A controlled trial of an advanced access appointment system in a residency family medicine center.

BACKGROUND AND OBJECTIVES: The implementation of advanced access appointment systems has improved continuity of care, patient and physician satisfaction, physician productivity, and average physician panel size in private practice and group-model HMO settings. This study's purpose was to document the patient care benefits, practice management benefits, and educational outcomes from the controlled implementation of an advanced access appointment system in a residency family medicine center. METHODS: Two faculty-resident teams were created. One team adopted the advanced access system while the other team continued using a traditional access system. Outcome measures included length of time needed to obtain an appointment (days to third available appointment), continuity (percentage of visits with the patient's designated provider), no-show rates, productivity, visits lost to outside providers, panel sizes, and patient satisfaction. Outcomes were measured at baseline and quarterly for 1 year after initial implementation. RESULTS: After implementation, the "days to third available appointment" for the advanced access group was 5 days, compared to 21 days for the traditional access group. A significant improvement in continuity (ie, a match between the primary care physician and patient) for the advanced access team was found. Comparison of no-show rates between the advanced access and traditional access teams revealed significant between-subjects effect, but controlling for within-subject variation using repeated measures ANOVA eliminated this effect. Advanced access residents increased their continuity above 50% while increasing provider satisfaction with office practice and scope of practice. CONCLUSIONS: Faculty and residents can successfully use advanced access. Advanced access can enhance residency education by reducing appointment delays and significantly increasing the patient-primary care physician match.

Epitope-specific immunotherapy of rheumatoid arthritis: clinical responsiveness occurs with immune deviation and relies on the expression of a cluster of molecules associated with T cell tolerance in a double-blind, placebo-controlled, pilot phase II trial.

OBJECTIVE: Induction of immune tolerance to maintain clinical control with a minimal drug regimen is a current research focus in rheumatoid arthritis (RA). Accordingly, we are developing a tolerization approach to dnaJP1, a peptide part of a pathogenic mechanism that contributes to autoimmune inflammation in RA. We undertook this study to test 2 hypotheses: 1) that mucosal induction of immune tolerance to dnaJP1 would lead to a qualitative change from a proinflammatory phenotype to a more tolerogenic functional phenotype, and 2) that immune deviation of responses to an inflammatory epitope might translate into clinical improvement. METHODS: One hundred sixty patients with active RA and with immunologic reactivity to dnaJP1 were enrolled in a pilot phase II trial. They received oral doses of 25 mg of dnaJP1 or placebo daily for 6 months. RESULTS: The dnaJP1 peptide was safe and well-tolerated. In response to treatment with dnaJP1, there was a significant reduction in the percentage of T cells producing tumor necrosis factor alpha and a corresponding trend toward an increased percentage of T cells producing interleukin-10. Coexpression of a cluster of molecules (programmed death 1 and its ligands) associated with T cell regulation was also found to be a prerequisite for successful tolerization in clinical responders. Analysis of the primary efficacy end point (meeting the American College of Rheumatology 20% improvement criteria at least once on day 112, 140, or 168) showed a difference between treatment groups that became significant in post hoc analysis using generalized estimating equations. Differences in clinical responses were also found between treatment groups on day 140 and at followup. Post hoc analysis showed that the combination of dnaJP1 and hydroxychloroquine (HCQ) was superior to the combination of HCQ and placebo. CONCLUSION: Tolerization to dnaJP1 leads to immune deviation and a trend toward clinical efficacy. Susceptibility to treatment relies on the coexpression of molecules that can down-regulate adaptive immunity.