Reviewing the Reviewer: Medical Student Course Feedback as a Marker of Professional Identity Formation.

Professional identity formation refers to the process by which medical trainees develop and internalize their new roles. In this work, we analyze medical student evaluations of teaching (SETs) as a window into students' developing identities as physicians. Our data consisted of 389 open-ended comments written anonymously by first-year (pre-clerkship) students in mid- and end-of-semester evaluations of small group sessions (mandatory attendance) during one full academic year at Yale School of Medicine. Using a combination of existing frameworks on professional identity formation, the purpose of this project was to: (1) describe the characteristics of comments made by medical students about first-year courses and instructors; (2) categorize the student comments; and (3) explore the usefulness of comments as markers of students' professional identity formation as physicians. Having established baseline information, we hope to follow the same cohort of students through their medical school career to assess if and how their evaluative comments shed light on the development of their professional identities as physicians.

The impact of key modifiable risk factors on leading chronic conditions.

We studied associations between 7 cardiovascular disease (CVD) risk factors (RFs) and 9 chronic conditions and estimated population-attributable risk. Data (N = 358,218) were from the 2017 Behavioral Risk Factor Surveillance System. Outcomes included asthma, arthritis, chronic obstructive pulmonary disease (COPD), cognitive impairment, CVD, and kidney disease. Risk factors (RF) were obesity, ever smoking, sedentary lifestyle, and inadequate fruit and vegetable consumption, while hypertension, high cholesterol, and diabetes were considered in both categories. Stata was used to study associations in both unadjusted and adjusted analysis. Population-attributable risk was estimated in Excel using adjusted odds ratios (AORs) and compared results using all RFs versus only those where causality was confirmed by other studies. RF prevalence rates ranged from 10.8% (95% CI 10.6, 11.0) for diabetes to 84.1% (83.8, 84.3) for inadequate fruit and vegetable consumption. Almost all adults (95.2%) reported ≥1 RF. Highest total PARs for RFs with confirmed causality were for obesity and ever smoking, and for hypertension when all RFs were considered. Total PARs for the 9 outcomes averaged 37.2-41.5% when results were limited to RFs with confirmed causality. Although the number of risk factors for which causality had been confirmed ranged from 1 to 6, all 9 outcomes showed linear dose response gradients with added risk factors. While all 7 RFs appeared important to address, targeting smoking and obesity with programs that have shown previous success offers the greatest potential for reducing burden for these 9 chronic diseases.

Linear association between number of modifiable risk factors and multiple chronic conditions: Results from the Behavioral Risk Factor Surveillance System.

Multiple (≥2) chronic conditions (MCCs) are responsible for a large fraction of healthcare costs. Our aim was to examine possible associations between MCCs and composite measures of behavioral risk factors (RFs). Data were publicly available 2013 Behavioral Risk Factor Surveillance System and included 483,865 non-institutionalized US adults ages ≥18years. Chronic conditions included asthma, arthritis, chronic obstructive pulmonary disease, cognitive impairment, heart disease, stroke, cancer, and kidney disease. RFs included obesity, current smoking, sedentary lifestyle, inadequate fruit and vegetable consumption, and sleeping other than 7-8h, while depression, hypertension, high cholesterol, and diabetes were considered in each category. Stata was used to study associations between 2 different MCCs and 2 composite measures of RFs in both unadjusted and adjusted analysis. Over 96% of respondents reported ≥1 of the 9 RFs and 71.5% reported ≥1 of the chronic conditions. For each combination there was a linear increase (with similar slopes) in MCC rate with more RFs and a statistically significant increase in adjusted odds ratios (ORs) for the MCC with each additional RF. For the MCC based on 8 chronic conditions, ORs were 1.3 (95% CI 1.1, 1.6) for 1 RF, 2.3 (1.9, 2.7) for 2, 3.7 (3.1, 4.4) for 3, 5.7 (4.8, 6.8) for 4, 9.1 (7.6, 10.8) for 5, 14.6 (12.2, 17.4) for 6, 24.0 (19.7, 29.2) for 7, 38.1 (29.6, 48.9) for 8, and 100.0 (56.3, 177.8) for all 9, each vs. zero RFs. Findings highlight the need for effective integrated programs to address multiple RFs and chronic conditions.

