Evaluation of online educational curriculum on HPV vaccination practices among adult primary care providers.

BACKGROUND: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. While HPV is a vaccine-preventable illness, vaccine utilization rates in the United States remain low, particularly among adults. METHODS: The objective of this study was to assess the impact of an online, asynchronous educational module on HPV vaccination for adult primary care providers. We designed and implemented the module for family medicine, internal medicine, medicine/pediatrics, and obstetrics/gynecology providers in a community practice network affiliated with a large academic health system. We evaluated the effect of the module on provider knowledge, attitudes, and self-reported behaviors with pre-, post-, and delayed post-tests, using Likert-scales for measurement. We summarized data with descriptive statistics and compared changes in individuals using paired t-tests. RESULTS: One hundred forty-four out of 223 providers completed the module (response rate of 65%). At baseline, internists had the lowest knowledge scores compared to other specialties (pre-test mean of 3.6, out of 5, SD 1.2). Internists were also the least likely to counsel patients on HPV vaccination (mean 1.6, SD 0.9). There was a statistically significant improvement in knowledge from pre-test to post-test (from mean of 3.8 to 4.6, out of 5, p < .001) across all specialties. There was also statistically significant improvement in mean confidence for all providers from pre-test to post-test to identify patients aged 19-26 (3.3 to 3.7, p < .001) and patients aged 27-45 (2.7 to 3.5, p < .001) who needed vaccination. There was a statistically significant improvement in likelihood to counsel eligible patients on the risks of HPV infection (mean 2.3 to 2.8, p-value 0.002). The delayed post-test demonstrated retention of improved knowledge, confidence, and self-reported behavior. CONCLUSIONS: This study demonstrated that an asynchronous online module was effective at improving confidence, knowledge, and self-reported behavior of adult primary care providers in recommending HPV immunization. Given the important role that healthcare providers play in vaccine uptake, this study suggests that an online educational intervention can be a powerful tool to encourage increased utilization and delivery of the HPV vaccine. Further efforts are needed to educate internists and providers who take care of the adult population on HPV vaccination.

High Value Care in Cancer Surveillance and Screening: Evaluating an e-Curriculum for Primary Care Providers.

BACKGROUND: With an expected shortage of oncologists, primary care providers (PCPs) may need to manage more cancer surveillance and screening, areas where educational resources for PCPs have been limited. The goal of this e-curriculum was for PCPs to learn surveillance and screening for several common cancers. METHODS: The e-curriculum covered breast and colorectal cancer surveillance and lung cancer screening with (1) a pre-test assessing knowledge, attitudes, practice patterns, and confidence; (2) case vignette-based teaching; and (3) an immediate post-test (with knowledge and confidence items identical to the pre-test) providing feedback. A delayed post-test was administered several months later. The curriculum and test items were developed by content experts and evaluated in a primary care group practice. RESULTS: Of 167 community PCPs, 152 completed the pre-test (91%), 145 completed the immediate post-test (87%), and 63 completed the delayed post-test (37%); 62 PCPs completed all three tests (37%). The median score on the pre-test was 43%, immediate post-test was 93%, and delayed post-test was 70%. For PCPs completing all three tests, the median scores were 50%, 90%, and 70%, respectively (p < 0.0001). The percentage of PCPs confident in their knowledge 4 to 6 months after module completion compared to the pre-test baseline was statistically significant for lung cancer screening but not for cancer surveillance. CONCLUSION: This curriculum provided concise, effective education for PCPs on 3 common cancers. Limitations include content breadth and lack of data reflecting physician ordering patterns. Curricular strengths include its accessibility, immediate feedback, and effectiveness, with a significant improvement in immediate and delayed post-test knowledge. Given a lack of increased confidence to provide cancer surveillance, PCPs should rely on electronic medical record tools and other resources to guide appropriate surveillance care.

The association between organizational cultural competence and teamwork climate in a network of primary care practices.

