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1.
Grant R. Martsolf Ryan Kandrack Eric C. Schneider Mark W. Friedberg 《Journal of general internal medicine》2015,30(6):817-823
BACKGROUND
Healthcare purchasers have created financial incentives for primary care practices to achieve medical home recognition. Little is known about how changes in practice structure vary across practices or relate to medical home recognition.OBJECTIVE
We aimed to characterize patterns of structural change among primary care practices participating in a statewide medical home pilot.DESIGN
We surveyed practices at baseline and year 3 of the pilot, measured associations between changes in structural capabilities and National Committee for Quality Assurance (NCQA) medical home recognition levels, and used latent class analysis to identify distinct classes of structural transformation.PARTICIPANTS
Eighty-one practices that completed surveys at baseline and year 3 participated in the study.MAIN MEASURES
Study measures included overall structural capability score (mean of 69 capabilities); eight structural subscale scores; and NCQA recognition levels.RESULTS
Practices achieving higher year-3 NCQA recognition levels had higher overall structural capability scores at baseline (Level 1: 28.4 % of surveyed capabilities, Level 2: 40.9 %, Level 3: 48.7 %; p value = 0.001). We found no association between NCQA recognition level and change in structural capability scores (Level 1: 33.2 % increase, Level 2: 30.8 %, Level 3: 33.7 %; p value = 0.88). There were four classes of practice transformation: 27 % of practices underwent “minimal” transformation (changing little on any scale); 20 % underwent “provider-facing” transformation (adopting electronic health records, patient registries, and care reminders); 26 % underwent “patient-facing” transformation (adopting shared systems for communicating with patients, care managers, referral to community resources, and after-hours care); and 26 % underwent “broad” transformation (highest or second-highest levels of transformation on each subscale).Conclusions and Relevance
In a large, state-based medical home pilot, multiple types of practice transformation could be distinguished, and higher levels of medical home recognition were associated with practices’ capabilities at baseline, rather than transformation over time. By identifying and explicitly incentivizing the most effective types of transformation, program designers may improve the effectiveness of medical home interventions.KEY WORDS: patient-centered medical home, structural transformation, primary care 相似文献2.
Jean Yoon PhD MHS Danielle E. Rose PhD MPH Ismelda Canelo MPA Anjali S. Upadhyay MS Gordon Schectman MD Richard Stark MD Lisa V. Rubenstein MD MSPH Elizabeth M. Yano PhD MSPH 《Journal of general internal medicine》2013,28(9):1188-1194
Background
As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings.Objective
We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations.Design
Secondary patient data was linked to clinic administrative and survey data. Patient and clinic factors in the baseline year (FY2009) were used to predict patient outcomes in the follow-up year.Participants
2,853,030 patients from 814 VHA primary care clinicsMain Measures
Patient outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC) and their costs and identified through diagnosis and procedure codes from inpatient records. Clinic adoption of medical home features was obtained from the American College of Physicians Medical Home Builder®.Key Results
The overall mean home builder score in the study clinics was 88 (SD = 13) or 69 %. In adjusted analyses an increase of 10 points in the medical home adoption score in a clinic decreased the odds of an ACSC hospitalization for patients by 3 % (P = 0.032). By component, higher access and scheduling (P = 0.004) and care coordination and transitions (P = 0.020) component scores were related to lower risk of an ACSC hospitalization, and higher population management was related to higher risk (P = 0.023). Total medical home features was not related to ACSC hospitalization costs among patients with at least one (P = 0.074).Conclusion
Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors.KEY WORDS: medical home, avoidable hospitalizations, access, care coordination 相似文献3.