A healthy lifestyle composite measure: Significance and potential uses.

OBJECTIVES: Our objective was to create and explore potential uses of a composite "Healthy Lifestyle" measure based on Healthy People 2020 (HP2020) Objectives for behaviors shown to be associated with morbidity and mortality. METHODS: Data were from the 2013 Behavioral Risk Factor Surveillance System (N=412,942) on five modifiable behaviors with HP2020 Objectives (leisure time exercise, eating fruits and vegetables 5 or more times/day, getting ≥7h of sleep/24h, not smoking and not drinking excessively). These indicators were combined to form an all-or-none composite Healthy Lifestyle (HLS) measure. Associations between the HLS measure and demographic and other measures, plus details of component measures, were reported. RESULTS: Results indicated that only 7.7% of adults reported a HLS with wide variation among states and demographic groups. Both unadjusted and logistic regression results found associations between a HLS and better health, lower rates of chronic disease and better access to health care. Over one fourth of all respondents (28.0%) needed to only improve fruit and vegetable consumption to be practicing a HLS. CONCLUSIONS: In conclusion, few adults were practicing five behaviors that are generally recognized as healthy. All-or-none metrics like this HLS measure offer a fresh perspective on modifiable behaviors and the need for improvement. Examination of measure components can help explain demographic differences and identify strategies for improvement.

Polling places, pharmacies, and public health: Vote & Vax 2012.

US national elections, which draw sizable numbers of older voters, take place during flu-shot season and represent an untapped opportunity for large-scale delivery of vaccinations. In 2012, Vote & Vax deployed a total of 1585 clinics in 48 states; Washington, DC; Guam; Puerto Rico; and the US Virgin Islands. Approximately 934 clinics were located in pharmacies, and 651 were near polling places. Polling place clinics delivered significantly more vaccines than did pharmacies (5710 vs 3669). The delivery of vaccines was estimated at 9379, and approximately 45% of the recipients identified their race/ethnicity as African American or Hispanic. More than half of the White Vote & Vax recipients and more than two thirds of the non-White recipients were not regular flu shot recipients.

Clinical preventive services for older adults: the interface between personal health care and public health services.

Healthy aging must become a priority objective for both population and personal health services, and will require innovative prevention programming to span those systems. Uptake of essential clinical preventive services is currently suboptimal among adults, owing to a number of system- and office-based care barriers. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable, deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes. Significant reductions in health disparities, mortality, and morbidity, along with decreases in health spending, are achievable through improved collaboration and synergy between population health and personal health systems.

Developing an integrated strategy to reduce ethnic and racial disparities in the delivery of clinical preventive services for older Americans.

OBJECTIVES: To determine the optimum strategy for increasing up-to-date (UTD) levels in older Americans, while reducing disparities between White, Black, and Hispanic adults, aged 65 years and older. METHODS: Data were analyzed from the 2008 Behavioral Risk Factor Surveillance System, quantifying the proportion of older Americans UTD with influenza and pneumococcal vaccinations, mammograms, Papanicolaou tests, and colorectal cancer screening. A comparison of projected changes in UTD levels and disparities was ascertained by numerically accounting for UTD adults lacking 1 or more clinical preventive services (CPS). Analyses were performed by gender and race/ethnicity. RESULTS: Expanded provision of specific vaccinations and screenings each increased UTD levels. When those needing only vaccinations were immunized, there was a projected decrease in racial/ethnic disparities in UTD levels (2.3%-12.2%). When those needing only colorectal cancer screening, mammography, or Papanicolaou test were screened, there was an increase in UTD disparities (1.6%-4.5%). CONCLUSIONS: A primary care and public health focus on adult immunizations, in addition to other CPS, offers an effective strategy to reduce disparities while improving UTD levels.