BACKGROUND: A health system's commitment to delivering culturally competent care is essential in creating a culture of respect for patients, clinicians, and administrative staff. As the diversity of the health care workforce grows, gaining an understanding of the perspectives among different health care personnel and the value that they place on organizational cultural competence is a first step in developing more effective team environments. PURPOSE: The aim of the study was to determine whether an association exists between perceptions of organizational cultural competence and teamwork climate among employees in a health system. METHODOLOGY/APPROACH: One thousand eighty employees in a primary care network consisting of 49 ambulatory practices were surveyed on their perceptions of senior management's efforts in organizational cultural competence and teamwork climate in their own work setting using 5-point Likert scales. Linear regression models were used to evaluate the association between organizational cultural competence and teamwork climate. RESULTS: The overall organizational response rate for the survey was 84%. Higher perception of organizational cultural competence was associated with better teamwork climate (coef. = 0.4, p <0.001) after adjusting for gender, age, years in specialty, race, and position type. The association was stronger in magnitude for support staff compared to administrators and clinicians and stronger for younger compared to older age groups. CONCLUSIONS: Higher employee perceptions of organizational cultural competence are associated with better self-reported teamwork climate, and this relationship is magnified for support staff and younger employees. PRACTICE IMPLICATIONS: Senior leaders of health systems should consider investment in cultural competence as a contributor toward team effectiveness. Specifically, organizations may help support cultural competence by committing resources to the following: developing a comprehensive plan that addresses patients' cultural needs, recruiting and retaining a diverse staff and leadership, collaborating with the community, recognizing and rewarding care that meets patients' cultural needs, and providing adequate diversity training.

National Survey of Primary Care Physicians' Knowledge, Practices, and Perceptions of Prediabetes.

BACKGROUND: Despite strong evidence and national policy supporting type 2 diabetes prevention, little is known about type 2 diabetes prevention in the primary care setting. OBJECTIVE: Our objective was to assess primary care physicians' knowledge and practice regarding perceived barriers and potential interventions to improving management of prediabetes. DESIGN: Cross-sectional mailed survey. PARTICIPANTS: Nationally representative random sample of US primary care physicians (PCPs) identified from the American Medical Association Physician Masterfile. MAIN MEASURES: We assessed PCP knowledge, practice behaviors, and perceptions related to prediabetes. We performed chi-square and Fisher's exact tests to evaluate the association between PCP characteristics and the main survey outcomes. KEY RESULTS: In total, 298 (33%) eligible participants returned the survey. PCPs had limited knowledge of risk factors for prediabetes screening, laboratory diagnostic criteria for prediabetes, and management recommendations for patients with prediabetes. Only 36% of PCPs refer patients to a diabetes prevention lifestyle change program as their initial management approach, while 43% discuss starting metformin for prediabetes. PCPs believed that barriers to type 2 diabetes prevention are both at the individual level (e.g., patients' lack of motivation) and at the system level (e.g., lack of weight loss resources). PCPs reported that increased access to and insurance coverage of type 2 diabetes prevention programs and coordination of referral of patients to these resources would facilitate type 2 diabetes preventive efforts. CONCLUSIONS: Addressing gaps in PCP knowledge may improve the identification and management of people with prediabetes, but system-level changes are necessary to support type 2 diabetes prevention in the primary care setting.

Survey of primary care providers' knowledge of screening for, diagnosing and managing prediabetes.

BACKGROUND: Prediabetes affects 86 million US adults, but primary care providers' (PCPs') knowledge, practices, attitudes and beliefs toward prediabetes are unclear. OBJECTIVE: Assess PCPs' (1) knowledge of risk factors that should prompt prediabetes screening, laboratory criteria for diagnosing prediabetes and guidelines for management of prediabetes; (2) management practices around prediabetes; (3) attitudes and beliefs about prediabetes. DESIGN: Self-administered written survey of PCPs. PARTICIPANTS: One hundred forty of 155 PCPs (90%) attending an annual provider retreat for academically affiliated multispecialty practices in the mid-Atlantic region. MAIN MEASURES: Descriptive analyses of survey questions on knowledge, management, and attitudes and beliefs related to prediabetes. Multivariate logistic regression was used to determine the association between provider characteristics (gender, race/ethnicity, years since training, specialty and provider type) and knowledge, management, and attitudes and beliefs about prediabetes. KEY RESULTS: Six percent of PCPs correctly identified all of the risk factors that should prompt prediabetes screening. Only 17% of PCPs correctly identified the laboratory parameters for diagnosing prediabetes based on both fasting glucose and hemoglobin A1c. Nearly 90% of PCPs reported close follow-up (within 6 months) of patients with prediabetes. Few PCPs (11%) selected referral to a behavioral weight loss program as the recommended initial management approach to prediabetes. PCPs agreed that patient-related factors are important barriers to lifestyle change and metformin use. Provider characteristics were generally not associated with knowledge, management, attitudes and beliefs about prediabetes in multivariate analyses. CONCLUSIONS: Addressing gaps in knowledge and the underutilization of behavioral weight loss programs in prediabetes are two essential areas where PCPs could take a lead in curbing the diabetes epidemic.