Adam P. Sawatsky Thomas J. Beckman Jithinraj Edakkanambeth Varayil Jayawant N. Mandrekar Darcy A. Reed Amy T. Wang 《Journal of general internal medicine》2015,30(8):1172-1177
Background
Studies reveal that 44.5 % of abstracts presented at national meetings are subsequently published in indexed journals, with lower rates for abstracts of medical education scholarship.Objective
We sought to determine whether the quality of medical education abstracts is associated with subsequent publication in indexed journals, and to compare the quality of medical education abstracts presented as scientific abstracts versus innovations in medical education (IME).Design
Retrospective cohort study.Participants
Medical education abstracts presented at the Society of General Internal Medicine (SGIM) 2009 annual meeting.Main Measures
Publication rates were measured using database searches for full-text publications through December 2013. Quality was assessed using the validated Medical Education Research Study Quality Instrument (MERSQI).Key Results
Overall, 64 (44 %) medical education abstracts presented at the 2009 SGIM annual meeting were subsequently published in indexed medical journals. The MERSQI demonstrated good inter-rater reliability (intraclass correlation range, 0.77–1.00) for grading the quality of medical education abstracts. MERSQI scores were higher for published versus unpublished abstracts (9.59 vs. 8.81, p = 0.03). Abstracts with a MERSQI score of 10 or greater were more likely to be published (OR 3.18, 95 % CI 1.47–6.89, p = 0.003). ). MERSQI scores were higher for scientific versus IME abstracts (9.88 vs. 8.31, p < 0.001). Publication rates were higher for scientific abstracts (42 [66 %] vs. 37 [46 %], p = 0.02) and oral presentations (15 [23 %] vs. 6 [8 %], p = 0.01).Conclusions
The publication rate of medical education abstracts presented at the 2009 SGIM annual meeting was similar to reported publication rates for biomedical research abstracts, but higher than publication rates reported for medical education abstracts. MERSQI scores were associated with higher abstract publication rates, suggesting that attention to measures of quality—such as sampling, instrument validity, and data analysis—may improve the likelihood that medical education abstracts will be published.KEY WORDS: medical education, medical education research, quality, publication 相似文献4.
Audrey L. Jones Susan D. Cochran Arleen Leibowitz Kenneth B. Wells Gerald Kominski Vickie M. Mays 《Journal of general internal medicine》2015,30(12):1828-1836
BACKGROUND
The benefits of the patient-centered medical home (PCMH) over and above that of a usual source of medical care have yet to be determined, particularly for adults with mental health disorders.OBJECTIVE
To examine qualities of a usual provider that align with PCMH goals of access, comprehensiveness, and patient-centered care, and to determine whether PCMH qualities in a usual provider are associated with the use of mental health services (MHS).DESIGN
Using national data from the Medical Expenditure Panel Survey, we conducted a lagged cross-sectional study of MHS use subsequent to participant reports of psychological distress and usual provider and practice characteristics.PARTICIPANTS
A total of 2,358 adults, aged 18–64 years, met the criteria for serious psychological distress and reported on their usual provider and practice characteristics.MAIN MEASURES
We defined “usual provider” as a primary care provider/practice, and “PCMH provider” as a usual provider that delivered accessible, comprehensive, patient-centered care as determined by patient self-reporting. The dependent variable, MHS, included self-reported mental health visits to a primary care provider or mental health specialist, counseling, and psychiatric medication treatment over a period of 1 year.RESULTS
Participants with a usual provider were significantly more likely than those with no usual provider to have experienced a primary care mental health visit (marginal effect [ME] = 8.5, 95 % CI = 3.2–13.8) and to have received psychiatric medication (ME = 15.5, 95 % CI = 9.4–21.5). Participants with a PCMH were additionally more likely than those with no usual provider to visit a mental health specialist (ME = 7.6, 95 % CI = 0.7–14.4) and receive mental health counseling (ME = 8.5, 95 % CI = 1.5–15.6). Among those who reported having had any type of mental health visit, participants with a PCMH were more likely to have received mental health counseling than those with only a usual provider (ME = 10.0, 95 % CI = 1.0–19.0).CONCLUSIONS
Access to a usual provider is associated with increased receipt of needed MHS. Patients who have a usual provider with PCMH qualities are more likely to receive mental health counseling.KEY WORDS: patient-centered medical home, primary care, mental health services, Affordable Care Act, race 相似文献5.
Wenli Ouyang Monica M. Cuddy David B. Swanson 《Journal of general internal medicine》2015,30(9):1307-1312
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 相似文献6.
