Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics.

BACKGROUND: At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. OBJECTIVE: To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. PARTICIPANTS: General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. MAIN MEASURE: An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). KEY RESULTS: Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. CONCLUSIONS: Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.

Structured interdisciplinary bedside rounds improve interprofessional communication and workplace efficiency among residents and nurses on an inpatient internal medicine unit.

Structured Interdisciplinary Bedside Rounds (SIBR) is a standardized, team-based intervention for hospitals to deliver high quality interprofessional care. Despite its potential for improving IPC and the workplace environment, relatively little is known about SIBR's effect on these outcomes. Our study aimed to assess the fidelity of SIBR implementation on an inpatient medicine teaching unit and its effects on perceived IPC and workplace efficiency. We conducted a quasi-experimental study with 88 residents and 44 nurses at a large academic medical center and observed 1308 SIBR encounters over 24 weeks. Of these 1308 encounters, the bedside nurse was present for 96.7%, physician for 97.6%, and care manager for 94.7, and 64.7% occurred at the bedside. Following SIBR implementation, perceived IPC improved significantly among residents (93.3% versus 67.9%, p < .024) and nurses (73.7% versus 36.0%, p < .008) compared to before implementation. Moreover, residents perceived greater workplace efficiency operationalized as being paged less frequently with questions by nurses (20.0% versus 49.1%, p = .01). No statistically significant improvements were reported regarding burnout, meaning at work, and workplace satisfaction. Our implementation of SIBR significantly improved perceived IPC and workplace efficiency, which are two important domains of healthcare quality. Future work should examine the impact of SIBR on patient-centered outcomes such as patient experience.

Patients' Perceptions of Bedside Rounding.

OBJECTIVES: Concerns regarding lack of privacy, poor patient understanding, and physician discomfort have led to a decline in rounding at the bedside. Our project explored patient perceptions of the implementation and value of bedside rounding. METHODS: This mixed-methods study used semi-structured qualitative interviews and a five-item Likert survey, which included questions about patients' experiences with rounds, their comfort level with the rounding process, and their understanding of care after rounds. Interviews were analyzed using the constant comparative method and conducted until thematic saturation occurred. RESULTS: Patients described positive attributes of bedside rounds: meeting the medical team, helping teach the medical team, and understanding more about their illness. Although patients enjoyed undivided attention from physicians, distractions included too many participants in rounds, confusion about roles, and unclear expectations about the goal of rounds. Although physicians sought to use patient-centered language, 53% of patients stated that medical jargon was still used. Male patients reported a statistically significant improvement in their understanding about the plan for the day and borderline significance regarding knowing who was responsible for their care as compared with female patients. CONCLUSIONS: Well-conducted, patient-centered bedside rounds greatly enhance patient-physician rapport and foster patient understanding and satisfaction.

Resident and Faculty Perceptions of Chart-Stimulated Recall.

OBJECTIVES: Chart-stimulated recall (CSR) is a case-based interviewing technique advocated by the Accreditation Council for Graduate Medical Education as an assessment tool across a variety of clinical competencies, yet resident and faculty perceptions of this exercise have not been reported previously. The authors incorporated a CSR exercise into an internal medicine residency program and sought to assess the perceptions of residents and faculty participants. METHODS: Faculty met weekly with night float residents at the end of their shift. The resident presented verbally while the faculty reviewed his or her written note. In the course of 3 years, 7 faculty and 73 residents participated. Participating residents completed an anonymous survey at the end of each academic year and faculty underwent a semistructured interview administered by the authors. RESULTS: A total of 73% of resident respondents believed that CSR was a valuable component of the night float rotation and should be continued. Faculty believed that the exercise allowed time for focused teaching of the night team, who otherwise received limited formal instruction. The most common critique of the sessions was the timing, because the residents often reported feeling too tired to engage actively in the sessions. CONCLUSIONS: CSR was easy to implement, received well, and educationally valued by both residents and faculty. Participants viewed the exercise as useful for both teaching and formative assessment.

Discharge Rounds: Implementation of a Targeted Intervention for Improving Patient Throughput on an Inpatient Medical Teaching Service.

