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BACKGROUND: An integrated practice unit (IPU) that provides a multidisciplinary approach to patient care, typically involving a primary care provider, registered nurse, social worker, and pharmacist has been shown to reduce healthcare utilization among high-cost super-utilizer (SU) patients or multi-visit patients (MVP). However, less is known about differences in the impact of these interventions on insured vs. uninsured SU patients and super high frequency SUs ([Formula: see text]8 ED visits per 6 months) vs. high frequency SUs (4-7 ED visits per 6 months). METHODS: We assessed the percent reduction in ED visits, ED cost, hospitalizations, hospital days, and hospitalization costs following implementation of an IPU for SUs located in an academic tertiary care facility. We compared outcomes for publicly insured with uninsured patients, and super high frequency SUs with high frequency SUs 6 months before vs. 6 months after enrollment in the IPU. RESULTS: There was an overall 25% reduction in hospitalizations (p < 0.001), and 23% reduction in hospital days (p = 0.0045), when comparing 6 months before vs. 6 months after enrollment in the program. There was a 26% reduction in average total direct hospitalization costs per patient (p = 0.002). Further analysis revealed a greater reduction in health care utilization for uninsured SU patients compared with publicly insured patients. The program reduced hospitalizations for super high frequency SUs. However, there was no statistically significant impact on overall health care utilization of super high frequency SUs when compared with high frequency SUs. CONCLUSIONS: Our study supports existing evidence that dedicated IPUs for SUs can achieve significant reductions in acute care utilization, particularly for uninsured and high frequency SU patients. TRIAL REGISTRATION: IRB201500212. Retrospectively registered.

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In 2011, Texas received federal approval of the 1115 Healthcare Transformation waiver, which went to support the Texas Delivery System Reform Incentive Payment Program (DSRIP) incentivizing the transformation of service delivery practices which included expanded coverage of preventive cancer screenings. There is limited evidence that quality improvement initiatives stemming from DSRIP improve cancer screening outcomes for the Medicaid, low-income, and uninsured (MLIU) patient population. The present the results of a quality initiative to improve breast, cervical, and colorectal cancer screening rates for MLIU patients receiving primary care at an academic medical center. The initiative included engaging multidisciplinary primary care teams, health information technology (IT), and quality departments to standardize workflows. We found significantly improved rates of cervical and colorectal cancer screening among patients eligible to receive one or more screenings. Aligning primary care, IT, and quality processes resulted in significant improvement in cancer screening.

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PURPOSE: Traditionally, Morbidity and Mortality Conference (M&MC) are forums where medical errors are discussed. Though M&MC can lead to identification of opportunities for system wide improvements, there is little in the literature to describe the use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches systems-based practice and can engage residents in improving systems of care. METHODS: Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2104 to September 2017. Residents used case review worksheets to categorize and track causes of mortality. The residents then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. RESULTS: The residents identified a diagnosis mismatch from admission to death in 54.5 % (n=189) of cases and possible need for improvement in management in 48.0% cases. Three 'management failure' themes were identified including failures to plan, failure to communicate and failure to rescue, consisting of 21.9%, 10.7 %, and 10.1% of cases respectively. Following the reviews, quality improvement initiatives proposed by residents lead to system-based changes. CONCLUSION: A resident-driven mortality review curriculum can lead to improvement in systems of care. This type of novel curriculum can teach systems-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.

