What do patients think about year-end resident continuity clinic handoffs? A qualitative study

Primary care physician involvement during hospitalisation: a qualitative analysis of perspectives from frequently hospitalised patients

OBJECTIVE

To explore frequently hospitalised patients' experiences and preferences related to primary care physician (PCP) involvement during hospitalisation across two care models.

DESIGN

Qualitative study embedded within a randomised controlled trial. Semistructured interviews were conducted with patients. Transcripts were analysed using qualitative template analysis.

SETTING

In the Comprehensive Care Programme (CCP) Study, in Illinois, USA, Medicare patients at increased risk of hospitalisation are randomly assigned to: (1) care by a CCP physician who serves as a PCP across both inpatient and outpatient settings or (2) care by a PCP as outpatient and by hospitalists as inpatients (standard care).

PARTICIPANTS

Twelve standard care and 12 CCP patients were interviewed.

RESULTS

Themes included: (1) Positive attitude towards PCP; (2) Longitudinal continuity with PCP valued; (3) Patient preference for PCP involvement in hospital care; (4) Potential for in-depth involvement of PCP during hospitalisation often unrealised (involvement rare in standard care; in CCP, frequent interaction with PCP fostered patient involvement in decision making); and (5) PCP collaboration with hospital-based providers frequently absent (no interaction for standard care patients; CCP patients emphasising PCP's role in interdisciplinary coordination).

CONCLUSION

Frequently hospitalised patients value PCP involvement in the hospital setting. CCP patients highlighted how an established relationship with their PCP improved interdisciplinary coordination and engagement with decision making. Inpatient-outpatient relational continuity may be an important component of programmes for frequently hospitalised patients. Opportunities for enhancing PCP involvement during hospitalisation should be considered.

Impact of an Educational Comic to Enhance Patient-Physician-Electronic Health Record Engagement: Prospective Observational Study

Background

Electronic health record (EHR) use can impede or augment patient-physician communication. However, little research explores the use of an educational comic to improve patient-physician-EHR interactions.

Objective

To evaluate the impact of an educational comic on patient EHR self-advocacy behaviors to promote patient engagement with the EHR during clinic visits.

Methods

We conducted a prospective observational study with adult patients and parents of pediatric patients at the University of Chicago General Internal Medicine (GIM) and Pediatric Primary Care (PPC) clinics. We developed an educational comic highlighting EHR self-advocacy behaviors and distributed it to study participants during check-in for their primary care visits between May 2017 and May 2018. Participants completed a survey immediately after their visit, which included a question on whether they would be interested in a follow-up telephone interview. Of those who expressed interest, 50 participants each from the adult and pediatric parent cohorts were selected at random for follow-up telephone interviews 8 months (range 3-12 months) post visit.

Results

Overall, 71.0% (115/162) of adult patients and 71.6% (224/313) of pediatric parents agreed the comic encouraged EHR involvement. African American and Hispanic participants were more likely to ask to see the screen and become involved in EHR use due to the comic (adult P=.01, P=.01; parent P=.02, P=.006, respectively). Lower educational attainment was associated with an increase in parents asking to see the screen and to be involved (ρ=−0.18, P=.003; ρ=−0.19, P<.001, respectively) and in adults calling for physician attention (ρ=−0.17, P=.04), which was confirmed in multivariate analyses. Female GIM patients were more likely than males to ask to be involved (median 4 vs 3, P=.003). During follow-up phone interviews, 90% (45/50) of adult patients and all pediatric parents (50/50) remembered the comic. Almost half of all participants (GIM 23/50, 46%; PPC 21/50, 42%) recalled at least one best-practice behavior. At subsequent visits, adult patients reported increases in asking to see the screen (median 3 vs 4, P=.006), and pediatric parents reported increases in asking to see the screen and calling for physician attention (median 3 vs 4, Ps<.001 for both). Pediatric parents also felt that the comic had encouraged them to speak up and get more involved with physician computer use since the index visit (median 4 vs 4, P=.02) and that it made them feel more empowered to get involved with computer use at future visits (median 3 vs 4, P<.001).

Conclusions

Our study found that an educational comic may improve patient advocacy for enhanced patient-physician-EHR engagement, with higher impacts on African American and Hispanic patients and patients with low educational attainment.

Changes in Health Care Use and Outcomes After Turnover in Primary Care

IMPORTANCE

Disruptions of continuity of care may harm patient outcomes, but existing studies of continuity disruption are limited by an inability to separate the association of continuity disruption from that of other physician-related factors.