Julie Silverman James Krieger Meghan Kiefer Paul Hebert June Robinson Karin Nelson 《Journal of general internal medicine》2015,30(10):1476-1480
BACKGROUND
Food insecurity— lack of dependable access to adequate food—may play a role in poor diabetes control.OBJECTIVE
We aimed to determine the relationship between food security status and depression, diabetes distress, medication adherence and glycemic control.DESIGN
Secondary analysis of baseline data from Peer Support for Achieving Independence in Diabetes, a randomized controlled trial that enrolled patients from November 2011 to October 2013.PARTICIPANTS
Participants had poorly controlled type 2 diabetes (A1c ≥ 8.0 % on eligibility screen), household income < 250 % of the federal poverty level, were 30–70 years old, and were recruited from a large public hospital, a VA medical center and a community-health center in King County, Washington.MAIN MEASURES
We measured food insecurity determined by the Department of Agriculture’s 6-Item Food Security Module. Depression, diabetes distress and medication adherence measured by PHQ-8, Diabetes Distress Scale and Morisky Medication Adherence Scale, respectively. Diet was assessed through Summary of Diabetes Self-Care Activities and Starting the Conversation tool. Incidence of hypoglycemic episodes was by patient report. Glycemic control was assessed with glycosylated hemoglobin (A1c) values from fingerstick blood sample.KEY RESULTS
The prevalence of food insecurity was 47.4 %. Chi-square tests revealed participants with food insecurity were more likely to be depressed (40.7 % vs. 15.4 %, p < 0.001), report diabetes distress (55.2 % vs. 33.8 %, p < 0.001) and have low medication adherence (52.9 % vs. 37.2 %, p = 0.02). Based on linear regression modeling, those with food insecurity had significantly higher mean A1c levels (β = 0.51; p = 0.02) after adjusting for sex, age, race/ethnicity, language, education, marital status, BMI, insulin use, depression, diabetes distress and low medication adherence.CONCLUSIONS
Almost half of participants had food insecurity. Food insecurity was associated with depression, diabetes distress, low medication adherence and worse glycemic control. Even with adjustment, people with food insecurity had higher mean A1c levels than their food-secure counterparts, suggesting there may be other mediating factors, such as diet, that explain the relationship between food security status and diabetes control.KEY WORDS: food insecurity, diabetes, glycemic control 相似文献7.
Tyler N. A. Winkelman Lisa Soleymani Lehmann Navjyot K. Vidwan Meredith Niess Cynthia S. Davey Derek Donovan Joseph Cofrancesco Jr. Mia Mallory Sandi Moutsios Ryan M. Antiel John Y. Song 《Journal of general internal medicine》2015,30(7):1018-1024
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 相似文献8.
Michelle van Ryn Rachel Hardeman Sean M. Phelan Diana J. Burgess PhD John F. Dovidio Jeph Herrin Sara E. Burke David B. Nelson Sylvia Perry Mark Yeazel Julia M. Przedworski 《Journal of general internal medicine》2015,30(12):1748-1756
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 相似文献9.
James E. Aikens Ranak Trivedi Alicia Heapy Paul N. Pfeiffer John D. Piette 《Journal of general internal medicine》2015,30(6):797-803
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 相似文献10.
Robert O. Morgan David M. Bass Katherine S. Judge C. F. Liu Nancy Wilson A. Lynn Snow Paul Pirraglia Maurilio Garcia-Maldonado Paul Raia N. N. Fouladi Mark E. Kunik 《Journal of general internal medicine》2015,30(6):804-809
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 相似文献11.
