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J Am Board Fam Med ; 31(2): 201-210, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29535236


BACKGROUND: Preterm birth, birth defects, and unintended pregnancy are major sources of infant and maternal morbidity, mortality, and associated resource use in American health care. Interconception Care (ICC) is recommended as a strategy to improve birth outcomes by modifying maternal risks between pregnancies, but no established model currently exists. The Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network developed and implemented a unique approach to ICC by assessing mothers during their baby's well-child visits (WCVs) up to 24 months. METHODS: Mothers who accompanied their children to WCVs at eleven eastern US family medicine residency programs underwent screening for four risk factors (tobacco use, depression risk, contraception use to avoid unintended pregnancy and prolong interpregnancy interval, and use of a multivitamin with folic acid). Positive screens in women were addressed through brief interventions or referrals to treatment. RESULTS: Mothers accompanied their babies to 92.7% of WCVs. At more than half of WCVs (69.1%), mothers were screened for presence of ICC behavioral risks, although significant practice variation existed. Risk factors were identified at significant rates (tobacco use, 16.2%; depression risk, 8.1%; lack of contraception use, 28.2%; lack of multivitamin use, 45.4%). Women screened positive for 1 or more ICC risk factor at 64.6% of WCVs. Rates of documented interventions for women who screened positive were also substantial (tobacco use, 80.0%; depression risk, 92.8%; lack of contraception use, 76.0%; lack of multivitamin use, 58.2%). CONCLUSION: WCVs provide a reliable point of contact with mothers and a unique opportunity to assess and address behavioral risks for future poor birth outcomes.

Medicina de Família e Comunidade/métodos , Comportamentos de Risco à Saúde , Cuidado Pós-Natal/métodos , Cuidado Pré-Concepcional/métodos , Cuidado Pré-Natal/métodos , Adolescente , Adulto , Criança , Anormalidades Congênitas/etiologia , Anormalidades Congênitas/prevenção & controle , Anticoncepção/métodos , Estudos de Viabilidade , Feminino , Humanos , Lactente , Recém-Nascido de Baixo Peso , Recém-Nascido , Recém-Nascido Prematuro , Mães/educação , Educação de Pacientes como Assunto , Gravidez , Gravidez não Planejada , Nascimento Prematuro/etiologia , Nascimento Prematuro/prevenção & controle , Fatores de Risco , Adulto Jovem
Fam Med ; 48(10): 784-794, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27875601


BACKGROUND AND OBJECTIVES: Primary care residencies are undergoing dramatic changes because of changing health care systems and evolving demands for updated training models. We examined the relationships between residents' exposures to patient-centered medical home (PCMH) features in their assigned continuity clinics and their satisfaction with training. METHODS: Longitudinal surveys were collected annually from residents evaluating satisfaction with training using a 5-point Likert-type scale (1=very unsatisfied to 5=very satisfied) from 2007 through 2011, and the presence or absence of PCMH features were collected from 24 continuity clinics during the same time period. Odds ratios on residents' overall satisfaction were compared according to whether they had no exposure to PCMH features, some exposure (1-2 years), or full exposure (all 3 or more years). RESULTS: Fourteen programs and 690 unique residents provided data to this study. Resident satisfaction with training was highest with full exposure for integrated case management compared to no exposure, which occurred in 2010 (OR=2.85, 95% CI=1.40, 5.80). Resident satisfaction was consistently statistically lower with any or full exposure (versus none) to expanded clinic hours in 2007 and 2009 (eg, OR for some exposure in 2009 was 0.31 95% CI=0.19, 0.51, and OR for full exposure 0.28 95% CI=0.16, 0.49). Resident satisfaction for many electronic health record (EHR)-based features tended to be significantly lower with any exposure (some or full) versus no exposure over the study period. For example, the odds ratio for resident satisfaction was significantly lower with any exposure to electronic health records in continuity practice in 2008, 2009, and 2010 (OR for some exposure in 2008 was 0.36; 95% CI=0.19, 0.70, with comparable results in 2009, 2010). CONCLUSIONS: Resident satisfaction with training was inconsistently correlated with exposure to features of PCMH. No correlation between PCMH exposure and resident satisfaction was sustained over time.