Cognitive Impairment and Cardiovascular Disease: A Comparison of Risk Factors, Disability, Quality of Life, and Access to Health Care.

OBJECTIVES: Cognitive difficulties or impairment may be an early step in the development of dementia. Several modifiable risk factors for cardiovascular disease (CVD) may also increase the risk of dementia. The objective of our study was to compare adults with subjective cognitive impairment (SCI), using the Behavioral Risk Factor Surveillance System (BRFSS) cognitive disability measure, with adults who reported CVD. METHODS: We examined data on 3 key outcomes among 302 008 adult respondents aged ≥45 in the 2017 BRFSS: respondents with SCI only, respondents with CVD only, and respondents with both conditions. We compared measures of disability, quality of life, access to health care, and a composite measure of the following 7 risk factors: current smoking, diabetes, high cholesterol, hypertension, inadequate fruit and vegetable consumption, obesity, and sedentary lifestyle. We also estimated population-attributable risk (PAR). RESULTS: Among respondents, 7.9% reported SCI only, 11.1% reported CVD only, and 3.2% reported both conditions, with differences by age and sex. Adults with SCI only were more likely than adults with CVD only to report other disability, worse access to health care, and poorer quality of life, even though adults with CVD were older. Compared with adults with neither condition, adults with any of the 3 outcomes were more likely to report having each of the 7 risk factors; we found a linear association with an increasing number of risk factors. Five or 6 risk factors contributed to PARs for each of the 3 key outcomes. PARs for SCI only were highest for ever smoking (17.2%) and sedentary lifestyle (12.8%), whereas for CVD only, PARs were highest for hypertension (35.5%) and high cholesterol (22.9%). CONCLUSION: Despite differences between adults with SCI and adults with CVD in several demographic and health-related measures, the overall similarity in PARs for SCI and CVD suggests potential benefits from using effective CVD interventions to address SCI.

Delivery of preventive services to adults aged 50-64: monitoring performance using a composite measure, 1997-2004.

OBJECTIVE: Population-based rates for the delivery of adult vaccinations or screenings are typically tracked as individual services. The current approach is useful in monitoring progress toward national health goals but does not yield information regarding how many U.S. adults receive a combination of preventive services routinely recommended based on a person's age and gender. A composite measure is important for policymaking, for developing public health interventions, and for monitoring the quality of clinical care. During the period under study, influenza vaccination was newly recommended (2000) to be routinely delivered to adults in this age range. The objective of the study was to compare the delivery of routine clinical preventive services to U.S. adults aged 50-64 years between 1997 and 2004 using a composite measure that includes cancer screenings and vaccinations. DESIGN: Data were collected via telephone surveys in 1997, 2002, and 2004 as part of the Behavioral Risk Factor Surveillance System. PARTICIPANTS: The participants were randomly selected adults aged 50-64 years in the 50 states and the District of Columbia in the selected years. Sample sizes ranged from 24,917 to 77,244. MEASUREMENTS AND MAIN RESULTS: The composite measure includes screening for colorectal cancer, cervical cancer, breast cancer, and vaccination against influenza (2002 and 2004 only). The composite measure quantifies the percentage of adults who are up-to-date with the complete set according to recommended schedules. With the inclusion of newly recommended influenza vaccination, the percentage of men and women aged 50-64 who were up-to-date on all selected measures in 2004 was 23.4% and 23.0%, respectively, compared with 37.6% and 30.5% in 1997. Without including influenza vaccination, the percentage of up-to-date adults aged 50-64 would have risen in 2004 to 50.5% (men) and to 44.7% (women). For both sexes, results varied by education, race/ethnicity, marriage status, insurance status, health status, and state. CONCLUSION: In 2004, the percentage of adults aged 50-64 years receiving routinely recommended cancer screenings and influenza vaccination was low with fewer than 1 in 4 being up to date.

Expanding the delivery of clinical preventive services through community collaboration: the SPARC model.