OBJECTIVES

To examine changes in health care use and outcomes among patients whose primary care physician (PCP) exited the workforce and to directly measure the association of this primary care turnover with patients' health care use and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used nationally representative Medicare billing claims for a random sample of 359 470 Medicare fee-for-service beneficiaries with at least 1 PCP evaluation and management visit from January 1, 2008, to December 31, 2017. Primary care physicians who stopped practicing were identified and matched with PCPs who remained in practice. A difference-in-differences analysis compared health care use and clinical outcomes for patients who did lose PCPs with those who did not lose PCPs using subgroup analyses by practice size. Subgroup analyses were done on visits from January 1, 2008, to December 31, 2017.

EXPOSURE

Patients' loss of a PCP.

MAIN OUTCOMES AND MEASURES

Primary care, specialty care, urgent care, emergency department, and inpatient visits, as well as overall spending for patients, were the primary outcomes. Receipt of appropriate preventive care and prescription fills were also examined.

RESULTS

During the study period, 9491 of 90 953 PCPs (10.4%) exited Medicare. We matched 169 870 beneficiaries whose PCP exited (37.2% women; mean [SD] age, 71.4 [6.1] years) with 189 600 beneficiaries whose PCP did not exit (36.9% women; mean [SD] age, 72.0 [5.0] years). The year after PCP exit, beneficiaries whose PCP exited had 18.4% (95% CI, -19.8% to -16.9%) fewer primary care visits and 6.2% (95% CI, 5.4%-7.0%) more specialty care visits compared with beneficiaries who did not lose a PCP. This outcome persisted 2 years after PCP exit. Beneficiaries whose PCP exited also had 17.8% (95% CI, 6.0%-29.7%) more urgent care visits, 3.1% (95% CI, 1.6%-4.6%) more emergency department visits, and greater spending ($189 [95% CI, $30-$347]) per beneficiary-year after PCP exit. These shifts were most pronounced for patients of exiting PCPs in solo practice, whose beneficiaries had 21.5% (95% CI, -23.8% to -19.3%) fewer primary care visits, 8.8% (95% CI, 7.6%-10.0%) more specialty care visits, 4.4% more emergency department visits (95% CI, 2.1%-6.7%), and $260 (95% CI, $12-$509) in increased spending.

CONCLUSIONS AND RELEVANCE

Loss of a PCP was associated with lower use of primary care and increased use of specialty, urgent, and emergency care among Medicare beneficiaries. Interrupting primary care relationships may negatively impact health outcomes and future engagement with primary care.

Importance of Communication and Relationships: Addressing Disparities in Hospitalizations for African-American Patients in Academic Primary Care

BACKGROUND

There are many interventions to facilitate seamless continuity of care for patients in transition from hospital back to primary care; however, disparities remain in readmission rates for vulnerable populations, especially African-Americans.

OBJECTIVES

We set out to investigate the association of race and ethnicity with 30-day readmission in our urban academic setting and to identify factors that could be leveraged in primary care to address disparities in hospitalizations.

METHODS/APPROACH

Using data originally collected for quality improvement purposes, we evaluated 30-day readmission rates for our primary care patients (January 1, 2013-September 30, 2014) by race and ethnicity, adjusting for demographic and clinical characteristics. Then, using inductive and deductive methods, we coded semi-structured interviews with 24 African-American primary care patients who were discharged from the Medicine or Cardiology service at our tertiary care hospital during the study period.

KEY RESULTS

African-Americans had the highest readmission rate (21.7%) and a higher adjusted odds of readmission (1.37; 95% CI 1.04-1.81) compared to Whites. Five major themes emerged as having potential to be leveraged in primary care to help prevent multiple hospitalizations: (1) dependable patient-physician relationships, (2) healthcare coordination across settings, (3) continuity with one primary care provider (PCP), (4) disease self-management, and (5) trust in resident physicians. Participants also made several recommendations to keep patients like themselves from returning to the hospital: increased time to tell their story during their primary care visit, more direct patient-physician communication during the visit, and improved access between visits.

CONCLUSIONS

While African-American patients in our practice experience higher rates of hospital readmissions than their White counterparts, they emphasize the significance of their PCP relationship and communication to enhance disease management and prevent hospitalizations. Ongoing efforts are needed to establish and implement best practice communication trainings for patients at increased risk of hospitalization, particularly for resident physicians.

