The Society of General Internal Medicine's Recommendations to Improve LGBTQ + Health.

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ +) individuals experience bias in healthcare with 1 in 6 LGBTQ + adults avoiding healthcare due to anticipated discrimination and overall report poorer health status compared to heterosexual and cisgendered peers. The Society of General Internal Medicine (SGIM) is a leading organization representing academic physicians and recognizes that significant physical and mental health inequities exist among LGBTQ + communities. As such, SGIM sees its role in improving LGBTQ + patient health through structural change, starting at the national policy level all the way to encouraging change in individual provider bias and personal actions. SGIM endorses a series of recommendations for policy priorities, research and data collection standards, and institutional policy changes as well as community engagement and individual practices to reduce bias and improve the well-being and health of LGBTQ + patients.

The Impact of Internal Medicine Clerkship Characteristics and NBME Subject Exams on USMLE Step 2 Clinical Knowledge Exam Performance.

BACKGROUND: Residency program directors will likely emphasize the United States Medical Licensing Exam (USMLE) Step 2 clinical knowledge (CK) exam more during residency application given the recent USMLE Step 1 transition to pass/fail scoring. We examined how internal medicine clerkship characteristics and NBME subject exam scores affect USMLE Step 2 CK performance. DESIGN: The authors used univariable and multivariable generalized estimating equations to determine associations between Step 2 CK performance and internal medicine clerkship characteristics and NBME subject exams. The sample had 21,280 examinees' first Step 2 CK scores for analysis. RESULTS: On multivariable analysis, Step 1 performance (standardized ß = 0.45, p < .001) and NBME medicine subject exam performance (standardized ß = 0.40, p < .001) accounted for approximately 60% of the variance in Step 2 CK performance. Students who completed the internal medicine clerkship last in the academic year scored lower on Step 2 CK (Mdiff = -3.17 p < .001). Students who had a criterion score for passing the NBME medicine subject exam scored higher on Step 2 CK (Mdiff = 1.10, p = .03). There was no association between Step 2 CK performance and other internal medicine clerkship characteristics (all p > 0.05) nor with the total NBME subject exams completed (ß=0.05, p = .78). CONCLUSION: Despite similarities between NBME subject exams and Step 2 CK, the authors did not identify improved Step 2 CK performance for students who had more NBME subject exams. The lack of association of Step 2 CK performance with many internal medicine clerkship characteristics and more NBME subject exams has implications for future clerkship structure and summative assessment. The improved Step 2 CK performance in students that completed their internal medicine clerkship earlier warrants further study given the anticipated increase in emphasis on Step 2 CK.

Patient-Level Factors Associated with Utilization of Telemedicine Services from a Free Clinic During COVID-19.

Background: Disparities in telemedicine use by race, age, and income have been consistently documented. To date, research has focused on telemedicine use among patients with adequate insurance coverage. To address this gap, this study identifies patient-level factors associated with telemedicine use during the coronavirus (COVID-19) pandemic among one free clinic network's patients who are underinsured or uninsured. Methods: Electronic health record data were reviewed for patient-level data on patients seen from March 2020 to September 2020. Patients were grouped by telemedicine use history. We controlled for sociodemographic factors (e.g., age, race/ethnicity) and comorbidities. Logistic regression analyses were conducted. Results: Across 198 adult patients, 56.6% received telemedicine care. Of these, 99.1% elected for audio-only telemedicine instead of video telemedicine. Telemedicine use was more likely among those living within 15 miles of their clinic (adjusted odds ratio [aOR] = 4.43, 95% confidence interval [CI] 1.70-11.53). It was less likely to be used by older patients (aOR = 0.97, 95% CI 0.94-1.00), patients of male sex (aOR = 0.85, 95% CI 0.18-0.92), and those establishing care as a new patient (aOR = 0.01, 95% CI 0.00-0.07). Conclusion: The moderate usage of telemedicine suggests that its implementation in free clinics may be feasible. Solutions specific to patients with smartphone-only internet access are needed to improve the use of video telemedicine as smartphone-specific factors (e.g., data use limits) may influence the ability for underserved patients to receive video telemedicine.

An Interprofessional Primary Care-Based Transition of Care Clinic to Reduce Hospital Readmission.