BACKGROUND: Population-based rates of adult vaccinations and cancer screenings are low, with less than 40% of older adults up to date with routinely recommended prevention services. Delivery rates are lower still in poor and minority communities. CONTEXT: During the past 10 years, Sickness Prevention Achieved through Regional Collaboration (SPARC), a New England-based nonprofit agency, has developed a promising model for increasing community-wide delivery of prevention services. However, the SPARC model has not been tested in communities elsewhere. In 2006, the Centers for Disease Control and Prevention facilitated a partnership between SPARC and the Aging Services division of the Atlanta Regional Commission to evaluate the program's replicability. METHODS: SPARC coalitions involving local public health agencies, hospitals, social service organizations, and advocacy groups were established in two counties of the region, with the Atlanta Regional Commission providing regional coordination. Using the SPARC model, the coalitions planned, marketed, and implemented community-based activities to deliver adult screenings and vaccinations. CONSEQUENCES: During a 3-week pilot phase, SPARC clinics were held in central Atlanta at three senior housing facilities, a local fire station, and a charter middle school, delivering 353 prevention services to 314 residents. In Fayette County, 634 people received influenza vaccinations on Election Day at SPARC clinics located near 10 polling places. INTERPRETATION: The SPARC model provides a practical framework for improving the community-wide delivery of disease prevention services. The model can galvanize local health services providers to develop successful locally tailored interventions, and the approach is applicable in communities outside of SPARC's home region.

The Vote and Vax program: public health at polling places.

Although influenza-associated illness is a major cause of hospitalizations and death among older Americans, only half of adults aged 50 or older-for whom influenza vaccinations are recommended-receive an annual influenza vaccination. National elections, which draw a large number of older voters, take place during influenza vaccination season and represent an untapped opportunity for large-scale delivery of vaccinations. In 2006, the Robert Wood Johnson Foundation launched a program to evaluate the feasibility of delivering influenza vaccinations near polling places. Twenty-five public health agencies were each provided grants of $8000 and asked to implement at least two Vote and Vax clinics. Immunizers were required to obtain prior permission from local election authorities and to charge fees as they would at their other community-based clinics. Influenza vaccination had to be made available both to voters and to nonvoters. On election day, the initiative delivered 13790 influenza vaccinations at 127 polling places in 14 states. More than 80 percent of adult vaccine recipients were in the Centers for Disease Prevention and Control-defined priority groups and 28 percent were "new" influenza vaccination recipients. Vote and Vax is a potentially national strategy that could significantly expand the delivery of influenza vaccinations.

Receipt of preventive services by elders based on composite measures, 1997-2004.

BACKGROUND: The receipt of routine vaccinations and cancer screening is typically tracked separately. Monitoring trends in this way does not measure the overall protection conferred by these services on a target population. DESIGN: Telephone surveys were conducted in 1997, 2002, and 2004 as part of the Behavioral Risk Factor Surveillance System. SETTING/PARTICIPANTS: Randomly selected adults aged 65 and older from 49 states and Washington DC. MAIN OUTCOME MEASURES: Statistically significant changes (p <0.05) in a composite measure of the prevalence of U.S. men aged 65 or older who were up to date with recommendations for colorectal cancer screening, influenza vaccination, pneumococcal vaccination; and for the prevalence of U.S. women aged 65 or older who were up to date for these measures as well as for Pap test and screening mammography. RESULTS: The percentage of men who reported being up to date on all tests increased from 24.4% (1997) to 39.6% (2002) to 41.0% (2004), and the percentage of women increased from 18.6% (1997) to 32.4% (2002) to 32.5% (2004). For both groups, results varied by education, race/ethnicity, marital status, insurance status, and state, as well as whether they had a personal doctor. CONCLUSIONS: Despite increases between 1997 and 2004 in the reported receipt of individual cancer screenings and vaccinations among U.S. adults aged 65 or older, approximately seven of ten women and six of ten men were not up to date on these routine preventive services in 2004.