S. Beth Bierer Elaine F. Dannefer John E. Tetzlaff 《Journal of general internal medicine》2015,30(9):1339-1343
BACKGROUND
Remediation in the era of competency-based assessment demands a model that empowers students to improve performance.AIM
To examine a remediation model where students, rather than faculty, develop remedial plans to improve performance.SETTING/PARTICIPANTS
Private medical school, 177 medical students.PROGRAM DESCRIPTION
A promotion committee uses student-generated portfolios and faculty referrals to identify struggling students, and has them develop formal remediation plans with personal reflections, improvement strategies, and performance evidence. Students submit reports to document progress until formally released from remediation by the promotion committee.PROGRAM EVALUATION
Participants included 177 students from six classes (2009–2014). Twenty-six were placed in remediation, with more referrals occurring during Years 1 or 2 (n = 20, 76 %). Unprofessional behavior represented the most common reason for referral in Years 3–5. Remedial students did not differ from classmates (n = 151) on baseline characteristics (Age, Gender, US citizenship, MCAT) or willingness to recommend their medical school to future students (p < 0.05). Two remedial students did not graduate and three did not pass USLME licensure exams on first attempt. Most remedial students (92 %) generated appropriate plans to address performance deficits.DISCUSSION
Students can successfully design remedial interventions. This learner-driven remediation model promotes greater autonomy and reinforces self-regulated learning.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-015-3343-1) contains supplementary material, which is available to authorized users. 相似文献12.
Jaya Aysola Rachel M. Werner Shimrit Keddem Richard SoRelle Judy A. Shea 《Journal of general internal medicine》2015,30(10):1461-1467
Background
What patients perceive and experience within a patient-centered medical home (PCMH) is an understudied area, and to date, the patient perspective has not been an integral component of existing PCMH measurement standards. However, upcoming guidelines necessitate the use of patient-reported experiences and satisfaction in evaluations of practice and provider performance.Objective
To characterize patients’ experiences with care after PCMH adoption and their understanding and perceptions of the PCMH model and its key components, and to compare responses by degree of practice-level PCMH adoption and patient race/ethnicity.Design
Qualitative study.Participants
Adult patients with diabetes and/or hypertension (n = 48).Approach
We surveyed and ranked all PCMH adult primary care practices affiliated with one academic medical center with at least three providers (n = 23), using an instrument quantifying the degree of PCMH adoption. We purposively sampled minority and non-minority patients from the four highest-ranked and four lowest-ranked PCMH-adopting practices to determine whether responses varied by degree of PCMH adoption or patient race/ethnicity. We conducted semi-structured telephone interviews with patients about their experiences with care and their perceptions and understanding of key PCMH domains. Interviews were recorded, transcribed, and imported into NVivo 10 for coding and analysis, using a modified grounded theory approach.Key Results
We found that patients uniformly lacked awareness of the PCMH concept, and the vast majority perceived no PCMH-related structural changes, regardless of the degree of practice-reported PCMH adoption or the patient''s race/ethnicity. Despite this lack of awareness, patients overwhelmingly reported positive relationships with their provider and positive overall experiences.Conclusions
As we continue to redesign primary care delivery with an emphasis on patient experience measures as performance metrics, we need to better understand what, if any, aspects of practice structure relate to patient experience and satisfaction with care.KEY WORDS: Patient-centered care, Primary care redesign, Health care delivery, Health services research, Health policy 相似文献13.
Kimberly M. Tartaglia Nicholas Kman Cynthia Ledford 《Journal of general internal medicine》2015,30(10):1491-1496
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 consciousnessDesign
Retrospective qualitative analysis of medical student narrativesParticipants
Third-year medical students during their inpatient internal medicine clerkshipMain 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. 相似文献14.
P D Chandler J B Scott B F Drake K Ng A T Chan B W Hollis K M Emmons E L Giovannucci C S Fuchs G G Bennett 《Nutrition & diabetes》2015,5(1):e147
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. 相似文献15.
Laura Panattoni Ashley Stone Sukyung Chung Ming Tai-Seale 《Journal of general internal medicine》2015,30(3):327-333
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 相似文献16.
