3.6–6.0], OR = 1.2 [1.02–1.5], respectively).

CONCLUSIONS

The majority of students in our sample support the ACA. Support was highest among students who anticipate a medical specialty, self-identify as political moderates or liberals, and have an above-average knowledge score. Support of the ACA by future physicians suggests that they are willing to engage with health care reform measures that increase access to care.KEY WORDS: Medical students, Health care reform, Affordable Care Act, Survey     

Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report

BACKGROUND

Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown.

OBJECTIVE

To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school.

DESIGN

Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school.

PARTICIPANTS

A total of 3547 students from a stratified random sample of 49 U.S. medical schools.

MAIN OUTCOME(S) AND MEASURE(S)

Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school.

KEY RESULTS

In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (−5.34, p ≤ 0.001: mixed effects regression with random intercept across schools). Students'' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (−2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias.

CONCLUSIONS

Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.KEY WORDS: disparities, medical education, implicit racial bias, physician–patient relations, attitude of health personnel     

Racial,Gender, and Socioeconomic Status Bias in Senior Medical Student Clinical Decision-Making: A National Survey

Background

Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students.

Objective

The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students.

Design

We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status.

Participants

The study included senior medical students.

Main Measures

We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status.

Key Results

Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p < .001). Analysis by subgroup, however, showed significant regional geographic variation in the influence of patient race and gender on decision-making. Multilevel analysis showed that white female patients were least likely to receive procedural recommendations.

Conclusions

In the sample as a whole, we found no evidence of racial or gender bias in student clinical decision-making. However, we did find evidence of bias with regard to the influence of patient socioeconomic status, geographic variations, and the influence of interactions between patient race and gender on student recommendations.KEY WORDS: students, medical; decision-making; health care disparities     

Reducing PSA-Based Prostate Cancer Screening in Men Aged?75?Years and Older with the Use of Highly Specific Computerized Clinical Decision Support

INTRODUCTION

In 2012, the Veterans Health Administration (VHA) implemented guidelines seeking to reduce PSA-based screening for prostate cancer in men aged 75 years and older.

OBJECTIVES

To reduce the use of inappropriate PSA-based prostate cancer screening among men aged 75 and over.

SETTING

The Veterans Affairs Greater Los Angeles Healthcare System (VA GLA)

PROGRAM DESCRIPTION

We developed a highly specific computerized clinical decision support (CCDS) alert to remind providers, at the moment of PSA screening order entry, of the current guidelines and institutional policy. We implemented the tool in a prospective interrupted time series study design over 15 months, and compared the trends in monthly PSA screening rate at baseline to the CCDS on and off periods of the intervention.

RESULTS

A total of 30,150 men were at risk, or eligible, for screening, and 2,001 men were screened. The mean monthly screening rate during the 15-month baseline period was 8.3 %, and during the 15-month intervention period, was 4.6 %. The screening rate declined by 38 % during the baseline period and by 40 % and 30 %, respectively, during the two periods when the CCDS tool was turned on. The screening rate ratios for the baseline and two periods when the CCDS tool was on were 0.97, 0.78, and 0.90, respectively, with a significant difference between baseline and the first CCDS-on period (p < 0.0001), and a trend toward a difference between baseline and the second CCDS-on period (p = 0.056).

CONCLUSION

Implementation of a highly specific CCDS tool alone significantly reduced inappropriate PSA screening in men aged 75 years and older in a reproducible fashion. With this simple intervention, evidence-based guidelines were brought to bear at the point of care, precisely for the patients and providers for whom they were most helpful, resulting in more appropriate use of medical resources.KEY WORDS: electronic health records, physician decision support, cancer screening, applied informatics, implementation research, quality improvement     

Potential Impact of Incorporating a Patient-Selected Support Person into mHealth for Depression

Background

Although telephone care management improves depression outcomes, its implementation as a standalone strategy is often not feasible in resource-constrained settings. Moreover, little research has examined the potential role of self-management support from patients’ trusted confidants.

Objective

To investigate the potential benefits of integrating a patient-selected support person into automated mobile health (mHealth) for depression.

Design

Patient preference trial.

Participants

Depressed primary care patients who were at risk for antidepressant nonadherence (i.e., Morisky Medication Adherence Scale total score > 1).

Intervention

Patients received weekly interactive voice response (IVR) telephone calls for depression that included self-management guidance. They could opt to designate a lay support person from outside their home to receive guidance on supporting their self-management. Patients’ clinicians were automatically notified of urgent patient issues.