Routine preventive services for older women: a composite measure highlights gaps in delivery.

BACKGROUND: We used a composite measure to examine the delivery of routine clinical preventive services to U.S. women aged 50-64 years and > or =65 years in 2004. METHODS: We analyzed state data from the 2004 Behavioral Risk Factor Surveillance System (BRFSS) and created a composite measure that included screening of women > or =50 years for colorectal cancer, cervical cancer, breast cancer, vaccination against influenza, and, for women aged > or =65 years only, pneumococcal vaccination. The composite measure quantified the percentage of women who were up-to-date (UTD) according to recommended schedules for these services. RESULTS: Approximately 23% of women aged 50-64 years and 32.5% of women aged > or =65 years were UTD in 2004. Results varied by education, race/ethnicity, marriage status, insurance status, and health status. There was also considerable geographic variation in state-specific UTD estimates, ranging from 16.7% (California) to 38.4% (Minnesota) for women aged 50-64 years and from 25.7% (Indiana) to 48.5% (Minnesota) for women aged > or =65 years. CONCLUSIONS: Although rates for some individual services were > or =75%, the percentage of women aged 50-64 years and > or =65 years UTD on all routinely recommended cancer screenings and vaccinations was low, with <1 in 3 being UTD.

Are older adults up-to-date with cancer screening and vaccinations?

INTRODUCTION: Public health organizations in the United States emphasize the importance of providing routine screening for breast cancer, cervical cancer, and colorectal cancer, as well as vaccinations against influenza and pneumococcal disease among older adults. We report a composite measure of adults aged 50 years and older who receive recommended cancer screening services and vaccinations. METHODS: We analyzed state data from the 2002 Behavioral Risk Factor Surveillance System, which included 105,860 respondents aged 50 and older. We created a composite measure that included colonoscopy or sigmoidoscopy within 10 years or a fecal occult blood test in the past year, an influenza vaccination in the past year, a Papanicolaou test within 3 years for women with an intact cervix, a mammogram, and for adults aged 65 and older, a pneumonia vaccination during their lifetime. We performed separate analyses for four age and sex groups: men aged 50 to 64, women aged 50 to 64, men aged 65 and older, and women aged 65 and older. RESULTS: The percentage of each age and sex group that was up-to-date according to our composite measure ranged from 21.1% of women aged 50 to 64 (four tests) to 39.6% of men aged 65 and older (three tests). For each group, results varied by income, education, race/ethnicity, insurance status, and whether the respondent had a personal physician. CONCLUSION: These results suggest the need to improve the delivery of cancer screenings and vaccinations among adults aged 50 and older. We propose continued efforts to measure use of clinical preventive services.

Clinical and community delivery systems for preventive care: an integration framework.

Although clinical preventive services (CPS)-screening tests, immunizations, health behavior counseling, and preventive medications-can save lives, Americans receive only half of recommended services. This "prevention gap," if closed, could substantially reduce morbidity and mortality. Opportunities to improve delivery of CPS exist in both clinical and community settings, but these activities are rarely coordinated across these settings, resulting in inefficiencies and attenuated benefits. Through a literature review, semi-structured interviews with 50 national experts, field observations of 53 successful programs, and a national stakeholder meeting, a framework to fully integrate CPS delivery across clinical and community care delivery systems was developed. The framework identifies the necessary participants, their role in care delivery, and the infrastructure, support, and policies necessary to ensure success. Essential stakeholders in integration include clinicians; community members and organizations; spanning personnel and infrastructure; national, state, and local leadership; and funders and purchasers. Spanning personnel and infrastructure are essential to bring clinicians and communities together and to help patients navigate across care settings. The specifics of clinical-community integrations vary depending on the services addressed and the local context. Although broad establishment of effective clinical-community integrations will require substantial changes, existing clinical and community models provide an important starting point. The key policies and elements of the framework are often already in place or easily identified. The larger challenge is for stakeholders to recognize how integration serves their mutual interests and how it can be financed and sustained over time.

