Durability of Severe Acute Respiratory Syndrome Coronavirus 2 Messenger RNA Booster Vaccine Protection Against Omicron Among Healthcare Workers With a Vaccine Mandate.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant has spread rapidly throughout the world since being identified in South Africa in November 2021. Few studies have assessed primary series and booster vaccine effectiveness against Omicron among US healthcare workers. METHODS: We conducted a test-negative case-control design to estimate BNT162b2 and mRNA1273 primary vaccination and booster effectiveness against SARS-CoV-2 infection and symptomatic coronavirus disease 2019 during an Omicron surge among employees of the University of Pennsylvania Health System. The study period was between 1 July 2021 and 5 April 2022. We defined the Delta period as 1 July to 12 December 2021 and the Omicron period as beginning 12 December 21. RESULTS: Our sample included 14 520 tests (2776 [19%] positive)-7422 (506 [7%] positive) during Delta and 7098 (2270 [32%] positive) during Omicron. Benchmarked against Delta, the vaccine effectiveness of 2 vaccine doses was lower during Omicron, with no significant protection against infection. Booster doses added significant protection, although they also showed reduced effectiveness during Omicron. Compared with findings in employees who had received 2 vaccine doses, 3 doses of BNT162b2 had a relative effectiveness of 50% (95% confidence interval, 42%-56%) during Omicron, relative to 78% (63%-87%) during Delta; 3 doses of mRNA1273 had a relative effectiveness of 56% (45%-65%) during Omicron, relative to 96% (82%-99%) during Delta. Restricting the sample to symptomatic tests yielded similar results to our primary analysis. After initial waning in BNT162b2 booster protection against infection, it remained largely stable for ≥16 weeks after vaccination. CONCLUSIONS: Our findings provide a strong rationale for boosters among healthcare workers in the Omicron era.

A Survey of the National Comprehensive Cancer Network on Approaches Toward Addressing Patients' Transportation Insecurity.

BACKGROUND: Addressing patients' social determinants of health is a national priority for cancer treatment centers. Transportation insecurity is one major challenge for patients undergoing active cancer treatment, and missing treatments can result in worse cancer treatment outcomes, including worse morbidity and mortality. How cancer treatment centers are addressing transportation insecurity is understudied. METHODS: In January and February 2022, the NCCN Best Practices Committee conducted a survey of NCCN's 31 Member Institutions (currently 32 member institutions as of April 2022) to assess how centers were addressing patient transportation insecurity: how they screen for transportation insecurity, coordinate transportation, and fund transportation initiatives, and their plans to address transportation insecurity in the future. RESULTS: A total of 25 of 31 (81%) NCCN Member Institutions responded to the survey, of which 24 (96%) reported supporting the transportation needs of their patients through screening, coordinating, and/or funding transportation. Patients' transportation needs were most often identified by social workers (96%), clinicians (83%), or patients self-declaring their needs (79%). Few centers (33%) used routine screening approaches (eg, universal screening of social risk factors) to systematically identify transportation needs, and 54% used the support of technology platforms or a vendor to coordinate transportation. Transportation was predominantly funded via some combination of philanthropy (88%), grants (63%), internal dollars (63%), and reimbursement from insurance companies (58%). Over the next 12 months, many centers were either going to continue their current transportation programs in their current state (60%) or expand existing programs (32%). CONCLUSIONS: Many NCCN Member Institutions are addressing the transportation needs of their patients. Current efforts are heterogeneous. Few centers have systematic, routine screening approaches, and funding relies on philanthropy more so than institutional dollars or reimbursement from insurers. Opportunities exist to establish more structured, scalable, and sustainable programs for patients' transportation needs.

Patient and clinician perspectives of a remote monitoring program for COVID-19 and lessons for future programs.