Disparities in Quality of Primary Care by Resident and Staff Physicians: Is There a Conflict Between Training and Equity?

BACKGROUND

Outpatient primary care experience is vital to internal medicine resident training but may impact quality and equity of care delivered in practices that include resident physicians. Understanding whether quality differences exist among resident and staff primary care physicians (PCPs) may present an opportunity to address health disparities within academic medical centers.

OBJECTIVE

To determine whether there are differences in the quality of primary care provided by resident PCPs compared to staff PCPs.

DESIGN

A retrospective cohort study with a propensity-matched analysis.

PARTICIPANTS

143,274 patients, including 10,870 patients managed by resident PCPs, seen in 16 primary care practices affiliated with an academic medical center.

MAIN MEASURES

Guideline-concordant chronic disease management of diabetes (HbA1c, LDL) and coronary artery disease (LDL), preventive breast, cervical, and colorectal cancer screening, and resource utilization measures including emergency department (ED) visits, hospitalizations, high-cost imaging, and patient-reported health experience.

KEY RESULTS

At baseline, there were significant differences in sociodemographic and clinical characteristics between resident and staff physician patients. Resident patients were less likely to achieve chronic disease and preventive cancer screening outcome measures including LDL at goal (adjusted OR [aOR] 0.77 [95% CI 0.65, 0.92]) for patients with coronary artery disease; HbA1c at goal (aOR 0.73 [95% CI 0.62, 0.85]) for patients with diabetes; breast (aOR 0.56 [95% CI 0.49, 0.63]), cervical (aOR 0.66 [95% CI 0.60, 0.74]), and colorectal (aOR 0.72 [95% CI 0.65, 0.79] cancer screening. Additionally, resident patients had higher rates of ED visits and hospitalizations but lower rates of high-cost imaging. Resident patients reported lower rates of satisfaction with certain access to care and communication measures. Similar outcomes were noted in propensity-matched sensitivity analyses.

CONCLUSION

After controlling for differences in sociodemographic and clinical factors, resident patients were less likely to achieve chronic disease and preventive cancer screening outcomes compared to staff patients. Further efforts to address ambulatory trainee education and primary care quality along with novel approaches to the management of the disproportionately disadvantaged resident patient panels are needed.

An evolutionary view of patient experience in primary care: A concept analysis

AIM

This concept analysis explores "patient experience" in the context of primary care.

BACKGROUND

In the 21st century, person-centered care became the manner to address the healthcare quality needs of the United States. This study led to using measures of patient experience as an evaluation of patient-centered care.

DESIGN

Concept analysis.

DATA SOURCES

CINAHL, Cochrane Review, PUBMED Central, PsycINFO, Web of Science, and Scopus were queried using "patient experience" and "primary care." All peer-reviewed US-based articles were included from January 2000 to October 2017 (n = 59).

REVIEW METHODS

Rodgers' evolutionary view of concept analysis guided this inquiry.

RESULTS

Patient experience is any process discernible by patients, including subjective experiences, objective experiences, and observations of provider or staff behavior. Patient experience reports are mediated and moderated by many variables and reflect care experiences that directly measure patient-centeredness from the patient's viewpoint. Consequences of patient experience may lead to adherence to shared plans of care, patient engagement, and appropriate use of healthcare services.

CONCLUSION

Conceptual clarity of patient experience adds to the understanding of how patients experience healthcare quality. If healthcare aspires to deliver patient-centered care, understanding quality from the viewpoint of the patient is essential.

Developing a Virtual Teach-To-Goal™ Inhaler Technique Learning Module: A Mixed Methods Approach

BACKGROUND

Most hospitalized patients with asthma or chronic obstructive pulmonary disease misuse respiratory inhalers. An in-person educational strategy, teach-to-goal (TTG), improves inpatients' inhaler technique.

OBJECTIVE

To develop an effective, portable education intervention that remains accessible to hospitalized patients postdischarge for reinforcement of proper inhaler technique.

METHODS

A mixed methods approach at an urban academic hospital was used to iteratively develop, modify, and test a virtual teach-to-goal™ (V-TTG™) educational intervention using patient end-user feedback. A survey examined access and willingness to use technology for self-management education. Focus groups evaluated patients' feedback on access, functionality, and quality of V-TTG™.