The Association Between Sensemaking During Physician Team Rounds and Hospitalized Patients’ Outcomes
Luci K. Leykum Hannah Chesser Holly J. Lanham Pezzia Carla Ray Palmer Temple Ratcliffe Heather Reisinger Michael Agar Jacqueline Pugh 《Journal of general internal medicine》2015,30(12):1821-1827
BACKGROUND
Sensemaking is the social act of assigning meaning to ambiguous events. It is recognized as a means to achieve high reliability. We sought to assess sensemaking in daily patient care through examining how inpatient teams round and discuss patients.OBJECTIVE
Our purpose was to assess the association between inpatient physician team sensemaking and hospitalized patients’ outcomes, including length of stay (LOS), unnecessary length of stay (ULOS), and complication rates.DESIGN
Eleven inpatient medicine teams’ daily rounds were observed for 2 to 4 weeks. Rounds were audiotaped, and field notes taken. Four patient discussions per team were assessed using a standardized Situation, Task, Intent, Concern, Calibrate (STICC) framework.PARTICIPANTS
Inpatient physician teams at the teaching hospitals affiliated with the University of Texas Health Science Center at San Antonio participated in the study. Outcomes of patients admitted to the teams were included.MAIN MEASURES
Sensemaking was assessed based on the order in which patients were seen, purposeful rounding, patient-driven rounding, and individual patient discussions. We assigned teams a score based on the number of STICC elements used in the four patient discussions sampled. The association between sensemaking and outcomes was assessed using Kruskal-Wallis sum rank and Dunn’s tests.KEY RESULTS
Teams rounded in several different ways. Five teams rounded purposefully, and four based rounds on patient-driven needs. Purposeful and patient-driven rounds were significantly associated with lower complication rates. Varying the order in which patients were seen and purposefully rounding were significantly associated with lower LOS, and purposeful and patient-driven rounds associated with lower ULOS. Use of a greater number of STICC elements was associated with significantly lower LOS (4.6 vs. 5.7, p = 0.01), ULOS (0.3 vs. 0.6, p = 0.02), and complications (0.2 vs. 0.5, p = 0.0001).CONCLUSIONS
Improving sensemaking may be a strategy for improving patient outcomes, fostering a shared understanding of a patient’s clinical trajectory, and enabling high reliability.KEY WORDS: complexity science, sensemaking, length of stay, complication rates, inpatient teams 相似文献17.
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Catherine H. Y. Yu Sharon Straus Ryan Brydges PhD 《Journal of general internal medicine》2015,30(9):1319-1332
Background
Clinical management of diabetic ketoacidosis (DKA) continues to be suboptimal; simulation-based training may bridge this gap and is particularly applicable to teaching DKA management skills given it enables learning of basic knowledge, as well as clinical reasoning and patient management skills.Objectives
1) To develop, test, and refine a computer-based simulator of DKA management; 2) to collect validity evidence, according to National Standard’s validity framework; and 3) to judge whether the simulator scoring system is an appropriate measure of DKA management skills of undergraduate and postgraduate medical trainees.Design
After developing the DKA simulator, we completed usability testing to optimize its functionality. We then conducted a preliminary validation of the scoring system for measuring trainees’ DKA management skills.Participants
We recruited year 1 and year 3 medical students, year 2 postgraduate trainees, and endocrinologists (n = 75); each completed a simulator run, and we collected their simulator-computed scores.Main Measures
We collected validity evidence related to content, internal structure, relations with other variables, and consequences.Key Results
Our simulator consists of six cases highlighting DKA management priorities. Real-time progression of each case includes interactive order entry, laboratory and clinical data, and individualised feedback. Usability assessment identified issues with clarity of system status, user control, efficiency of use, and error prevention. Regarding validity evidence, Cronbach’s α was 0.795 for the seven subscales indicating favorable internal structure evidence. Participants’ scores showed a significant effect of training level (p < 0.001). Scores also correlated with the number of DKA patients they reported treating, weeks on Medicine rotation, and comfort with managing DKA. A score on the simulation exercise of 75 % had a sensitivity and specificity of 94.7 % and 51.8%, respectively, for delineating between expert staff physicians and trainees.Conclusions
We demonstrate how a simulator and scoring system can be developed, tested, and refined to determine its quality for use as an assessment modality. Our evidence suggests that it can be used for formative assessment of trainees’ DKA management skills.KEY WORDS: medical education, assessment/evaluation, medical education, clinical skills training, medical education, computer/web-based training, medical education, instructional design, medical education, simulation 相似文献20.
O. Kenrik Duru Norman Turk Susan L. Ettner Romain Neugebauer Tannaz Moin Jinnan Li Lindsay Kimbro Charles Chan Robert H. Luchs Abigail M. Keckhafer Anya Kirvan Sam Ho Carol M. Mangione 《Journal of general internal medicine》2015,30(11):1645-1650