COVID Watch is a remote patient monitoring program implemented during the pandemic to support home dwelling patients with COVID-19. The program conferred a large survival advantage. We conducted semi-structured interviews of 85 patients and clinicians using COVID Watch to understand how to design such programs even better. Patients and clinicians found COVID Watch to be comforting and beneficial, but both groups desired more clarity about the purpose and timing of enrollment and alternatives to text-messages to adapt to patients' preferences as these may have limited engagement and enrollment among marginalized patient populations. Because inclusiveness and equity are important elements of programmatic success, future programs will need flexible and multi-channel human-to-human communication pathways for complex clinical interactions or for patients who do not desire tech-first approaches.

Comparative Effectiveness of an Automated Text Messaging Service for Monitoring COVID-19 at Home.

BACKGROUND: Although most patients with SARS-CoV-2 infection can be safely managed at home, the need for hospitalization can arise suddenly. OBJECTIVE: To determine whether enrollment in an automated remote monitoring service for community-dwelling adults with COVID-19 at home ("COVID Watch") was associated with improved mortality. DESIGN: Retrospective cohort analysis. SETTING: Mid-Atlantic academic health system in the United States. PARTICIPANTS: Outpatients who tested positive for SARS-CoV-2 between 23 March and 30 November 2020. INTERVENTION: The COVID Watch service consists of twice-daily, automated text message check-ins with an option to report worsening symptoms at any time. All escalations were managed 24 hours a day, 7 days a week by dedicated telemedicine clinicians. MEASUREMENTS: Thirty- and 60-day outcomes of patients enrolled in COVID Watch were compared with those of patients who were eligible to enroll but received usual care. The primary outcome was death at 30 days. Secondary outcomes included emergency department (ED) visits and hospitalizations. Treatment effects were estimated with propensity score-weighted risk adjustment models. RESULTS: A total of 3488 patients enrolled in COVID Watch and 4377 usual care control participants were compared with propensity score weighted models. At 30 days, COVID Watch patients had an odds ratio for death of 0.32 (95% CI, 0.12 to 0.72), with 1.8 fewer deaths per 1000 patients (CI, 0.5 to 3.1) (P = 0.005); at 60 days, the difference was 2.5 fewer deaths per 1000 patients (CI, 0.9 to 4.0) (P = 0.002). Patients in COVID Watch had more telemedicine encounters, ED visits, and hospitalizations and presented to the ED sooner (mean, 1.9 days sooner [CI, 0.9 to 2.9 days]; all P < 0.001). LIMITATION: Observational study with the potential for unobserved confounding. CONCLUSION: Enrollment of outpatients with COVID-19 in an automated remote monitoring service was associated with reduced mortality, potentially explained by more frequent telemedicine encounters and more frequent and earlier presentation to the ED. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Delivering Urgent Care Using Telemedicine: Insights from Experienced Clinicians at Academic Medical Centers.

BACKGROUND: Care delivered using telemedicine has been steadily growing in the USA but represented a small fraction of overall visits before the COVID-19 pandemic as few clinicians had been providing care using telemedicine. Understanding how experienced clinicians have practiced telemedicine can help guide today's exponential adoption of telemedicine. OBJECTIVE: The objective of this study was to explore barriers and facilitators to providing effective, high-quality urgent care using telemedicine ("tele-urgent care") from the perspective of clinicians experienced in telemedicine. APPROACH: We conducted semi-structured interviews between July 2018 and March 2019 of clinicians who had been providing tele-urgent care services to patients as a part of their routine clinical practice. Themes were identified using content analysis with a constant comparative coding approach. KEY RESULTS: Among the 20 clinicians interviewed, the majority were female (90%) and nurse practitioners (65%). We identified four themes related to barriers and facilitators to providing effective, high-quality tele-urgent care. Workplace factors such as a strong information technology (IT) infrastructure, real-time IT support, an electronic health record, and a collegial work environment, often virtual, were necessary standards. Communication and exam techniques from in-person encounters were adapted to tele-urgent care including active listening skills and teaching patients to conduct specific exam maneuvers virtually. The convenience of tele-urgent care should be preserved to support improvements in access to care. Finally, patients and clinicians occasionally had mismatched expectations about what could or would be provided during a tele-urgent care encounter. Managing the added tension that can occur during a telemedicine encounter was important. CONCLUSION: As telemedicine becomes an integral part of the care continuum, incorporating and accounting for these key insights when we train and support clinicians will be necessary to provide effective, high-quality care to patients in the future.