OBJECTIVES: Patient throughput and early discharges are important for decreasing emergency department wait times and creating available beds for new hospital admissions. The educational schedule of internal medicine trainees can interfere with timely discharges, but targeted interventions can help residents meet the hospital's patient flow needs. Our training program instituted daily morning discharge rounds on the inpatient service, requiring each team to prepare potential discharges 1 day ahead and prioritizing these discharges the next day. METHODS: We conducted a retrospective, pre-post analysis 1 month before and 3 months after implementation in August 2013 to assess discharge order entry times, the proportion of discharges before 11:00 am, and hospital departure times. RESULTS: One month post-implementation, discharge orders were entered 59 minutes earlier (from 1:07 pm to 12:08 pm; P = 0.001), the percentage of pre-11:00 am discharges increased from 21% to 39% (P < 0.01), and patients departed the hospital 50 minutes earlier (from 3:21 pm to 2:31 pm; P = 0.005). These effects, however, returned to pre-implementation times during the subsequent 2 months. CONCLUSIONS: A targeted intervention can significantly improve early discharges and should be replicable at other academic medical centers. Reinforcement is needed for these gains to be sustainable, however.

Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE).

BACKGROUND: The Accreditation Council for Graduate Medical Education and American Board of Internal Medicine have identified cost-awareness as an important component to residency training. Cost-awareness is generally not emphasized in current, traditional residency curricula despite the recognized importance of this topic. DESCRIPTION: Using a traditional Morning Report structure and actual charge data from our institution, the charges associated with trainee-directed workup of clinical cases are compared in a friendly competition among medical students, interns, residents, and faculty. EVALUATION: Anonymous, voluntary survey of all participants and comparison of expenditures by training level were used to assess this pilot program. The educational quality of the I-CARE was rated higher than the prior format of Morning Report by participants (10-point Likert scale; 8.57, 6.81 respectively; p < .001). Open-ended comments were overwhelmingly supportive from faculty and trainees. Cost was lower for attending physicians than for trainees ($1,027.45 vs. $4,264.00, p = .02) and diagnostic accuracy was also highest for attending physicians. CONCLUSIONS: The I-CARE is easy and quick to implement, and the preliminary results show a popular cost-awareness educational experience for internal medicine trainees. Further study is needed to determine change in practice habits.

On Medicaid and the Affordable Care Act in Connecticut: the problem with subspecialty services.

BACKGROUND: Medicaid is the federal program, administered by states, for health care for the poor. The Affordable Care Act (ACA) has added a large number of new recipients to this program. HYPOTHESIS: Medicaid programs in some, if not many, states do not provide patients uniform access to subspecialty care guaranteed by the federal statutes. Insofar as the ACA does not address this pre-existing "sub-specialty gap" and more patients are now covered by Medicaid under the ACA, the gap is likely to increase and may contribute to disparities of health care access and outcomes. METHODS: A brief description of previous studies demonstrating or suggesting a subspecialty gap in Medicaid services is accompanied by perspectives of the authors, using published literature - most notably the Denver, Colorado health care system - to propose various solutions that may be deployed to address gaps in subspecialty coverage. RESULTS: All published studies describing the Medicaid subspecialty gap are qualitative, survey designs. There are no authoritative objective data regarding the exact prevalence of gaps for each subspecialty in each state. However, surveys of caregivers suggest that gaps were prevalent in the United States prior to initiation of the ACA. Even fewer papers have addressed solutions (in light of the paucity of data describing the magnitude of the problem), and proposed solutions remain speculative and not grounded in objective data. CONCLUSIONS: There is reason to believe that a substantial proportion of U.S. citizens - those who are guaranteed a full complement of health services through Medicaid - have difficult or no access to some subspecialty services, many of which other citizens take for granted. This problem deserves greater attention to verify its existence, quantify its magnitude, and develop solutions.

Clinical Reasoning: Perspectives of Expert Clinicians on Reasoning Through Complex Clinical Cases.

Introduction Clinical reasoning is a core skill for physicians; most doctors do not attain the level of expertise associated with that of an expert clinician (EC). The purpose of this study is to identify the clinical reasoning strategies ECs prioritize when reasoning through complex cases. Methods We interviewed 14 ECs and performed a thematic analysis to identify strategies ECs prioritize when reasoning through complex clinical cases. The authors chose ECs based on the recognition of clinical and teaching expertise by trainees and other faculty members (ECs within our institution) and institutional recognition of high achievement in medicine and medical education (ECs outside our institution). We used a semi-structured guide to interview each EC, then reviewed and coded the interview transcriptions. We developed themes based on agreements between all transcript reviewers.  Results We interviewed 11 male and three female ECs, one from outside the study institution. Two (14%) ECs were primary care physicians, and the remaining were sub-specialists. The authors organized strategies for clinical reasoning through complex cases around four themes, which were as follows: (1) connecting clinical reasoning to patient context; (2) embracing uncertainty, then reducing it; (3) returning to the patient's bedside; and (4) remaining humble to limit diagnostic errors. Conclusion Clinical reasoning is a core clinical skill of physicians, and this article describes clinical reasoning strategies prioritized by ECs for complex clinical cases. Recognition and integration of these strategies into medical training and clinical educator practice may facilitate the evolution of clinical reasoning skills and reduce diagnostic errors.