Main Measures

Each week over a period of 6 months, we used IVR calls to monitor depression with the Patient Health Questionnaire-9 (PHQ-9; with total < 5 classified as remission), adherence (single item reflecting perfect adherence over the past week), and functional impairment (any bed days due to mental health).

Key Results

Of 221 at-risk patients, 61% participated with a support person. Analyses were adjusted for race, medical comorbidity, and baseline levels of symptom severity and adherence. Significant interaction effects indicated that during the initial phase of the program, only patients who participated with a support person improved significantly in their likelihood of either adhering to antidepressant medication (AOR = 1.31, 95% CI: 1.16–1.47, p < 0.001) or achieving remission of depression symptoms (AOR = 1.24, 95% CI: 1.14–1.34, p < 0.001). These benefits were maintained throughout the 6-month observation period.

Conclusions

Incorporating the “human factor” of a patient-selected support person into automated mHealth for depression self-management may yield sustained improvements in antidepressant adherence and depression symptom remission. However, this needs to be confirmed in a subsequent randomized controlled trial.KEY WORDS: depression, mHealth, self-management, caregiving, social support     

The Adverse Effect of Weight Stigma on the Well-Being of Medical Students with Overweight or Obesity: Findings from a National Survey

BACKGROUND

The stigma of obesity is a common and overt social bias. Negative attitudes and derogatory humor about overweight/obese individuals are commonplace among health care providers and medical students. As such, medical school may be particularly threatening for students who are overweight or obese.

OBJECTIVE

The purpose of our study was to assess the frequency that obese/overweight students report being stigmatized, the degree to which stigma is internalized, and the impact of these factors on their well-being.

DESIGN

We performed cross-sectional analysis of data from the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES) survey.

PARTICIPANTS

A total of 4,687 first-year medical students (1,146 overweight/obese) from a stratified random sample of 49 medical schools participated in the study.

MAIN MEASURES

Implicit and explicit self-stigma were measured with the Implicit Association Test and Anti-Fat Attitudes Questionnaire. Overall health, anxiety, depression, fatigue, self-esteem, sense of mastery, social support, loneliness, and use of alcohol/drugs to cope with stress were measured using previously validated scales.

KEY RESULTS

Among obese and overweight students, perceived stigma was associated with each measured component of well-being, including anxiety (beta coefficient [b] = 0.18; standard error [SE] = 0.03; p < 0.001) and depression (b = 0.20; SE = 0.03; p < 0.001). Among the subscales of the explicit self-stigma measure, dislike of obese people was associated with several factors, including depression (b = 0.07; SE = 0.01; p < 0.001), a lower sense of mastery (b = −0.10; SE = 0.02; p < 0.001), and greater likelihood of using drugs or alcohol to cope with stress (b = 0.05; SE = 0.01; p < 0.001). Fear of becoming fat was associated with each measured component of well-being, including lower body esteem (b = −0.25; SE = 0.01; p < 0.001) and less social support (b = −0.06; SE = 0.01; p < 0.001). Implicit self-stigma was not consistently associated with well-being factors. Compared to normal-weight/underweight peers, overweight/obese medical students had worse overall health (b = −0.33; SE = 0.03; p < 0.001) and body esteem (b = −0.70; SE = 0.02; p < 0.001), and overweight/obese female students reported less social support (b = −0.12; SE = 0.03; p < 0.001) and more loneliness (b = 0.22; SE = 0.04; p < 0.001).