US local public health department spending between 2008 and 2016 did not increase for communities in need.

BACKGROUND: Greater US local public health department (LPHD) spending has been associated with decreases in population-wide mortality. We examined the association between changes in LPHD spending between 2008 and 2016 and county-level sociodemographic indicators of public health need. METHODS: Multivariable linear regression was used to estimate the association between changes in county-level per-capita LPHD spending and 2008 sociodemographic indicators of interest: percent of population that was over 65 years old, Black, Hispanic, in poverty, unemployed, and uninsured. A second model assessed the relationship between changes in LPHD spending and sociodemographic shifts between 2008 and 2016. RESULTS: LPHD spending increases were associated with higher percentage points of 2008 adults over 65 years of age (+$0.53 per higher percentage point; 95% CI: +$0.01 to +$1.06) and unemployment (-$1.31; 95% CI: -$2.34 to -$0.27). Spending did not increase for communities with a higher proportion of people who identified as Black or Hispanic, or those with a greater proportion of people in poverty or uninsured, using either baseline or sociodemographic shifts between 2008 and 2016. CONCLUSION: Future LPHD funding decisions should consider increasing investments in counties serving disadvantaged communities to counteract the social, political, and structural barriers which have historically prevented these communities from achieving better health.

Identifying Medication-Related Intents From a Bidirectional Text Messaging Platform for Hypertension Management Using an Unsupervised Learning Approach: Retrospective Observational Pilot Study.

BACKGROUND: Free-text communication between patients and providers plays an increasing role in chronic disease management, through platforms varying from traditional health care portals to novel mobile messaging apps. These text data are rich resources for clinical purposes, but their sheer volume render them difficult to manage. Even automated approaches, such as natural language processing, require labor-intensive manual classification for developing training data sets. Automated approaches to organizing free-text data are necessary to facilitate use of free-text communication for clinical care. OBJECTIVE: The aim of this study was to apply unsupervised learning approaches to (1) understand the types of topics discussed and (2) learn medication-related intents from messages sent between patients and providers through a bidirectional text messaging system for managing participant blood pressure (BP). METHODS: This study was a secondary analysis of deidentified messages from a remote, mobile, text-based employee hypertension management program at an academic institution. We trained a latent Dirichlet allocation (LDA) model for each message type (ie, inbound patient messages and outbound provider messages) and identified the distribution of major topics and significant topics (probability >.20) across message types. Next, we annotated all medication-related messages with a single medication intent. Then, we trained a second medication-specific LDA (medLDA) model to assess how well the unsupervised method could identify more fine-grained medication intents. We encoded each medication message with n-grams (n=1-3 words) using spaCy, clinical named entities using Stanza, and medication categories using MedEx; we then applied chi-square feature selection to learn the most informative features associated with each medication intent. RESULTS: In total, 253 participants and 5 providers engaged in the program, generating 12,131 total messages: 46.90% (n=5689) patient messages and 53.10% (n=6442) provider messages. Most patient messages corresponded to BP reporting, BP encouragement, and appointment scheduling; most provider messages corresponded to BP reporting, medication adherence, and confirmatory statements. Most patient and provider messages contained 1 topic and few contained more than 3 topics identified using LDA. In total, 534 medication messages were annotated with a single medication intent. Of these, 282 (52.8%) were patient medication messages: most referred to the medication request intent (n=134, 47.5%). Most of the 252 (47.2%) provider medication messages referred to the medication question intent (n=173, 68.7%). Although the medLDA model could identify a majority intent within each topic, it could not distinguish medication intents with low prevalence within patient or provider messages. Richer feature engineering identified informative lexical-semantic patterns associated with each medication intent class. CONCLUSIONS: LDA can be an effective method for generating subgroups of messages with similar term usage and facilitating the review of topics to inform annotations. However, few training cases and shared vocabulary between intents precludes the use of LDA for fully automated, deep, medication intent classification. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1101/2021.12.23.21268061.