Strategies to Improve Teaching Point-of-Care Ultrasound at the Bedside.

Point-of care-ultrasound (POCUS) is becoming a core clinical skill in many medical specialties. Teaching POCUS at the bedside allows for observation of learners during actual patient encounters, provides a medium for role modeling skills and behaviors, and incorporates all core POCUS competencies. Nonetheless, bedside teaching can be time consuming and intimidating for learners and teachers, and the full benefits of teaching at the bedside can be difficult to attain. We provide strategies for improving bedside POCUS teaching based on our collective experience as medical educators and POCUS instructors at both the undergraduate and graduate levels in medical education.

Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation.

Reflective practice is essential for the ongoing maturation of clinicians and requires regular self-evaluation in association with ongoing mentoring and feedback. Currently, most resident physicians do not have access to educational experiences that fulfill these needs. We present a novel model for structured one-on-one longitudinal coaching using the principles of deliberate practice to improve diagnostic skills. This is an easily implementable educational model that can be replicated in residencies across the country to improve clinical reasoning. Skills learned through this program have the potential not only to bolster the academic approach to patients but to also directly improve the clinical assessment and care of patients under the trainee's care.

The epidemiology and clinical characteristics of patients with newly diagnosed alcohol-related liver disease: results from population-based surveillance.

GOALS: We describe the epidemiology of outpatients newly diagnosed with chronic alcoholic liver disease and describe predictors of cirrhosis and referral for specialty care. BACKGROUND: Alcohol is a major cause of liver disease in the United States. Most previous work has described hospitalized patients. STUDY: Participants were identified through prospective population-based surveillance in gastroenterology practices Multnomah County, Oregon and New Haven County, Connecticut; and primary care and gastroenterology practices from Kaiser Permanente Northern California in Alameda County during 1999 to 2001. Patients were interviewed, a blood specimen obtained, and their medical record reviewed. RESULTS: We identified 82 patients from gastroenterology practices with newly diagnosed alcoholic liver disease. Their median age was 50.0 years. 72.0% were male and 79.3% were White. The median age at initiation of alcohol use was 17.0 years. 43.9% of patients had evidence of cirrhosis at the time of diagnosis. Only 40.2% reported alcohol as the cause of their liver disease. Patients with cirrhosis were more likely to be older, have a higher median number of years of heavy alcohol consumption, and to have been hospitalized for a liver-related complication than noncirrhotic patients. An additional 83 primary care patients were more likely to be older, to be drinking alcohol at study interview, and to not have cirrhosis than patients referred for gastroenterology care. CONCLUSIONS: Patients with alcoholic liver disease may present at a late stage and may not identify alcohol as a cause for their liver disease. Improved patient screening and education may limit morbidity and mortality.

Complementary and alternative medicine use in chronic liver disease patients.

GOALS: To examine a wide range of sociodemographic and clinical characteristics as potential predictors of complementary and alternative medicine (CAM) use among chronic liver disease (CLD) patients, with a focus on CAM therapies with the greatest potential for hepatotoxicity and interactions with conventional treatments. BACKGROUND: There is some evidence that patients with CLD commonly use CAM to address general and CLD-specific health concerns. STUDY: Patients enrolled in a population-based surveillance study of persons newly diagnosed with CLD between 1999 and 2001 were asked about current use of CAM specifically for CLD. Sociodemographic and clinical information was obtained from interviews and medical records. Predictors of CAM use were examined using univariate and multivariate logistic regression analysis. RESULTS: Of the 1040 participants, 284 (27.3%) reported current use of at least 1 of 3 CAM therapies of interest. Vitamins or other dietary supplements were the most commonly used therapy, reported by 188 (18.1%) patients. This was followed by herbal medicine (175 patients, 16.8%) and homeopathy (16 patients, 1.5%). Several characteristics were found to be independent correlates of CAM use: higher education and family income, certain CLD etiologies (alcohol, hepatitis C, hepatitis C and alcohol, and hepatitis B), and prior hospitalization for CLD. CONCLUSIONS: Use of CAM therapies that have the potential to interact with conventional treatments for CLD was quite common among this population-based sample of patients with CLD. There is a need for patient and practitioner education and communication regarding CAM use in the context of CLD.