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BACKGROUND: The recommendations of the American Board of Internal Medicine Foundation's "Choosing Wisely®" initiative recognize the importance of improving the appropriateness of testing behavior and reducing the number of duplicate laboratory tests. OBJECTIVE: To assess the effectiveness of an electronic medical record Best Practice Alert (BPA or "pop up") intervention aimed at reducing duplicate laboratory tests and hospital costs. DESIGN: Comparison of the number of duplicated laboratory tests performed on inpatients before and after the intervention. SETTING: University of Florida Health Shands Hospital, Gainesville, FL, USA, during 2014-2017. INTERVENTION: The electronic medical record intervention was a BPA pop-up alert that informed the ordering physician if a recent identical order already existed along with the "ordering time", "collecting time", "resulting time", and the result itself. MAIN OUTCOME MEASURES: Percentage change in the number of inpatient duplicate orders of selected clinical biochemistry tests and cost savings from reduction of the duplicates. Student's t-test and beta-binomial models were used to analyze the data. RESULTS: Results from the beta-binomial model indicated that the intervention reduced the overall duplicates by 18% (OR=0.82, standard error=0.016, P-value<0.000). Percent reductions in 9 of the 17 tests were statistically significant: serum hemoglobin A1C level, vitamin B12, serum erythrocyte sedimentation rate, serum folate, serum iron, lipid panel, respiratory viral panel, serum thyroid stimulating hormone level, and Vitamin D. Additionally, important cost savings were realized from the reduction of duplicates for each lab test (with the exception of CRP) with an estimated overall savings of $72,543 over 17 months in the post-intervention period. CONCLUSIONS: The present study included all hospital inpatients and covered 17 clinical laboratory tests. This rather simple and low-cost intervention resulted in significant reductions in percentage duplicates of several tests and resulted in cost savings. The study also highlights the role of hospitalists in quality improvement.

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Economic pressure has led the evolution of the role of the medical school dean from a clinician educator to a health care system executive. In addition, other dynamic requirements also have likely led to changes in their leadership characteristics. The most important relationship a dean has is with the chairs, yet in the context of the dean's changing role, little attention has been paid to this relationship. To frame this discussion, we asked medical school chairs what characteristics of a dean's leadership were most beneficial. We distributed a 26-question survey to 885 clinical and basic science chairs at 41 medical schools. These chairs were confidentially surveyed on their views of six leadership areas: evaluation, barriers to productivity, communication, accountability, crisis management, and organizational values. Of the 491 chairs who responded (response rate =55%), 88% thought that their dean was effective at leading the organization, and 89% enjoyed working with their dean. Chairs indicated that the most important area of expertise of a dean is to define a strategic vision, and the most important value for a dean is integrity between words and deeds. Explaining the reasons behind decisions, providing good feedback, admitting errors, open discussion of complex or awkward topics, and skill in improving relations with the teaching hospital were judged as desirable attributes of a dean. Interestingly, only 23% of chairs want to be a dean in the future. Financial acumen was the least important skill a chair thought a dean should hold, which is in contrast to the skill set for which many deans are hired and evaluated. After reviewing the literature and analyzing these responses, we assert that medical school chairs want their dean to maintain more traditional leadership than that needed by a health care system executive, such as articulating a vision for the future and keeping their promises. Thus, there appears to be a mismatch between what medical school chairs perceive they need from their dean and how the success of a dean is evaluated.

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OBJECTIVE: To estimate the prevalence of hypertension, diabetes and chronic kidney disease and their risk factors in a rural and urban region of Haiti. SETTING AND PARTICIPANTS: Community health workers enumerated 2648 households (909 rural and 1739 urban) via a multistage cluster random sampling method from July 2015 to May 2016, completed 705 rural and 1419 urban assessments for adults aged 25-65 years. OUTCOME MEASURES: We performed a WHO STEPS based questionnaire, measured two blood pressure values, weight, height, abdominal circumference and point of care test finger stick blood sample for haemoglobin A1c, creatinine and cholesterol (total, high density lipoprotein (HDL) and triglycerides). RESULTS: After adjusting for age and sex, the overall prevalence rates of hypertension, diabetes and chronic kidney disease were 15.6% (±2.93%), 19.7% (±1.57%) and 12.3% (±2.72%), respectively. Of the three non-communicable diseases (NCDs), only diabetes showed a significant difference between rural and urban sites (p=0.000), with the rural site (23.1%) having a higher prevalence than the urban site (16.4%). When comparing male and female participants, females were significantly more likely than males to have an NCD (p≤0.011). Females had a higher prevalence of most of the risk factors when compared with males. The urban location had a higher prevalence than the rural location for four risk factors that showed a significant difference between location (p≤0.037). CONCLUSIONS: Women in Haiti had significantly higher prevalence rates of most NCDs and risk factors than men, and urban populations frequently, but not always, had higher rates of NCDs risk factors than the rural population. Further, it was shown that using point of care blood tests combined with community health workers, it is feasible to screen for NCDs and risk factors in remote areas which otherwise have limited access to healthcare.