Primary Care Appointment Completion Rates and Telemedicine Utilization Among Black and Non-Black Patients from 2019 to 2020.

Objective: To understand how differences in primary care appointment completion rates between Black and non-Black patients changed in 2020 within the context of the COVID-19 pandemic and when telemedicine utilization peaked. Materials and Methods: We conducted a retrospective cohort study using the electronic health record from January 1 to December 31, 2020, among all adults scheduled for a primary care appointment within a large academic medical center. We used mixed-effects logistic regression to estimate adjusted appointment completion rates for Black patients compared with those for non-Black patients in 2020 as compared with those in 2019 within four time periods: (1) prepandemic (January 1, 2020, to March 12, 2020), (2) shutdown (March 13, 2020, to June 3, 2020), (3) reopening (June 4, 2020, to September 30, 2020), and (4) second wave (October 1, 2020, to December 31, 2020). Results: Across 1,947,399 appointments, differences in appointment completion rates between Black and non-Black patients improved in all time periods: +1.4 percentage points prepandemic (95% confidence interval [CI]: +0.8 to +2.0), +11.7 percentage points during shutdown (95% CI: +11.0 to +12.3), +8.2 percentage points during reopening (95% CI: +7.8 to +8.7), and +7.1 percentage points during second wave (95% CI: +6.4 to +7.8) (all p-values <0.001). The types of conditions managed by primary care shifted during the shutdown period, but the remainder of 2020 mirrored those from 2019. Discussion: Racial differences in appointment completion rates narrowed significantly in 2020 even as the mix of disease conditions began to mirror patterns observed in 2019. Conclusions and Relevance: Telemedicine may be an important tool for improving access to primary care for Black patients. These findings should be key considerations as regulators and payors determine telemedicine's future.

Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine.

BACKGROUND: Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians. METHODS: We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores. RESULTS: There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). od Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818 .). CONCLUSIONS: There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blo

Communication and role clarity inform TeleICU use: a qualitative analysis of opportunities and barriers in an established program using AACN framework.

BACKGROUND: Understanding the use of tele-intensive care unit (ICU) services is an essential component in evaluating current practice and informing future use as the adoption and application of teleICU services expands. We sought to explore if novel ways to utilize teleICU services can emerge within an established, consulting-style teleICU model considering the program's flexible, provider-driven operation. METHODS: This was a qualitative study of one teleICU/hospital dyad using semi-structured interviews from a convenience sample of ICU (n = 19) and teleICU (n = 13) nurses. Interviews were analyzed using directed content analysis to identify themes that describe their experiences with teleICU using a deductive codebook developed from an expert consensus (American Association of Critical Care Nurses) AACN statement on teleICU nursing. RESULTS: Three themes were identified through the qualitative content analysis: [1] nurses described unique teleICU knowledge, including systems thinking and technological skills, [2] the teleICU partnership supported quality improvement initiatives, and [3] elements of the work environment influenced perceptions of teleICU and its use. When elements of the work environment, such as effective communication and role clarity, were not present, teleICU use was variable. CONCLUSIONS: Flexible, provider-driven approaches for integrating teleICU services into daily practice may help define the future use of the teleICU model's applicability. Future work should focus on the importance of effective communication and role clarity in integrating the emerging teleICU services into teleICU/ICU practice.

Nudging New York: adaptive models and the limits of behavioral interventions to reduce no-shows and health inequalities.