BACKGROUND: Hospital readmission is a major burden for patients, caregivers, and health systems. Some readmissions may be avoided through timely follow-up in a transition clinic with an interprofessional approach to care. METHODS: We prospectively evaluated a cohort of adults >18 years, n = 203, who are patients of an affiliated academic internal medicine clinic with University of Florida Health and discharged from the hospital between November 1, 2016, and May 1, 2017. We sought to determine if follow-up in an interprofessional transition-of-care (TCM) clinic after discharge was associated with a reduction in hospital readmission when compared to standard follow-up at 30, 60, and 90 days. RESULTS: Follow-up in the TCM clinic was associated with reduced odds of hospital readmission at 90 days by 60%, (odds ratio [OR]: 0.40, P = 0.044, 95% confidence interval [CI] 0.16-0.97). Although the clinic failed to demonstrate a statistically significant association between clinic follow-up and in readmission at 30 (OR: 0.66, P = 0.36, 95% CI 0.27-1.59) and 60 days (OR: 0.67, P = 0.31, 95% CI 0.31-1.47), fewer readmissions were seen in patients seen by the TCM clinic. CONCLUSIONS: A primary care nested interprofessional transition-of-care clinic was associated with a reduction in hospital readmission.

The Effects of Resident Peer- and Self-Chart Review on Outpatient Laboratory Result Follow-up.

PURPOSE: Performing and teaching appropriate follow-up of outpatient laboratory results (LRs) is a challenge. The authors tested peer-review among residents as a potentially valuable intervention. METHOD: Investigators assigned residents to perform self-review (n = 27), peer-review (n = 21), or self- + peer-review (n = 30) of outpatient charts. They also compared residence performance with that of historical controls (n = 20). In September 2012, residents examined 10 LRs from April 2012 onward. A second review in November 2012 ascertained whether performing chart review improved residents' practice behaviors. RESULTS: Initially, the least-square (LS) mean number of LRs without documentation of follow-up per resident in the self-, peer-, and self- + peer-review group was, respectively, 0.5 (SD 1.0), 1.0 (SD 1.7), and 0.9 (SD 1.3), and post intervention, this was 1.0 (SD 0.2), 0.3 (SD 0.2), and 0.6 (SD 0.2) (self- versus peer-review P = .03). Initially the LS mean follow-up time per resident in the self-, peer-, and self- + peer-review group was, respectively, 4.2 (SD 1.2), 6.9 (SD 1.4), and 5.9 (SD 1.2) days, and after the intervention, LS mean time was 5.0 (SD 0.5), 2.5 (SD 0.6), and 3.9 (SD 0.5) days (self- versus peer-review P < .01). Self-review was not associated with significant improvements in practice. CONCLUSIONS: In this comparison of self- and peer-review, only residents who performed peer-review demonstrated significant improvements in their documentation practices. These findings support the use of resident peer-review in improving LR follow-up, and potentially, in other, broader resident quality improvement initiatives.

Inpatient-outpatient transitions for patients with resident primary care physicians: access and readmission.

BACKGROUND: Transition from hospitalization to postdischarge care is a vulnerable period for patients. How the experience of this transition differs for patients with resident primary care physicians is unknown. METHODS: In a single, large academic primary care practice, we examined an inception cohort of consecutive hospitalizations and postdischarge visits of hospitalized patients with resident or faculty primary care physicians between 2008 and 2013. We compared patient demographics, readmission risk, and access to outpatient care between resident and faculty primary care physicians by using generalized estimating equations to account for repeated hospitalizations. RESULTS: We documented 8161 hospitalizations among patients with resident primary care physicians and 20,844 hospitalizations among patients with faculty primary care physicians. Hospitalized patients with resident primary care physicians were generally younger, more likely to be on Medicaid, and more likely to be African American (P < .001). Patients with resident primary care physicians were less likely to be seen within 7 and 30 days of discharge (adjusted relative risk, 0.83; 95% confidence interval [CI], 0.81-0.93 at 7 days; adjusted relative risk, 0.88; 95% CI, 0.85-0.92 at 30 days) and had an increased risk of readmission within 30 days (adjusted odds ratio, 1.25; 95% CI, 1.13-1.37). They also were considerably less likely to see their own provider at first follow-up (relative risk, 0.55; 95% CI, 0.52-0.59). CONCLUSIONS: Hospitalized patients with resident primary care physicians had lower rates of timely postdischarge follow-up, higher rates of readmission, and a lower likelihood of seeing their own provider than did patients with faculty primary care physicians. These findings highlight the challenges facing academic centers for patients with resident primary care physicians.