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Limited health literacy is a common but often unrecognized problem associated with poor health outcomes. Well-validated screening tools are available to identify and provide the opportunity to intervene for at-risk patients in a resource-efficient manner. This is a multimethod study describing the implementation of a hospital-wide routine health literacy assessment at an academic medical center initiated by nurses in April 2014 and applied to all adult inpatients. Results were documented in the electronic health record, which then generated care plans and alerts for patients who screened positive. A nursing survey showed good ease of use and adequate patient acceptance of the screening process. Six months after hospital-wide implementation, retrospective chart abstraction of 1,455 patients showed that 84% were screened. We conclude that a routine health literacy assessment can be feasibly and successfully implemented into the nursing workflow and electronic health record of a major academic medical center.

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PROBLEM: Academic physician reimbursement has moved to productivity-based compensation plans. To be sustainable, such plans must be self-funding. Additionally, unless research and education are appropriately valued, faculty involved in these efforts will become disillusioned, yet revenue generation in these activities is less robust than for clinical care activities. APPROACH: Faculty at the Department of Medicine, University of Florida Health, elected a committee of junior and senior faculty and division chiefs to restructure the compensation plan in fiscal year (FY) 2011. This committee was charged with designing a new compensation plan based on seven principles of organizational philosophy: equity, compensation coupled to productivity, authority aligned with responsibility, respect for all academic missions, transparency, professionalism, and self-funding in each academic mission. OUTCOMES: The new compensation plan was implemented in FY2013. A survey administered at the end of FY2015 showed that 61% (76/125) of faculty were more satisfied with this plan than the previous plan. Since the year before implementation, clinical relative value units per faculty increased 7% (from 3,458 in FY2012 to 3,704 in FY2015, P < .002), incentives paid per faculty increased 250% (from $3,191 in FY2012 to $11,153 in FY2015, P ≤ .001), and publications per faculty increased 15% (from 2.6 in FY2012 to 3.0 in FY2015, P < .001). Grant submissions, external funding, and teaching hours also increased per faculty but did not reach statistical significance. NEXT STEPS: An important next step will be to incorporate quality metrics into the compensation plan, without affecting costs or throughput.

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INTRODUCTION: A subpopulation of sickle-cell disease patients, termed super-utilizers, presents frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the healthcare needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that alter utilization through coordinated care. Our goals were to assess feasibility primarily, and to assess resource use secondarily. METHODS: We evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (seven months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). Our approach included patient-specific best practice advisories (BPA); an ED management protocol; and formation of a "medical home" for these patients. RESULTS: For 10 subjects targeted initially we developed and implemented coordinated care plans; after deployment, we observed a tendency toward reduction in ED and inpatient utilization across all measured indices. Between the annualized pre- and post-implementation periods we found the following: ED visits decreased by 16.5 visits/pt-yr (95% confidence interval [CI] [-1.32-34.2]); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI [-82.9-313.5]); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI [-1.73-10.1]); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI [-74.9-146.7]); and visits where the patient left before treatment were reduced by an annualized total of 13.7 visits. We observed no patient mortality in our 10 subjects, and no patient required admission to the intensive care unit 72 hours following discharge. CONCLUSION: This effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.