BACKGROUND: Missed healthcare appointments (no-shows) are costly and operationally inefficient for health systems. No-show rates are particularly high for vulnerable populations, even though these populations often require additional care. Few studies on no-show behavior or potential interventions exist specifically for Federally Qualified Health Centers (FQHCs), which care for over 24 million disadvantaged individuals in the United States. The purpose of this study is to identify predictors of no-show behavior and to analyze the effects of a reminder intervention in urban FQHCs in order to design effective policy solutions to a protracted issue in healthcare. METHODS: This is a retrospective observational study using electronic medical record data from 11 facilities belonging to a New York City-based FQHC network between June 2017 to April 2018. This data includes 53,149 visits for 41,495 unique patients. Seven hierarchical generalized linear models and generalized additive models were used to predict no-shows, and multiple regression models evaluated the effectiveness of a reminder. All analyses were conducted in R. RESULTS: The strongest predictor of no-show rates in FQHCs is whether or not patients are assigned to empaneled providers (z = - 91.45, p < 10- 10), followed by lead time for appointments (z = 23.87, p < 10- 10). These effects were fairly stable across facilities. The reminder had minimal effects on no-show rates overall (No show rate before: 41.6%, after: 42.1%). For individuals with appointments before and after the reminder, there was a small decrease in no-shows of 2%. CONCLUSIONS: The limited effects of the reminder intervention suggest the need for more personalized behavioral interventions to reduce no-shows. We recommend that these begin with increasing the use of empaneled providers for preventive care appointments and reducing the lag time between setting the appointment and the actual date of the appointment, at least for individuals with a high rate of no-show. By complementing these with low-intensity, low-cost behavioral interventions, we would expect greater impacts for improved access to care, contributing to the well-being of vulnerable populations.

Patient Interaction Phenotypes With an Automated Remote Hypertension Monitoring Program and Their Association With Blood Pressure Control: Observational Study.

BACKGROUND: Automated texting platforms have emerged as a tool to facilitate communication between patients and health care providers with variable effects on achieving target blood pressure (BP). Understanding differences in the way patients interact with these communication platforms can inform their use and design for hypertension management. OBJECTIVE: Our primary aim was to explore the unique phenotypes of patient interactions with an automated text messaging platform for BP monitoring. Our secondary aim was to estimate associations between interaction phenotypes and BP control. METHODS: This study was a secondary analysis of data from a randomized controlled trial for adults with poorly controlled hypertension. A total of 201 patients with established primary care were assigned to the automated texting platform; messages exchanged throughout the 4-month program were analyzed. We used the k-means clustering algorithm to characterize two different interaction phenotypes: program conformity and engagement style. First, we identified unique clusters signifying differences in program conformity based on the frequency over time of error alerts, which were generated to patients when they deviated from the requested text message format (eg, ###/## for BP). Second, we explored overall engagement styles, defined by error alerts and responsiveness to text prompts, unprompted messages, and word count averages. Finally, we applied the chi-square test to identify associations between each interaction phenotype and achieving the target BP. RESULTS: We observed 3 categories of program conformity based on their frequency of error alerts: those who immediately and consistently submitted texts without system errors (perfect users, 51/201), those who did so after an initial learning period (adaptive users, 66/201), and those who consistently submitted messages generating errors to the platform (nonadaptive users, 38/201). Next, we observed 3 categories of engagement style: the enthusiast, who tended to submit unprompted messages with high word counts (17/155); the student, who inconsistently engaged (35/155); and the minimalist, who engaged only when prompted (103/155). Of all 6 phenotypes, we observed a statistically significant association between patients demonstrating the minimalist communication style (high adherence, few unprompted messages, limited information sharing) and achieving target BP (P<.001). CONCLUSIONS: We identified unique interaction phenotypes among patients engaging with an automated text message platform for remote BP monitoring. Only the minimalist communication style was associated with achieving target BP. Identifying and understanding interaction phenotypes may be useful for tailoring future automated texting interactions and designing future interventions to achieve better BP control.