Vaccinations and preventive screening services for older adults: opportunities and challenges in the USA.

Vaccinations and disease-screening services occupy an important position within the constellation of interventions designed to prevent, forestall or mitigate illness: they straddle the worlds of clinical medicine and public health. This paper focuses on a set of clinical preventive services that are recommended in the USA for adults aged 65 and older, based on their age and gender. These services include immunisations against influenza and pneumococcal disease, and screening for colorectal and breast cancers. We explore opportunities and challenges to enhance the delivery of these interventions, and describe some recently developed models for integrating prevention efforts based in clinician offices and in communities. We also report on a state-level surveillance measure that assesses whether older adults are 'up to date' on this subset of preventive services. To better protect the health of older Americans and change the projected trajectory of medical costs, expanded delivery of recommended vaccinations and disease screenings is likely to remain a focus for both US medicine and public health.

Routine checkups don't ensure that seniors get preventive services.

BACKGROUND: A small number of preventive services are recommended for all adults ages 65 years and older. It is well established that the combined delivery or being "up to date" on these measures is low. However, the effect of routine checkups on being up to date is not known. We examined the association between routine checkups and the delivery of a group of recommended clinical preventive services for US adults ages 65 and older. METHODS: In 2006 the Behavioral Risk Factor Surveillance System conducted telephone surveys. Participants ages 65 years and older were randomly selected in 50 states and the District of Columbia. Sample sizes were 32,243 male respondents and 58,762 female respondents. A composite measure was used that includes screening for colorectal, cervical, and breast cancers, and vaccinations against influenza and pneumococcal disease. The measure quantifies the percentage of adults who are up to date according to recommended schedules. RESULTS: Most adults ages 65 and older were fully insured, had a personal health care provider, reported no cost barrier to seeing a doctor in the past year, and had recently received a routine checkup. Associations between high health care access and checkups and the increased likelihood of being up to date on clinical preventive services were statistically significant. Although a large percentage of the population had high access to care and reported having a recent checkup, the percentage of all those who were up to date was low, and it was only slightly greater for those with high access or a recent checkup (42.6%, 45.1%, and 44.8%, respectively, for men; 35.2%, 37.0%, and 36.8%, respectively for women). For both sexes, the results varied by education, race/ethnicity, marriage, insurance, health, and state. CONCLUSIONS: Our study indicates that increasing the use of routine medical checkups will have a negligible impact on the delivery of preventive services.

Putting prevention in its place: the shift from clinic to community.

Despite widespread insurance coverage for adult vaccinations, cancer screening, and cardiovascular disease prevention measures, most U.S. adults are not up to date with these routine services. This paper reports the efforts of Sickness Prevention Achieved through Regional Collaboration (SPARC), a New England-based organization working to broaden delivery of preventive measures throughout its communities. SPARC's model regards the physician practice as only one element of a network of coordinated prevention activities. SPARC began with the conceptualization of a policy challenge, designed and evaluated interventions to address that problem, and is now influencing public health policies to expand the delivery of clinical preventive services.

Validation of self-reported pneumococcal vaccination in behavioral risk factor surveillance surveys: experience from the sickness prevention achieved through regional collaboration (SPARC) program.

Behavioral risk factor surveillance system (BRFSS) is the primary surveillance tool for the ongoing measurement of state-specific delivery of pneumococcal polysaccharide vaccine. This study is the first validity assessment of self-reported pneumococcal vaccination status in a population-wide BRFSS survey. A subset of respondents to the sickness prevention achieved through regional collaboration (SPARC) BRFSS survey, which was conducted from June to September 1997 in a four-county area were assessed. Self-reporting of pneumococcal vaccination status was validated either by matching to Medicare claims or by reviewing of medical records. Self-reporting of pneumococcal vaccination had a sensitivity of 75% and a specificity of 83%. We conclude that self-reporting of pneumococcal immunization is a moderately sensitive and specific measure and that population-based surveys in the community can be validated when undertaken in collaboration with a local health care agency.