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BACKGROUND: The integration of clinical decision support (CDS) in documentation practices remains limited due to obstacles in provider workflows and design restrictions in electronic health records (EHRs). The use of electronic problem-oriented templates (POTs) as a CDS has been previously discussed but not widely studied. OBJECTIVE: We evaluated the voluntary use of evidence-based POTs as a CDS on documentation practices. METHODS: This was a randomized cohort (before and after) study of Hospitalist Attendings in an Academic Medical Center using EPIC EHRs. Primary Outcome measurement was note quality, assessed by the 9-item Physician Documentation Quality Instrument (PDQI-9). Secondary Outcome measurement was physician efficiency, assessed by the total charting time per note. RESULTS: Use of POTs increased the quality of note documentation [score 37.5 vs. 39.0, P = 0.0020]. The benefits of POTs scaled with use; the greatest improvement in note quality was found in notes using three or more POTs [score 40.2, P = 0.0262]. There was no significant difference in total charting time [30 minutes vs. 27 minutes, P = 0.42]. CONCLUSION: Use of evidence-based and problem-oriented templates is associated with improved note quality without significant change in total charting time. It can be used as an effective CDS during note documentation.

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PROBLEM: Teaching hospital multidisciplinary work rounds are often inefficient, delaying the completion of patient care tasks and detracting from teaching. Participants often act as working groups rather than interdependent teams. Athletic principles were used to train multidisciplinary rounding teams to adopt the systems used by manufacturing to improve the efficiency and quality of patient care, as well as teamwork and didactic teaching. APPROACH: Experimental groups of general medical rounding teams-faculty member, house staff, medical students, bedside nurses, pharmacists, and a case manager-were introduced to individual job descriptions (playbooks), key customer-supplier relation ships, and efficient communication protocols, accompanied by weekly feed back (game films). A two-phase pilot 11-month prospective trial (February to July 2009 and September 2011 to January 2012) compared the experimental and control rounding teams on the basis of length of stay, 30-day readmission rates, and physician, student, and patient satisfaction. OUTCOMES: These interventions resulted in a 30% reduction in 30-day readmissions and, in the 2011-2012 phase, an 18% shorter length of stay. Anonymous surveys documented greater satisfaction of faculty, residents, and medical students, and student ratings of teaching were markedly improved. Patient satisfaction did not change. NEXT STEPS: The new rounding system has the potential to reduce waste and improve the quality of patient care while improving caregiver satisfaction and medical student teaching. Adaptive leadership skills will be required to overcome resistance to change. The use of athletic analogies can improve teamwork and facilitate the adoption of a systems approach to the delivery of patient care.

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INTRODUCTION: In anticipation of the 2011 ACGME duty hour requirements, we redesigned our internal medicine resident ward experience. Our previous ward structure included a maximum 30-hour duty period for postgraduate year-1 (PGY-1) residents. In the redesigned ward structure, PGY-1 residents had a maximum 18-hour duty period. METHODS: We evaluated resident conference attendance and duty hour violations before and after implementation of our new ward redesign. We administered a satisfaction survey to residents and faculty 6 months after implementation of the new ward redesign. RESULTS: Before implementation of the ward redesign, 30-hour continuous and 80-h/wk duty violations were each 2/year, and violations of the 10-hour rest between duty periods were 10/year for 74 residents. After implementation of the ward redesign, there were no 30-hour continuous or 80-h/wk duty violations, but violations of the 10-hour rest between duty periods more than doubled (26/year for 75 residents). Duty hours were reported by different mechanisms for the 2 periods. Conference attendance improved. Resident versus faculty satisfaction scores were similar. Both groups judged overall professional satisfaction as slightly worse after implementation. CONCLUSION: Our ward rotation redesign eliminated 30-hour continuous and 80-h/wk duty violations as well as improved conference attendance. These benefits occurred at the cost of more faculty hires, decreased resident elective time, and slightly worse postimplementation satisfaction scores.

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INTRODUCTION: Patients with chronic non-cancer pain (CNCP) are common and have a high degree of morbidity. Previous studies document clinician frustration and variability in CNCP management. We conducted this study to gather in-depth clinicians' views about factors that affect management of CNCP. METHODS: We conducted a survey in the Primary Care MultiEthnic Network, a consortium of PBRNs of primary care clinicians practicing in low-income, medically underserved communities, and in a network of private primary care offices. RESULTS: Of 792 clinicians surveyed, 497 (63%) participated. Responses and accompanying narrative comments clustered around 5 themes: (1) barriers to and uncertainties in optimal management; (2) the complex biopsychosocial nature of CNCP; (3) seriousness of prescription opioid abuse; (4) effort and burden required to properly manage CNCP; and (5) clinician commitment to provide care for CNCP patients and benefits of expanded care model for CNCP. One-third reported a severe outcome (death or life-threatening event) in a CNCP patient for whom they had prescribed opioids. Roughly one-third do not initiate prescribing of opioids. CONCLUSIONS: Guidelines and increased continuing medical education alone are unlikely to be the solutions to the challenges of CNCP management. Increased evidence for recommendations and resources for more comprehensive care management are needed.