Fostering Clinical Excellence Across an Academic Health System.

OBJECTIVES: Changes in the US healthcare economic system are requiring academic health centers (AHCs) to restructure in pursuit of their traditional tripartite missions; engaging the individuals focused on clinical care is becoming more important. We conducted this study to guide our institution's transformation by identifying ways to formally recognize clinicians who are excelling in patient care and understand which forms of acknowledgment would be acceptable and motivating. METHODS: A survey was developed by a large committee with representation spanning the AHC and was sent electronically in spring 2014 to stakeholders across the institution. Items assessed perceptions of the importance and present state of valuing clinical excellence, the utility of 14 potential metrics to assess clinical excellence, and the meaningfulness of seven potential rewards for clinical excellence. Bivariate and multivariate logistic regression models analyzed differences (P < 0.05) by respondent sex, ethnicity, academic rank, primary clinical affiliation, and time spent in patient care and research activities. RESULTS: A total of 1716 of 3168 (54%) stakeholders responded, including 1198 of 2151 (56%) individuals from academic hospitals, 114 of 276 (41%) from the outpatient affiliated practices, and 304 of 741 (54%) from satellite locations. Nearly everyone (96%) agreed that clinical accomplishments should be recognized, although a minority (47%) believed that clinicians were already valued. Most respondents selected 7 or more of 14 metrics as valid and reasonable for assessing clinical excellence. Popular metrics (eg, clinical productivity) were not believed to represent clinical excellence as much as others (eg, professionalism). Multivariate analysis found the least agreement among stakeholders on using published scholarship as evidence for clinical excellence, with the widest differences comparing senior faculty versus nonfaculty (88% vs 27%) and those with >75% of their time spent in patient care versus others (37% vs 73%). Most (six of seven) types of reward were perceived as meaningful by the majority of respondents, with little variation among subgroups across bivariate and multivariate analyses. CONCLUSIONS: This system-wide assessment was successful at identifying new strategies for recognizing clinical excellence. Other AHCs seeking institutional transformation may wish to perform a similar assessment.

Difference in medical student performance in a standardized patient encounter between telemedicine and in-person environments.

INTRODUCTION: Telemedicine is an increasingly common form of healthcare delivery in the United States. It is unclear how there are differences in clinical performance in early learners between in-person and telemedicine encounters. MATERIALS & METHODS: The authors conducted a single-site retrospective cohort study of 241 second-year medical students to compare performance between in-person and telemedicine standardized patient (SP) encounters. One hundred and twenty medical students in the 2020 academic year participated in a telemedicine encounter, and 121 medical students in the 2022 academic year participated in an in-person encounter. SPs completed a multi-domain performance checklist following the encounter, and the authors performed statistical analyses to compare student performance between groups. RESULTS: Students who completed in-person encounters had higher mean scores in overall performance (75.2 vs. 69.7, p < 0.001). They had higher scores in physical exam (83.3 vs. 50, p < 0.001) and interpersonal communication domains (95 vs. 85, p < 0.001) and lower scores in obtaining a history (73.3 vs. 80, p = 0.0025). There was no significant difference in assessment and plan scores (50 vs. 50, p = 0.96) or likelihood of appropriately promoting antibiotic stewardship (41.3% vs. 45.8%, p = 0.48). CONCLUSION: The authors identified significant differences in clinical performance between in-person and telemedicine SP encounters, indicating that educational needs may differ between clinical environments.