RESULTS

Forty-eight participants completed the survey, with most reporting having Internet access; 77% used the Internet at home and 82% used the Internet at least once every few weeks. More than 80% reported that they were somewhat or very likely to use V-TTG™ to gain skills to improve their health. Most participants reported smartphone access (73%); half owned laptop computers (52%). Participants with asthma versus chronic obstructive pulmonary disease were more likely to own a smartphone, have a data plan, and have daily Internet use (P < .05). Nine focus groups (n = 25) identified themes for each domain: access-platform and delivery, Internet access, and technological literacy; functionality-usefulness, content, and teaching strategy; and quality-clarity, ease of use, length, and likability.

CONCLUSIONS

V-TTG™ is a promising educational tool for improving patients' inhaler technique, iteratively developed and refined with patient input. Patients in our urban, academic hospital overwhelmingly reported access to platforms and willingness to use V-TTG™ for health education.

Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs

BACKGROUND

While there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern.

OBJECTIVES

The 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country.

DESIGN

Nationwide survey.

PARTICIPANTS

All internal medicine program directors registered with APDIM.

MAIN MEASURES

Descriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs.

KEY RESULTS

Of the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year-End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff.

CONCLUSIONS

Most internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.

Alternative Scheduling Models: Improving Continuity of Care, Medical Outcomes, and Graduate Medical Education in Resident Ambulatory Training

An association has been consistently made about continuity of care with improved quality of care and improved medical outcomes. However, resident ambulatory block scheduling prevents the optimization of continuity of care in ambulatory clinical education. The author performed a PubMed search for studies examining continuity of care and curriculum scheduling in US primary care residency clinics. These studies indicate the success of an X + Y scheduling model in resident ambulatory training. Additional benefits have also been noted, including improved clinical teaching and learning, increased sense of teamwork, increased resident satisfaction, improved recruitment and retention, improved patient satisfaction, and elimination of year-end patient care issues after graduation. Many allopathic institutions have begun to implement such curricular changes with demonstrated success. The author argues that osteopathic graduate medical education should embrace the X + Y scheduling model.

Year-End Resident Clinic Handoffs: Narrative Review and Recommendations for Improvement

BACKGROUND

Year-end clinic handoffs in resident continuity clinics are an important patient safety issue.

METHODS

Intervention articles addressing the year-end resident clinic handoff were identified in a targeted literature search. These articles were reviewed and abstracted to summarize the current literature. On the basis of these reviews and consensus expert opinion, recommendations to improve year-end clinic handoffs were developed.

RESULTS

Of 23 identified articles, 10 intervention articles in the fields of internal medicine, internal medicine-pediatrics, psychiatry, and family medicine were ultimately included. The additional 13 nonintervention studies were used as background material. There were 12 clinic handoff recommendations for improvement: (1) focus on patients most at risk during the handoff, (2) educate residents, (3) consider balancing caseloads for the residents, (4) prepare patients for the handoff and perform patient-centered outreach, (5) standardize a written method of sign-out and require verbal communication for a subset of patients, (6) use a standardized template or technology solution for the handoff, (7) identify specific tasks that require follow-up, (8) enhance attending supervision during the handoff, (9) make patient assignments clear after the handoff, (10) have patients establish care with the new provider as soon as possible after the handoff, (11) establish care with telephone contact prior to the first visit, (12) perform safety audits to ensure that sign-out occurs, patients receive appointments, no-shows are rescheduled, and task follow-up is completed.

CONCLUSION

There is emerging evidence for interventions to improve year-end resident clinic handoffs, and the recommendations provided are a starting point to guide training programs.

Patient Perceptions of Electronic Medical Record Use by Faculty and Resident Physicians: A Mixed Methods Study

BACKGROUND

While concerns remain regarding Electronic Medical Records (EMR) use impeding doctor-patient communication, resident and faculty patient perspectives post-widespread EMR adoption remain largely unexplored.

OBJECTIVE

We aimed to describe patient perspectives of outpatient resident and faculty EMR use and identify positive and negative EMR use examples to promote optimal utilization.

DESIGN

This was a prospective mixed-methods study.

PARTICIPANTS

Internal medicine faculty and resident patients at the University of Chicago's primary care clinic participated in the study.

APPROACH

In 2013, one year after EMR implementation, telephone interviews were conducted with patients using open-ended and Likert style questions to elicit positive and negative perceptions of EMR use by physicians. Interview transcripts were analyzed qualitatively to develop a coding classification. Satisfaction with physician EMR use was examined using bivariate statistics.