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BACKGROUND: The importance of Hepatitis C (HCV) as a public and individual health concern is well established. However, national groups differ in their recommendations to primary care clinicians about screening people at high risk for HCV. The purpose of this study was to explore the context of care within which primary care clinicians decide to detect and initially manage HCV. METHODS: The Primary Care Multiethnic Network conducted a web- and paper-based survey of primary care clinicians who largely practice in low-income, medically underserved communities in 3 regions across the country. RESULTS: A total of 494 clinicians participated, for a response rate of 61%. Most (68%) clinicians view HCV as an important problem; more than half (59%) consider screening for HCV to be important when compared with other conditions they screen for in practice. With regard to reported screening habits for risk factors, 54% of clinicians routinely ask new patients whether they have used intravenous drugs and 28% inquire about blood transfusions before 1992. Sixty-one percent order an alanine aminotransferase test when patients present with other risk factors for HCV. The majority of clinicians (54%) refer 75% or fewer of their patients with HCV for treatment; nearly one-fifth (18%) provide antiviral treatment themselves. Key factors influencing clinician HCV decision making are patient comorbidities (74% reported this as a factor), access to treatment (55% reported this as a factor), and tolerance (44% reported this as a factor) of treatment. CONCLUSIONS: In the face of conflicting national guideline recommendations about screening people at high risk for HCV, clinicians have varied views and practice habits influenced by multiple patient, access, and treatment issues.

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PURPOSE: The advent of Web-based survey tools has provided the investigator with an alternative to paper-based survey methods that in many instances may be less expensive to implement than traditional paper-based surveys. Newer technology, however, does not diminish the importance of obtaining an adequate response rate. METHODS: We analyzed response rate data obtained from a survey implemented across 3 practice-based research networks (PBRNs) in which the survey was first implemented electronically with 5 rounds of electronic solicitation for an Internet-based questionnaire and then by 2 rounds of a paper-based version mailed only to nonresponders. RESULTS: Overall, 24% of the total survey responses received were in the paper mode despite intense promotion of the survey in the electronic phase. CONCLUSIONS: Our results suggest there is still an important role for the use of paper-based methods in PBRN survey research. Both hard copy and electronic survey collection methods may be required to enhance clinician response rates in PBRNs.

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PURPOSE: Traditional approaches to improving preventive care have had limited success. In response, researchers have adopted new ways of examining the primary care environment and clinical encounters to better understand the factors that impact care delivery. We examined how clinicians make preventive counseling decisions to ascertain if self-determination theory (SDT) may further clarify influences on clinicians' decisions to take time for preventive counseling. METHODS: We studied clinical decision making through a mixed-method approach using obesity counseling as an example of preventive counseling. We conducted in-depth interviews and focus groups with 30 primary care clinicians in RIOS Net, a Southwestern US practice-based research network and distributed a survey, which was completed by 75% of 195 network members. We then used the components of SDT autonomy, competence, and relatedness to organize the factors that clinicians identified as most influential in their preventive counseling decisions. RESULTS: We found that SDT provides an organizing structure for understanding some of the psychology of clinicians' decisions to provide preventive counseling in the brief primary care encounter. In the specific case of obesity counseling clinicians expressed a high degree of autonomy, but barriers to competence and generally low levels of relatedness with professional colleagues seemed to limit their delivery of preventive counseling. CONCLUSION: SDT provides a new perspective on factors that impact preventive counseling delivery, with a focus on the psychology of clinical decision making. Further research testing the predictive value of SDT may open new avenues for enhancing the delivery of preventive services.