Qualitative evaluation of the SHARING Choices trial of primary care advance care planning for adults with and without dementia.

BACKGROUND: Primary care can be an important setting for communication and advance care planning (ACP), including for those with dementia and their families. The study objective was to explore experiences with a pragmatic trial of a communication and ACP intervention, SHARING Choices, in primary care for older adults with and without dementia. METHODS: We conducted qualitative interviews using tailored semi-structured guides with three groups: ACP facilitators who conducted the intervention; clinicians, managers, and administrators from sites randomized to the intervention; and patients and families who met with ACP facilitators. We used thematic analysis to identify and synthesize emergent themes based on key Consolidated Framework for Implementation Research concepts and Proctor's Implementation Outcomes, triangulating the three groups' perspectives. RESULTS: We identified five key themes. For acceptability, perceptions of the intervention were mostly positive, although some components were not generally implemented. For adoption, respondents perceived that ACP facilitators mainly focused on conducting ACP, although facilitators often did not implement the ADRD and family engagement aspects with the ACP. For relational connections, ACP facilitator-practice and clinician communication and engagement were key to how the intervention was implemented. For adaptability, ACP facilitators and health systems adapted how the ACP facilitation component was implemented to local preferences and over time, given the pragmatic nature of the trial. And, for sustainability, ACP facilitators and clinicians/managers/facilitators were positive that the intervention should be continued but noted barriers to its sustainability. Patients and families generally did not recall the intervention. CONCLUSIONS: ACP facilitators and clinicians, managers, and administrators had positive perceptions of the ACP facilitator component of the intervention in this pragmatic trial with adaptation to local preferences. However, engaging those with dementia and families was more challenging in the implementation of this intervention.

Patient safety perceptions of primary care providers after implementation of an electronic medical record system.

BACKGROUND: Increasing the use of electronic medical records (EMR) has been suggested as an important strategy for improving healthcare safety. OBJECTIVE: To sequentially measure, evaluate, and respond to safety culture and practice safety concerns following EMR implementation. DESIGN: Safety culture was assessed using a validated tool (Safety Attitudes Questionnaire; SAQ), immediately following EMR implementation (T1) and at 1.5 (T2) and 2.5 (T3) years post-implementation. The SAQ was supplemented with a practice-specific assessment tool to identify safety needs and barriers. PARTICIPANTS: A large medical group practice with a primary care core of 17-18 practices, staffed by clinicians in family medicine, pediatrics, internal medicine. INTERVENTIONS: Survey results were used to define and respond to areas of need between assessments with system changes and educational programs. MAIN MEASURES: Change in safety culture over time; perceived impact of EMR on practice. KEY RESULTS: Responses were received from 103 of 123 primary care providers in T1 (83.7 % response rate), 122 of 143 in T2 (85.3 %) and 142 of 181 in T3 (78.5 %). Safety culture improved over this period, with statistically significant improvement in all domains except for stress recognition. Time constraints, communications and patient adherence were perceived to be the most important safety issues. The majority of respondents in both T2 (77.9 %) and T3 (85.4 %) surveys agreed that the EMR improved their ability to provide care more safely. CONCLUSIONS: Implementation of an EMR in a large primary care practice required redesign of many organizational processes, and was associated with improvements in safety culture. Most primary care providers agreed that the EMR allowed them to provide care more safely.

Improvement of Medical Student Performance in Telemedicine Standardized Patient Encounters Following an Educational Intervention.