CONCLUSIONS

Perceived and internalized weight stigma may contribute to worse well-being among overweight/obese medical students.KEY WORDS: Medical students, Stigmatization, Psychological stress, Obesity, Body weightTo succeed academically and professionally, medical students must withstand the stress of medical school, including learning new and complex material, meeting faculty expectations, interacting with patients, making new friends and colleagues, and assimilating the culture of medicine.^1–3 Ability to cope with stress is important to health and professional development, as medical student stress is linked to burnout, substance use, mental health problems, suicidal thoughts, and poor academic performance.^1,4–6 Stress also disproportionately affects female medical students, who may then be more vulnerable to these outcomes.^5,7–9Self-esteem, physical and emotional health, fatigue, sense of mastery, and social support all affect vulnerability to stress.^10,11 Members of stigmatized groups, including overweight/obese individuals, may face additional stress.^12–17 Experiences of weight-related stigma can have negative effects on self-esteem, health, and well-being.^{12–14,17–23} Overweight/obese individuals may also be self-stigmatized, i.e., exhibit negative, self-deprecating attitudes about themselves, which may worsen their overall well-being.^24–26These additional stressors may challenge students’ ability to cope in the competitive medical school environment. Although little is known about the experience of these medical students, several studies have documented strong anti-fat attitudes among health care providers and trainees,^27–31 and suggest that overweight/obese individuals are a common target of derogatory humor among medical students.^32,33The present study aimed to assess whether stigma or self-stigma is associated with factors that affect vulnerability to stress among overweight and obese medical students. We hypothesized that 1) these medical students, and female students in particular, have worse self-reported outcomes than normal-weight/underweight medical students on factors affecting vulnerability to stress; and that 2) among overweight/obese students, experiencing more stigma/self-stigma is associated with worse outcomes.     

A Break-Even Analysis for Dementia Care Collaboration: Partners in Dementia Care

Background

Dementia is a costly disease. People with dementia, their families, and their friends are affected on personal, emotional, and financial levels. Prior work has shown that the “Partners in Dementia Care” (PDC) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care.

Objective

We examined whether PDC reduced direct Veterans Health Administration (VHA) health care costs compared with usual care.

Design

This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers.

Participants

Study subjects were veterans (N = 434) 50 years of age and older with dementia and their caregivers at two intervention (N = 269) and three comparison sites (N = 165).

Interventions

PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers, delivered through partnerships between VHA medical centers and local Alzheimer’s Association chapters.

Main Measures

We tested for differences in total VHA health care costs, including hospital, emergency department, nursing home, outpatient, and pharmacy costs, as well as program costs for intervention participants. Covariates included caregiver reports of veterans’ cognitive impairment, behavior problems, and personal care dependencies. We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period.

Key Results

Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods. Pre-baseline log cost (p ≤ 0.001), baseline cognitive impairment (p ≤ 0.05), number of personal care dependencies (p ≤ 0.01), and VA service priority (p ≤ 0.01) all predicted change in log total cost.

Conclusions

These analyses show that PDC meets veterans’ needs without significantly increasing VHA health care costs. PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer’s Disease, offering a low-cost, structured, protocol-driven, evidence-based method for effectively delivering care coordination.KEY WORDS: costs and cost analysis, dementia, veterans     

Patients Report Better Satisfaction with Part-Time Primary Care Physicians,Despite Less Continuity of Care and Access

BACKGROUND

The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient’s experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes.

OBJECTIVE

We aimed to examine the relationships between a physicians’ clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician.

DESIGN

We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010.

PARTICIPANTS

The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688).

MAIN MEASURES

Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0–100 % scale, were measured. Access to care was measured as days to the third next-available appointment.

KEY RESULTS

Physician FTE was directly associated with better continuity of care received (0.172 % per FTE, p < 0.001), better continuity of care provided (0.108 % per FTE, p < 0.001), and better access to care (−0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (−0.080 % per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016 % per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (−0.053 % per FTE, p = 0.03).

CONCLUSIONS

These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3104-6) contains supplementary material, which is available to authorized users.KEY WORDS: part-time work, continuity of care, access to care, patient satisfaction     

Impact of vitamin D supplementation on adiposity in African-Americans

Background:

African-Americans have higher rates of obesity-associated chronic diseases. Serum 25-hydroxyvitamin D (25(OH)D) shows an inverse association with obesity status. We investigated whether vitamin D supplementation changes body mass index (BMI).

Subjects:

In total, 328 overweight African-Americans were enrolled over three consecutive winter periods (2007–2010) into a randomized, double-blind, placebo-controlled trial to receive cholecalciferol supplementation (0, 1000 international units (IU), 2000 IU or 4000 IU per day) for 3 months. Plasma concentrations of 25(OH)D and anthropometric measurements were done at baseline, 3 and 6 months.

Results:

At 3 months, vitamin D supplementation in three dose groups (1000 IU, 2000 IU or 4000 IU per day) did not cause any significant changes in BMI as compared with placebo group 3-month change in BMI per 1000 IU per day estimate (SE): 0.01 (0.039); P=0.78.

Conclusions:

In overweight African-Americans, short-term high-dose vitamin D supplementation did not alter BMI.