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BACKGROUND: The problem of obesity is now epidemic in the United States. Despite the existence of clinical guidelines for prevention and treatment of obesity and documented clinician concern about this problem, counseling for obesity reduction in primary care is infrequent. The principal aim of this study was to examine the views of clinicians on obesity counseling and to compare these views to the recommendations of leading obesity guidelines. METHODS: Twenty individual, in-depth interviews and two focus groups of clinicians serving predominantly low-income minority populations were conducted in a practice-based research network. Data were analyzed using immersion/crystallization and template approaches. RESULTS: Clinicians believe obesity is an important problem and report using mostly brief, targeted, low-intensity counseling in the face of limited patient motivation and lack of resources to support weight loss. They view family, cultural, social, and community factors as central to the problem of obesity, and their own efforts as generally ineffective. These clinicians similarly were unconvinced of the long-term effectiveness of any weight-loss strategies. CONCLUSIONS: Low levels of obesity counseling in primary care may reflect clinicians' self-assessment of their ineffectiveness in this area rather than lack of interest or knowledge. These clinicians perceive that obesity control efforts aimed at local community factors and environmental modifications are key strategies in augmenting and linking their efforts to successful outcomes.

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PURPOSE: Studies have often shown low rates of preventive counseling in primary care, and interventions aimed at improving counseling rates have had disappointing results. Using obesity as a case study, we looked for factors that influence clinicians' decisions to include preventive counseling in the brief primary care encounter. METHODS: A sequential, mixed methods study was conducted among clinicians in RIOS (Research Involving Outpatient Settings) Net, a Southwestern US practice-based research network. Thirty primary care clinicians participated in in-depth interviews or analytic focus groups, and 75% of 195 network members responded to a survey used to estimate the frequency of factors influencing decisions to undertake preventive counseling. RESULTS: Clinicians described a complex set of factors that influence decisions to provide preventive counseling for obesity. These can be grouped into 2 sets of factors: (1) relatively stable factors that "set the stage" for the encounter, such as the clinician's life values, definitions of success, and the availability of community resources; and (2) factors that are more dynamic, exerting their influence "as the door opens" into the examination room. These factors include the patient's agenda and receptivity to the proposed counseling, as well as the presence of teachable moments. Clinician, patient, and external factors are found in both groups. CONCLUSIONS: Clinician decisions to include obesity and other types of preventive counseling in the brief encounter reflect the art and complexity of management of the encounter. Future efforts to enhance the delivery of preventive counseling will need to move beyond linear models of behavior change to recognize this complex environment.

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PURPOSE: The purpose of this study was to evaluate brief physician advice regarding seatbelt and bicycle helmet use in adolescents and young adults. METHODS: We recruited 200 patients ages 11-24 years presenting for all visits to a primary care clinic in the Southwestern United States from January 2000 to March 2001. Patients were randomized to control or a single 2- to 3-minute scripted motivational counseling intervention delivered by physicians with an educational brochure and discount helmet coupon. We conducted telephone follow-up evaluation at 3 months. Main outcome measures were self-reported seatbelt and bicycle helmet use assessed on a 4-point Likert scale and attitudes toward these behaviors assessed on a 5-point Likert scale and analyzed by the Wilcoxon signed-rank test. RESULTS: For the intervention group, mean Likert scores precounseling and postcounseling for self-reported seatbelt use were 1.3 and 1.4, respectively, with a mean difference of .04 (95% confidence interval [CI], -.1 to .2). For self-reported bicycle helmet use, scores were 3.1 and 3.0, respectively, with a mean difference of .1 (95% CI, -.3 to .2). Combined mean Likert scores measuring subject's attitudes about seat belt use were 13.8 and 14.0, respectively, with a mean difference of .2 (95% CI, -.3 to .6). For bicycle helmet use, scores were 20.0 and 20.9, respectively, with a mean difference of .9 (95% CI, -1.4 to 3.3). CONCLUSION: We were unable to detect a significant improvement in safety behaviors or attitudes by adolescents and young adults after a brief intervention by physicians during routine office visits.

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