BACKGROUND AND OBJECTIVES: The Association of American Medical Colleges identifies telemedicine competence as an important skill for graduating medical students, but which educational methods are effective in improving student performance is unclear. We aimed to assess the impact of two educational interventions on student performance in telemedicine standardized patient encounters. METHODS: Sixty second-year medical students participated in the telemedicine curriculum during their required longitudinal ambulatory clerkship. Students first completed a preintervention telemedicine standardized patient (SP) encounter in October 2020. They subsequently were assigned to two intervention groups (ie, a role-play intervention, N=30; a faculty demonstration, N=30) and completed a teaching case. In December 2020, they completed a postintervention telemedicine SP encounter. Each case was a unique clinical scenario. SPs scored the encounters across six domains based on a standardized performance checklist. We compared the median scores for these domains and the median total score pre- and postintervention (using Wilcoxon signed rank and rank-sum tests) and the difference in median score by intervention type. RESULTS: Students scored highly in history-taking and communication performance but had low physical exam (PE) and assessment/plan scores. Postintervention, median scores in PE (ie, median score difference 2, interquartile ranges [IQR] 1-3.5, P<.001), assessment/plan (ie, median score difference 0.5, IQR 0-2, P=.005), and overall performance improved significantly (ie, median score difference 3, IQR 0-5, P<.001). CONCLUSIONS: Early medical students had low performance at baseline in telemedicine PE and assessment/plan skills, but both a role-play intervention and faculty demonstration led to significant increases in student performance.

SHARING Choices: Lessons Learned from a Primary-Care Focused Advance Care Planning Intervention.

BACKGROUND: Few advance care planning (ACP) interventions have been scaled in primary care. PROBLEM: Best practices for delivering ACP at scale in primary care do not exist and prior efforts have excluded older adults with Alzheimer's Disease and Related Dementias (ADRD). INTERVENTION: SHARING Choices (NCT#04819191) is a multicomponent cluster-randomized pragmatic trial conducted at 55 primary care practices from two care delivery systems in the Mid-Atlantic region of the U.S. We describe the process of implementing SHARING Choices within 19 practices randomized to the intervention, summarize fidelity to planned implementation, and discuss lessons learned. OUTCOMES: Embedding SHARING Choices involved engagement with organizational and clinic-level partners. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 1215 conversations occurred. Most conversations (94.8%) were less than 45 minutes duration. Just 13.1% of ACP conversations included family. Patients with ADRD comprised a small proportion of patients who engaged in ACP. Implementation adaptations included transitioning to remote modalities, aligning ACP outreach with the Medicare Annual Wellness Visit, accommodating primary care practice flexibility. LESSONS LEARNED: Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with practice staff; adapting implementation processes to fit the unique needs of two health systems; and modifying efforts to meet health system goals and priorities.

Telemedicine Clinical Skills Needs Assessment in Early Medical Students.

BACKGROUND AND OBJECTIVES: As clinicians increasingly rely on telemedicine, medical students will need to learn how to appropriately use telemedicine in patient care. A formal approach to curriculum development is needed to identify gaps and needs in early medical student performance. METHODS: In October 2020, 120 second-year medical students completed a telemedicine visit with a standardized patient with chronic essential hypertension. Students were assessed across five domains (history-gathering, communication, vitals, physical exam, and assessment/management). An anonymous, voluntary survey was distributed to assess self-efficacy in telemedicine skills. RESULTS: Students perform well in history-gathering and communication (98% of student scored 4 or 5 out of 5 on history, 100% of students received a 7 or 8 out of 8 on communication). Students perform poorly in obtaining vital signs (23% scored 3 or 4 out of 4) and assessment/management (14% scored 3 or 4 out of 4). Students received their lowest scores in physical examination (2% score 4 or 5 out of 5). The number of telemedicine visits completed with patients prior to the standardized patient exercise had no impact on student performance during the exercise. Student response rate on the postexercise survey was 88%. Self-efficacy was lowest in physical examination telemedicine skills compared to other domains. CONCLUSIONS: Findings suggest that early medical students are able to gather history and communicate over telemedicine, but perform poorly on telemedicine physical examination skills. More robust curriculum development addressing telemedicine physical examinations skills is needed early in medical training.

Effects of screening for geriatric conditions and advance care planning at the Medicare Annual Wellness Visit.