Training to Cure-Implementing a Hepatitis C Clinic Curriculum in Primary Care Residency Training.

BACKGROUND: Residents lack exposure to chronic hepatitis C (HCV) infection management, limiting the pipeline of providers able to alleviate the treatment bottleneck. ACTIVITY: We surveyed 34 residents rotating through a new HCV curriculum comprised of a clinic primer, didactics, and supervised patient care. Outcome measures were knowledge and self-efficacy regarding HCV management. RESULTS: HCV knowledge scores improved significantly from 58% pre-clinic to 76% immediately post (p < 0.001)- and 66% 3-month post-clinic (p = 0.006). Residents felt more confident managing HCV after the clinic rotation. DISCUSSION: Our clinic curriculum is feasible, improves knowledge regarding HCV, and is a unique approach to preparing physicians to cure HCV.

A comparison of hepatopathologists' and community pathologists' review of liver biopsy specimens from patients with hepatitis C.

BACKGROUND & AIMS: Assessment of liver histology has an important role in the management of chronic liver disease. It is not clear whether there are interobserver variabilities between hepatopathologists and general community pathologists. We evaluated the effect of type of pathologist and biopsy specimen size on interobserver agreement for hepatic fibrosis. METHODS: Subjects were identified from a population-based sample of adults from a chronic liver disease surveillance network. Biopsy slides from 391 hepatitis C patients who had undergone liver biopsy were obtained and read by 2 study hepatopathologists blinded to the patients' diagnoses (the gold standard). The interobserver agreement of the fibrosis stage between the hepatopathologists and the general pathologists' report were evaluated by kappa index. RESULTS: There was complete agreement between the study pathologist and community pathologist in 49.9% of biopsy specimens. The overall kappa index across all stages of fibrosis was 0.409, with the best agreement occurring at higher stages of fibrosis (kappa: 0.482 for stage 3, 0.776 for stage 4). Overall agreement was good (kappa, 0.465) when biopsy samples were greater than 1.5 cm in size. The community pathologist understaged fibrosis in 73% of biopsy specimens with disagreement. A total of 26% of patients with stages 2 to 4 fibrosis were understaged by the community pathologist. CONCLUSIONS: Results from this population-based study show good overall interobserver agreement between hepatopathologists and general pathologists when determining fibrosis stage in liver biopsy specimens from hepatitis C patients when liver biopsy sizes are adequate. However, community pathologists tended to understage fibrosis, which could keep patients from receiving proper treatment.

Use of fax-back surveillance to determine epidemiologic and clinical characteristics of patients diagnosed with hepatitis C in Waterbury, Connecticut.

Hepatitis C (HCV) is a leading cause of chronic liver disease in the United States. Connecticut has a registry of laboratory reported cases of HCV. These reports include limited patient-level information. Using a one-page abstraction instrument, we used this registry to contact providers by fax to obtain contact, epidemiologic, and clinical information on Waterbury residents with newly reported HCV. We offered to perform the data abstraction if desired by the physician. In 2004, 376 new cases of HCV were reported. Eighty-eight percent of abstraction instruments were returned; most were completed by physician office staff. These included detailed information on age, race, gender, risk factors for acquisition of infection, clinical status, and confirmatory testing. Many patients appear to not have adequate follow-up for the management of this infection. Fax-back surveillance in the case of HCV is feasible and provides much-needed patient-level information.

The epidemiology of newly diagnosed chronic liver disease in gastroenterology practices in the United States: results from population-based surveillance.