Medicina de Família e Comunidade/educação , Internato e Residência , Assistência Centrada no Paciente/métodos , Satisfação Pessoal , Registros Eletrônicos de Saúde/estatística & dados numéricos , Humanos , Estudos Longitudinais , Estudos de Casos Organizacionais , Atenção Primária à Saúde , Inquéritos e Questionários , Estados Unidos
Ann Fam Med ; 14(4): 350-5, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-27401423


PURPOSE: Interconception care (ICC) is recommended to improve birth outcomes by targeting maternal risk factors, but little is known about its implementation. We evaluated the frequency and nature of ICC delivered to mothers at well-child visits and maternal receptivity to these practices. METHODS: We surveyed a convenience sample of mothers accompanying their child to well-child visits at family medicine academic practices in the IMPLICIT (Interventions to Minimize Preterm and Low Birth Weight Infants Through Continuous Improvement Techniques) Network. Health history, behaviors, and the frequency of the child's physician addressing maternal depression, tobacco use, family planning, and folic acid supplementation were assessed, along with maternal receptivity to advice. RESULTS: Three-quarters of the 658 respondents shared a medical home with their child. Overall, 17% of respondents reported a previous preterm birth, 19% reported a history of depression, 25% were smoking, 26% were not using contraception, and 58% were not taking folic acid. Regarding advice, 80% of mothers who smoked were counseled to quit, 59% reported depression screening, 71% discussed contraception, and 44% discussed folic acid. Screening for depression and family planning was more likely when the mother and child shared a medical home (P <.05). Most mothers, nearly 95%, were willing to accept health advice from their child's physician regardless of whether a medical home was shared (P >.05). CONCLUSIONS: Family physicians provide key elements of ICC at well-child visits, and mothers are highly receptive to advice from their child's physician even if they receive primary care elsewhere. Routine integration of ICC at these visits may provide an opportunity to reduce maternal risk factors for adverse subsequent birth outcomes.

Conhecimentos, Atitudes e Prática em Saúde , Mães/psicologia , Cuidado Pré-Concepcional/organização & administração , Atenção Primária à Saúde/organização & administração , Criança , Estudos Transversais , Serviços de Planejamento Familiar/organização & administração , Feminino , Humanos , Lactente , Recém-Nascido , Mães/estatística & dados numéricos , Cuidado Pré-Concepcional/normas , Inquéritos e Questionários
Fam Med ; 43(7): 510-3, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21761383


BACKGROUND: Extending the residency curriculum to 4 years has been proposed as a logical innovation in response to the Future of Family Medicine Report given the increasing complexity of medical care and reduction in available training time due to duty hour restrictions. Middlesex Hospital, a participant in the P4 Initiative, is the first family medicine residency program to require a comprehensive 4-year curriculum for all residents. METHODS: Over a 4-year time frame, the program transitioned from 8-8-8 to 6-6-6-6 staffing. The existing 3-year educational core of the program was left intact, and six additional core rotations and 7-month tracks of curricular enhancement were added. The residency practice transformed to a Patient-centered Medical Home (PCMH). RESULTS: Transition to a 4-year residency curriculum has proved smooth. Our funding model is sustainable, and practice income has increased. We have had no difficulty maintaining accreditation despite an innovative curriculum. A 4-year curriculum has resulted in substantially increased applicant interest and improved Match rates. The introduction of tracks has appealed to residents and has generated many positive spin-offs to the educational program as a whole. Transition to a PCMH has been of great value to both our patients and our learners. CONCLUSIONS: Transition to a comprehensive 4-year curriculum has been successful and has provided many benefits to our learners, practice, and educational program. Our graduates are substantially better prepared for practice.

Medicina de Família e Comunidade/educação , Internato e Residência/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Assistência Centrada no Paciente/organização & administração , Connecticut , Currículo , Medicina de Família e Comunidade/organização & administração , Medicina de Família e Comunidade/tendências , Humanos , Internato e Residência/tendências , Estudos de Casos Organizacionais , Inovação Organizacional , Equipe de Assistência ao Paciente/normas , Equipe de Assistência ao Paciente/tendências , Assistência Centrada no Paciente/normas , Assistência Centrada no Paciente/tendências , Avaliação de Programas e Projetos de Saúde , Fatores de Tempo