BACKGROUND: The Medicare Annual Wellness Visit (AWV) requires screening for geriatrics conditions and can include advance care planning (ACP). We examined (1) the prevalence of positive screens for falls, cognitive impairment, and activities of daily living (ADL) impairment, (2) referrals/orders generated potentially in response, and (3) the increase in ACP among those with two AWVs. METHODS: In this retrospective analysis, we used electronic medical record data from a Mid-Atlantic group ambulatory practice. We included adults age > 65 who had ≥1 AWV (n = 16,176) in years 2014-2017. Analyses on high-risk prescribing were limited to those (n = 13,537) with ≥3 months of follow up and ACP to those (n = 9097) with two AWVs. We used responses from the AWV health risk questionnaire to identify screening status for falls, cognitive and ADL impairment and whether an older adult had an ACP. For each screen we identified orders/referrals placed potentially in response (e.g., physical therapy for falls). High-risk medications were based on the 2019 Beers Criteria. RESULTS: Positive screening rates were 38% for falls, 23% for cognition, and 32% for ADL impairment. The adjusted odds of having an order placed potentially in response to the screening were 1.8 (95% CI 1.6-2.0) for falls, 1.4 (1.3-1.7) for cognition, 2.8 (2.4-3.3) for ADL impairment. The adjusted odds of a high-risk prescription in the 3 months after a positive screen were 2.1 (95% CI 1.8-2.5) for falls and 1.9 (95% CI 1.6-2.4) for cognition. Of those with two AWVs, 48% had an ACP at the first AWV. Among the remaining 52% with no ACP at the first AWV, the predicted probability of having an ACP at the second AWV was 0.22 (95% CI 0.18-0.25). CONCLUSION: Our results may indicate positive effects of screening for geriatric conditions at the AWV, and highlight opportunities to improve geriatrics care related to prescribing and ACP.

SHARING Choices: Design and rationale for a pragmatic trial of an advance care planning intervention for older adults with and without dementia in primary care.

BACKGROUND: Advance care planning (ACP) and involving family are particularly important in dementia, and primary care is a key setting. The purpose of this trial is to examine the impact and implementation of SHARING Choices, an intervention to improve communication for older adults with and without dementia through proactively supporting ACP and family engagement in primary care. METHODS: We cluster-randomized 55 diverse primary care practices across two health systems to the intervention or usual care. SHARING Choices is a multicomponent intervention that aims to improve communication through patient and family engagement in ACP, agenda setting, and shared access to the patient portal for all patients over 65 years of age. The primary outcomes include documentation of an advance directive or medical orders for life-sustaining treatment in the electronic health record (EHR) at 12 months for all patients and receipt of potentially burdensome care within 6 months of death for the subgroup of patients with serious illness. We plan a priori sub-analysis for patients with dementia. Data sources include the health system EHRs and the Maryland health information exchange. We use a mixed-methods approach to evaluate uptake, fidelity and adaptation of the intervention and implementation facilitators and barriers. CONCLUSIONS: This cluster-randomized pragmatic trial examines ACP with a focus on the key population of those with dementia, implementation in diverse settings and innovative approaches to trial design and outcome abstraction. Mixed-methods approaches enable understanding of intervention delivery and facilitators and barriers to implementation in rapidly changing health care systems. CLINICALTRIALS: gov Identifier: NCT04819191.

A Novel Curriculum on Using Life Expectancy to Inform Cancer Screening in Older Adults.

BACKGROUND: Many older adults with limited life expectancy still receive cancer screening. One potential contributor is that primary care providers (PCP) are not trained to incorporate life expectancy in cancer screening recommendations. We describe the development and evaluation of a novel curriculum to address this need. METHODS: We developed and implemented a web-based learning module within a large Maryland group practice with PCPs for older adults. We assessed attitude, knowledge, self-efficacy, and self-reported behavior outcomes before the module, immediately after completing the module, and 6 months afterwards. RESULTS: Of 172 PCPs who were invited, 86 (50%) completed the module and of these, 50 (58.1%) completed the 6-months follow up survey. Immediately after the module, there was a significant increase in perceived importance of life expectancy (increase of 0.50 point on 10-point scale, 95% confidence intervals (CI) = 0.27-0.73), confidence in predicting life expectancy (increase of 2.32 points on 10-point scale, 95% CI = 1.95-2.70) and confidence in discussion screening cessation (increase of 1.69 points on 10-point scale, 95% CI = 1.37-2.02). Knowledge in patient-preferred communication strategies improved from 55% correct response to 97% (P < .001). However, most of these improvements dissipated by 6 months and there was no change in self-reported behavior at 6 months compared to baseline (P = .34). CONCLUSION: Although the module resulted in significant short-term improvement in attitude, knowledge, and self-efficacy, the changes were not sustained over time. Educational interventions such as this can be coupled with ongoing reinforcing strategies and/or decision support interventions to improve cancer-screening practices in older adults.