OBJECTIVES: Chronic liver disease (CLD) is an important cause of morbidity and mortality, but the epidemiology is not well described. We conducted prospective population-based surveillance to estimate newly diagnosed CLD incidence, characterize etiology distribution, and determine disease stage. METHODS: We identified cases of CLD newly diagnosed during 1999-2001 among adult county residents seen in any gastroenterology practice in New Haven County, Connecticut; Multnomah County, Oregon; and Northern California Kaiser Permanente Medical Care Program (KPMCP, Oakland, California [total population 1.48 million]). We defined CLD as abnormal liver tests of at least 6 months' duration or pathologic, clinical, or radiologic evidence of CLD. Consenting patients were interviewed, a blood specimen obtained, and the medical record reviewed. RESULTS: We identified 2,353 patients with newly diagnosed CLD (63.9 cases/100,000 population), including 1,225 hepatitis C patients (33.2 cases/100,000). Men aged 45-54 yr had the highest hepatitis C incidence rate (111.3/100,000). Among 1,040 enrolled patients, the median age was 48 yr (range 19-86 yr). Hepatitis C, either alone (442 [42%]) or in combination with alcohol-related liver disease (ALD) (228 [22%]), accounted for two-thirds of the cases. Other etiologies included nonalcoholic fatty liver disease (NAFLD, 95 [9%]), ALD (82 [8%]), and hepatitis B (36 [3%]). Other identified etiologies each accounted for <3% of the cases. A total of 184 patients (18%) presented with cirrhosis, including 44% of patients with ALD. CONCLUSIONS: Extrapolating from this population-based surveillance network to the adult U.S. population, approximately 150,000 patients with CLD were diagnosed in gastroenterology practices each year during 1999-2001. Most patients had hepatitis C; heavy alcohol consumption among these patients was common. Almost 20% of patients, an estimated 30,000 per year, had cirrhosis at presentation. These results provide population-level baseline data to evaluate trends in identification of patients with CLD in gastroenterology practices.

The mortality burden of chronic liver disease may be substantially underestimated in the United States.

PURPOSE: The United States National Center for Health Statistics (NCHS) uses death certificate data to estimate the burden of serious disease. This study aimed to determine the accuracy of the NCHS method for estimating the burden of chronic liver disease (CLD). METHOD: The authors identified death certificates of New Haven County residents who died from October 1999-September 2000 that were assigned one of 115 ICD-10 codes that might indicate CLD. They reviewed medical charts, medical examiner records and a certifier questionnaire to determine whether CLD was the cause of death. RESULT: Using the authors' determination of CLD status as the gold standard, the specificity of the NCHS classification was high (86%), but the sensitivity was low (36%). The authors found that adding selected ICD-10 codes to those considered by the NCHS to be CLD (certain CLD malignancies and viral hepatitis) could improve sensitivity. Ensuring that deaths attributed by certifiers to "End Stage Liver Disease" were coded as CLD could also improve completeness. These modifications could increase sensitivity substantially with little effect on specificity. CONCLUSION: The NCHS method may understate the CLD burden substantially which could have a detrimental effect on planning for and evaluating prevention and treatment. Modifications could improve completeness.

Quantifying the burden of chronic viral hepatitis-related cirrhosis hospitalizations in New Haven County, Connecticut.

Chronic viral hepatitis can cause cirrhosis. Viral hepatitis-related cirrhosis may be causing an increasing health burden since exposure to hepatitis B virus and hepatitis C virus in the United States increased starting in the 1960s. Using hospital discharge data, we estimated the number of adult New Haven County residents hospitalized for cirrhosis and examined the proportion caused by chronic viral hepatitis. Data on etiology were obtained from hospital discharge records, death certificate information, and New Haven County Liver Study records. From 1 October 1999 to 30 September 2000, 269 adult New Haven County residents were hospitalized for cirrhosis in a New Haven County hospital, for an incidence of 43.2 per 100,000 population. The burden of viral hepatitis-related cirrhosis was 15.9 per 100,000. Hepatitis C virus was the most common viral etiology. Given the long period between initial infection and clinical decompensation, screening and treatment programs aimed at reducing viral hepatitis-related morbidity should reduce hospitalization rates.

Excess costs of hospital care associated with neonatal candidemia.

BACKGROUND: Nosocomial bloodstream infections are associated with increased hospital costs in adult and pediatric patients. Candida is an increasingly important nosocomial pathogen within intensive care nurseries. The purpose of this study was to determine the attributable cost of candidemia in neonates. METHODS: This case-control study included all neonates with candidemia receiving care in hospitals in Connecticut and in Baltimore County and the city of Baltimore, MD. We identified 47 cases and 130 control patients. Multivariable linear regression was used to control for state, birth weight and mortality to determine the effect of candidemia on length of stay, cost per day and total hospital costs. RESULTS: Candidemia was associated with a $28,000 increase in total hospital costs in multivariable analysis. This increase in total cost was the result of both an increase in costs per day and length of hospital stay. Other cost-increasing variables included in the analysis were: state of origin (Connecticut), survival and decreasing birth weight. CONCLUSIONS: This represents the first study of the adjusted costs of candidemia in neonates. In addition to high mortality, candidemia was associated with increased hospital costs. This cost analysis could be helpful in determining the financial benefits of preventing candidemia in high risk neonates.