Impact of a Multidisciplinary, Endocrinologist-Led Shared Medical Appointment Model on Diabetes-Related Outcomes in an Underserved Population.

A multidisciplinary endocrinologist-led shared medical appointment (SMA) model showed statistically significant reductions in A1C from baseline over 3 years that were not significantly different from appointments with endocrinologists or primary care providers alone within a resource-poor population. Similarly, the SMA model achieved clinical outcomes on par with endocrinologist-only visits with the added benefit of improving endocrine provider productivity and specialty access for patients. Greater patient engagement with the SMA model was associated with significantly lower A1C.

Eliminating Gender-Based Bias in Academic Medicine: More Than Naming the "Elephant in the Room".

Gender-based discrimination and bias are widespread in professional settings, including academic medicine. Overt manifestations such as sexual harassment have long been identified but attention is only more recently turning towards subtler forms of bias, including inequity in promotion and compensation. Barriers to progress vary across institutions and include lack of awareness, inadequate training, poor informational transparency, and challenging power dynamics. We propose five solutions that the academic medical community can adopt to not only name, but also address, gender-based bias as the proverbial elephant in the room: definitively identify the systemic nature of the problem, prompt those with influence and power to advance a culture of equity, broadly incorporate evidence-based explicit anti-sexist training, increase transparency of information related to professional development and compensation, and use robust research methods to study the drivers and potential solutions of gender inequity within academic medicine. While implementing these proposals is no small task, doing so is an important step in helping the academic medical community become more just.

Rideshare-Based Medical Transportation for Medicaid Patients and Primary Care Show Rates: A Difference-in-Difference Analysis of a Pilot Program.

BACKGROUND: Transportation to primary care is a well-documented barrier for patients with Medicaid, despite access to non-emergency medical transportation (NEMT) benefits. Rideshare services, which offer greater convenience and lower cost, have been proposed as an NEMT alternative. OBJECTIVE: To evaluate the impact of rideshare-based medical transportation on the proportion of Medicaid patients attending scheduled primary care appointments. DESIGN: In one of two similar practices, all eligible Medicaid patients were offered rideshare-based transportation ("rideshare practice"). A difference-in-difference analytical approach using logistic regression with robust standard errors was employed to compare show rate changes between the rideshare practice and the practice where rideshare was not offered ("control practice"). PARTICIPANTS: Our study population included residents of West Philadelphia who were insured by Medicaid and were established patients at two academic general internal medicine practices located in the same building. INTERVENTION: We designed a rideshare-based transportation pilot intervention. Patients were offered the service during their reminder call 2 days before the appointment, and rides were prescheduled by research staff. Patients then called research staff to schedule their return trip home. MAIN MEASURES: We assessed the effect of offering rideshare-based transportation on appointment show rates by comparing the change in the average show rate for the rideshare practice, from the baseline period to the intervention period, with the change at the control practice. KEY RESULTS: At the control practice, the show rate declined from 60% (146/245) to 51% (34/67). At the rideshare practice, the show rate improved from 54% (72/134) to 68% (41/60). In the adjusted model, controlling for patient demographics and provider type, the odds of showing up for an appointment before and after the intervention increased 2.57 (1.10-6.00) times more in the rideshare practice than in the control practice. CONCLUSIONS: Results of this pilot program suggest that offering a rideshare-based transportation service can increase show rates to primary care for Medicaid patients.

Why Aren't More Primary Care Residents Going into Primary Care? A Qualitative Study.

BACKGROUND: Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. OBJECTIVE: We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. DESIGN: This was a qualitative study based on semi-structured, in-person interviews. PARTICIPANTS: Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. APPROACH: We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. KEY RESULTS: We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. CONCLUSIONS: Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care.

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.