Novel first-year curriculum in high-value care.

BACKGROUND: Most medical schools teach a high-value care (HVC) curriculum during the clinical years. Currently, there lacks any research demonstrating the effectiveness of the HVC curriculum taught to students in their first year of medical school. METHODS: A total of 118 of 466 first-year medical students at Johns Hopkins School of Medicine between 2013 and 2017 enrolled on an HVC course that provided the initial framework necessary to practice cost-conscious clinical medicine. The curriculum was evaluated by comparing the performance of students who completed the course with the performance of students without training, through a standardised patient encounter on musculoskeletal back pain and how to approach a patient's request for imaging. Chi-square testing was used to assess the impact of the course on performance in a standardised patient encounter. RESULTS: Students enrolled on the HVC course were more likely, compared with their counterparts, to assure patients that back pain was a simple strain (48 versus 31%), and were less likely to ask for preceptor help on how to proceed with management (11 versus 29%) [χ2 (4, n = 466) = 14.28, p = 0.007]. There were no differences between students enrolled on the HVC course who had not yet received training compared with students taking another elective [χ2 (4, n = 385) = 8.73, p = 0.07]. DISCUSSION: This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice in a simulated clinical setting. This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice.

The Relationship Between Safety Culture and Voluntary Event Reporting in a Large Regional Ambulatory Care Group.

OBJECTIVES: The safety culture in the workplace may affect event reporting. We evaluated the relationship of safety culture and voluntary event reporting within a large network of ambulatory practices, most of which provided primary care. METHODS: This study was an observational, retrospective cohort study. Patient safety event reporting rates for 35 ambulatory practices were collected using a standard tool (UHC Patient Safety Net [PSN]) and normalized based on the number of patient visits in each practice. The overall and domain-specific safety culture of each practice was measured with a validated instrument (Safety Attitudes Questionnaire [SAQ]), distributed to 828 employees in 2013. We compared safety culture scores and the average event reporting rates during a 4-month window before and after the survey distribution. Poisson regression analyses were performed to determine the relationship between PSN reporting rates and SAQ results. RESULTS: The SAQ response rate was 87%. Practices varied widely in rates of reporting events, from 0.00 to 6.99 reports per 1000 total patient visits per month. Regression analyses indicated a positive association between PSN reporting rates and SAQ scores for the domains of overall culture (incidence rate ratio [IRR], 1.019; P = 0.004) and 4 safety culture domains: teamwork climate (IRR, 1.016; P = 0.019), safety climate (IRR, 1.018; P = 0.004), working conditions (IRR, 1.017; P = 0.006), and perceptions of local management (IRR, 1.016; P = 0.040). CONCLUSIONS: Our work provides new evidence to show that in the ambulatory setting more events and near misses are reported when there is a strong culture of safety.

Failure to intensify antihypertensive treatment by primary care providers: a cohort study in adults with diabetes mellitus and hypertension.