RESULTS

In total, 108 interviews were completed and analyzed. Two major themes were noted: (1) Clinical Functions of EMR and (2) Communication Functions of EMR; as well as six subthemes: (1a) Clinical Care (i.e., clinical efficiency), (1b) Documentation (i.e., proper record keeping and access), (1c) Information Access, (1d) Educational Resource, (2a) Patient Engagement and (2b) Physical Focus (i.e., body positioning). Overall, 85 % (979/1154) of patient perceptions of EMR use were positive, with the majority within the "Clinical Care" subtheme (n = 218). Of negative perceptions, 66 % (115/175) related to the "Communication Functions" theme, and the majority of those related to the "Physical Focus" subtheme (n = 71). The majority of patients (90 %, 95/106) were satisfied with physician EMR use: 59 % (63/107) reported the computer had a positive effect on their relationship and only 7 % (8/108) reported the EMR made it harder to talk with their doctors.

CONCLUSIONS

Despite concerns regarding EMRs impeding doctor-patient communication, patients reported largely positive perceptions of the EMR with many patients reporting high levels of satisfaction. Future work should focus on improving doctors "physical focus" when using the EMR to redirect towards the patient.

"Ms. B changes doctors": using a comic and patient transition packet to engineer patient-oriented clinic handoffs (EPOCH)

BACKGROUND

Few patient-centered interventions exist to improve year-end residency clinic handoffs.

AIM

Our purpose was to assess the impact of a patient-centered transition packet and comic on clinic handoff outcomes.

SETTING

The study was conducted at an academic medicine residency clinic.

PARTICIPANTS

Participants were patients undergoing resident clinic handoff 2011-2013 PROGRAM DESCRIPTION: Two months before the 2012 handoff, patients received a "transition packet" incorporating patient-identified solutions (i.e., a new primary care provider (PCP) welcome letter with photo, certificate of recognition, and visit preparation tool). In 2013, a comic was incorporated to stress the importance of follow-up.

PROGRAM EVALUATION

Patients were interviewed by phone with response rates of 32 % in 2011, 43 % in 2012 and 36 % in 2013. Most patients who were interviewed were aware of the handoff post-packet (95 %). With the comic, more patients recalled receiving the packet (44 % 2012 vs. 64 % 2013, p< 0.001) and correctly identified their new PCP (77 % 2012 vs. 98 % 2013, p< 0.001). Among patients recalling the packet, most (70 % 2012; 65 % 2013) agreed it helped them establish rapport. Both years, fewer patients missed their first new PCP visit (43 % in 2011, 31 % in 2012 and 26 % in 2013, p< 0.001).

DISCUSSION

A patient-centered transition packet helped prepare patients for clinic handoffs. The comic was associated with increased packet recall and improved follow-up rates.

Inpatient-outpatient transitions for patients with resident primary care physicians: access and readmission

BACKGROUND

Transition from hospitalization to postdischarge care is a vulnerable period for patients. How the experience of this transition differs for patients with resident primary care physicians is unknown.

METHODS

In a single, large academic primary care practice, we examined an inception cohort of consecutive hospitalizations and postdischarge visits of hospitalized patients with resident or faculty primary care physicians between 2008 and 2013. We compared patient demographics, readmission risk, and access to outpatient care between resident and faculty primary care physicians by using generalized estimating equations to account for repeated hospitalizations.

RESULTS

We documented 8161 hospitalizations among patients with resident primary care physicians and 20,844 hospitalizations among patients with faculty primary care physicians. Hospitalized patients with resident primary care physicians were generally younger, more likely to be on Medicaid, and more likely to be African American (P < .001). Patients with resident primary care physicians were less likely to be seen within 7 and 30 days of discharge (adjusted relative risk, 0.83; 95% confidence interval [CI], 0.81-0.93 at 7 days; adjusted relative risk, 0.88; 95% CI, 0.85-0.92 at 30 days) and had an increased risk of readmission within 30 days (adjusted odds ratio, 1.25; 95% CI, 1.13-1.37). They also were considerably less likely to see their own provider at first follow-up (relative risk, 0.55; 95% CI, 0.52-0.59).

CONCLUSIONS

Hospitalized patients with resident primary care physicians had lower rates of timely postdischarge follow-up, higher rates of readmission, and a lower likelihood of seeing their own provider than did patients with faculty primary care physicians. These findings highlight the challenges facing academic centers for patients with resident primary care physicians.