BACKGROUND: Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications. OBJECTIVE: To identify novel visit-based factors associated with intensification of antihypertensive medications in adults with diabetes. DESIGN: Non-concurrent prospective cohort study. PATIENTS: A total of 254 patients with type 2 diabetes and hypertension enrolled in an academically affiliated managed care program. Over a 24-month interval (1999-2001), we identified 1,374 visits at which blood pressure was suboptimally controlled (systolic BP >/= 140 mmHg or diastolic BP >/= 90 mmHg). MEASUREMENTS AND MAIN RESULTS: Intensification of antihypertensive medications at each visit was the primary outcome. Primary care providers intensified antihypertensive treatment in only 176 (13%) of 1,374 visits at which blood pressure was elevated. As expected, higher mean systolic and mean diastolic blood pressures were important predictors of intensification. Treatment was also more likely to be intensified at visits that were "routine" odds ratio (OR) 2.08; 95% Confidence Interval [95% CI] 1.36-3.18), or that paired patients with their usual primary care provider (OR 1.84; 95% CI 1.11-3.06). In contrast, several factors were associated with failure to intensify treatment, including capillary glucose >150 mg/dL (OR 0.54; 95% CI 0.31-0.94) and the presence of coronary heart disease (OR 0.61; 95% CI 0.38-0.95). Co-management by a cardiologist accounted partly for this failure (OR 0.65; 95% CI 0.41-1.03). CONCLUSIONS: Failure to appropriately intensify antihypertensive treatment is common in diabetes care. Clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.

Missed opportunities in diabetes management: a longitudinal assessment of factors associated with sub-optimal quality.

BACKGROUND: In diabetic adults, tight control of risk factors reduces complications. OBJECTIVE: To determine whether failure to make visits, monitor risk factors, or intensify therapy affects control of blood pressure, glucose, and lipids. DESIGN: A non-concurrent, prospective study of data from electronic files and standardized abstraction of hard-copy medical records for the period 1/1/1999-12/31/2001. PARTICIPANTS: Three hundred eighty-three adults with diabetes managed in an academically affiliated managed care program. MEASUREMENTS: Main exposure variable: Intensification of therapy or failure to intensify, reckoned on a quarterly basis. MAIN OUTCOME MEASURE: Hemoglobin A1c (A1c), systolic blood pressure (SBP), and LDL-cholesterol at the end of the interval. RESULTS: In this visit-adherent cohort, control of glycemia and lipids showed improvement over 24 months, but many patients did not achieve targets. Only those with the worst blood pressure control (SBP >or=160 mmHg) showed any improvement over 2 years. Failure to intensify treatment in patients who kept visits was the single strongest predictor of sub-optimal control. Compared to their counterparts with no failures of intensification, patients with failures in >or=3 quarters showed markedly worse control of blood glucose (A1c 1.4% higher: 95% CI: 0.7, 2.1); hypertension (SBP 22.2 mmHg higher: 95% CI: 16.6, 27.9) and LDL cholesterol (LDL 43.7 mg/dl higher: 95% CI: 24.1, 63.3). These relationships were strong, graded, and independent of socio-demographic factors, baseline risk factor values, and co-morbidities. CONCLUSIONS: Failure to intensify therapy leads to suboptimal control, even with adequate visits and monitoring. Interventions designed to promote appropriate intensification should enhance diabetes care in primary practice.

Building a Medicaid Ambulatory Complex Care Program Within an Urban Medical Home.

Five percent of Medicaid patients account for 50% of total costs. Preventable costs are often incurred by patients with complex medical, behavioral, and social needs who disproportionately utilize acute care services. Evidence for design, implementation, and evaluation of complex care programs in the urban Medicaid population is lacking. The article provides a description of a complex care program (CCP), challenges, and early outcomes based on a pre-post evaluation. The CCP was located within an existing urban medical home. Patients were eligible if they lived within 10 miles of the clinic and had at least 2 inpatient visits and/or 3 emergency room visits within the prior 6 months. Ambulatory Care Groups® were used to predict estimated total costs of patients, who were included if potential cost savings exceeded $5000. Patient experience and quality of care were assessed using validated measures and costs. Return on investment was calculated based on investment and cost savings. Costs include visits (clinic, specialty, and emergency room), hospital admissions, medications, tests and services, as well as salary and benefits of clinical staff. Eighty-six of 211 eligible patients (41%) were enrolled during the first 18 months of the pilot program. There were positive trends in quality metrics and patient satisfaction. The pre-post evaluation demonstrated a reduction in emergency room visits and hospitalizations (67% and 65%, respectively), which resulted in a 2.2:1 return on investment. This article offers lessons learned to colleagues considering population health approaches in the care of high-risk Medicaid patients.