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Connolly MJ, Weppner WG, Fortuna RJ, Snyder ED. Continuity and Health Outcomes in Resident Clinics: A Scoping Review of the Literature. Cureus 2022; 14:e25167. [PMID: 35747006 PMCID: PMC9206854 DOI: 10.7759/cureus.25167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 11/23/2022] Open
Abstract
Continuity of care is an essential component of primary care, resulting in improved satisfaction, management of chronic conditions, and adherence to screening recommendations. The impact of continuity of care in teaching practices remains unclear. We performed a scoping review of the literature to understand the impact of continuity on patients and trainees in teaching practices. A systematic search was performed through PubMed to identify articles published prior to January 2020 addressing continuity of care and health outcomes in resident primary care clinic settings. A total of 543 abstracts were evaluated by paired independent reviewers. In total, 24 articles met the inclusion criteria and were abstracted by four authors. These articles included a total of 6,973 residents (median = 96, range = 9-5,000) and over 1,000,000 patients (median = 428, range = 70-1,000,000). Most publications demonstrated that higher continuity was associated with better diabetic care (71%, n = five of seven), receipt of preventive care per guidelines (60%, n = three of five), and lower costs or administrative burden of care (100%, n = three of three). A smaller proportion of publications reported a positive association between continuity and hypertension control (28%, n = two of seven). The majority of publications evaluating patient/resident satisfaction demonstrated that better continuity was associated with higher patient (67%, n = four of six) and resident (67%, n = six of nine) satisfaction. A review of the existing literature revealed that higher continuity of care in resident primary care clinics was associated with better patient health outcomes and patient/resident satisfaction. Interventions to improve continuity in training settings are needed.
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Walker J, Payne B, Clemans-Taylor BL, Snyder ED. Continuity of Care in Resident Outpatient Clinics: A Scoping Review of the Literature. J Grad Med Educ 2018; 10:16-25. [PMID: 29467968 PMCID: PMC5821030 DOI: 10.4300/jgme-d-17-00256.1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/27/2017] [Accepted: 10/30/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Continuity between patients and physicians is a core principle of primary care and an accreditation requirement. Resident continuity clinics face challenges in nurturing continuity for their patients and trainees. OBJECTIVE We undertook a scoping review of the literature to better understand published benchmarks for resident continuity; the effectiveness of interventions to improve continuity; and the impact of continuity on resident and patient satisfaction, patient outcomes, and resident career choice. METHODS We developed a MEDLINE search strategy to identify articles that defined continuity in residency programs in internal medicine, family medicine, and pediatrics published prior to December 31, 2015, and used a quality evaluation tool to assess included studies. RESULTS The review includes 34 articles describing 12 different measures of continuity. The usual provider of care and continuity for physician formulas were most commonly utilized, and mean baseline continuity was 56 and 55, respectively (out of a total possible score of 100). Clinic and residency program redesign innovations (eg, advanced access scheduling, team-based care, and block scheduling) were studied and had mixed impact on continuity. Continuity in resident clinics is lower than published continuity rates for independently practicing physicians. CONCLUSIONS Interventions to enhance continuity in resident clinics have mixed effects. More research is needed to understand how changes in continuity affect resident and patient satisfaction, patient outcomes, and resident career choice. A major challenge to research in this area is the lack of empanelment of residents' patients, creating difficulties in scheduling and measuring continuity visits.
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Mullins TLK, Widdice LE, Rosenthal SL, Zimet GD, Kahn JA. Risk perceptions, sexual attitudes, and sexual behavior after HPV vaccination in 11-12 year-old girls. Vaccine 2015; 33:3907-12. [PMID: 26116249 DOI: 10.1016/j.vaccine.2015.06.060] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/11/2015] [Accepted: 06/12/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Among 11-12 year-old girls who received the human papillomavirus (HPV) vaccine, we explored, over the subsequent 30 months: (1) trajectories of knowledge about HPV/HPV vaccines and vaccine-related risk perceptions; (2) whether knowledge and risk perceptions impacted sexual attitudes and sexual experience; (3) whether mothers, clinicians, and media influenced girls' risk perceptions, attitudes, and behavior. METHODS Girls and mothers (n=25dyads) completed separate, semi-structured interviews within 2 days of, and 6, 18, and 30 months after, their first HPV vaccine dose. Knowledge, risk perceptions related to HPV and other sexually transmitted infections (STIs), and attitudes about sexual behaviors were assessed. Sexual experience was assessed at girls' 30 month interviews. Clinicians completed interviews at baseline. Transcribed interviews were analyzed using framework analysis. RESULTS Girls' baseline knowledge was poor but often improved with time. Most girls (n=18) developed accurate risk perceptions about HPV but only half (n=12) developed accurate risk perceptions about other STIs by 30 months. The vast majority of girls thought that safer sex was still important, regardless of knowledge, risk perceptions, or sexual experience. Girls whose HPV knowledge was high at baseline or increased over time tended to articulate accurate risk perceptions; those who were able to articulate accurate risk perceptions tended to report not having initiated sexual activity. Girls whose mothers demonstrated higher knowledge and/or communication about HPV vaccination tended to articulate accurate risk perceptions, whereas clinicians and media exposure did not appear to influence risk perceptions. CONCLUSIONS Higher knowledge about HPV vaccines among mothers and girls was linked with more accurate risk perceptions among girls. Clinicians may play an important role in providing education about HPV vaccines to mothers and girls.
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Affiliation(s)
- Tanya L Kowalczyk Mullins
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, MLC 4000, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 3235 Eden Avenue, P.O. Box 670555, Cincinnati, OH 45267, USA.
| | - Lea E Widdice
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, MLC 4000, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 3235 Eden Avenue, P.O. Box 670555, Cincinnati, OH 45267, USA
| | - Susan L Rosenthal
- Departments of Pediatrics and Psychiatry, Columbia University and New York Presbyterian Morgan Stanley Children's Hospital, 622 West 168 Street, Vanderbilt Clinic 4th Floor, Room 402, New York, NY 10032, USA
| | - Gregory D Zimet
- Division of Adolescent Medicine, Indiana University, 410 West 10th Street, HS 1001, Indianapolis, IN 46202, USA
| | - Jessica A Kahn
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, MLC 4000, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 3235 Eden Avenue, P.O. Box 670555, Cincinnati, OH 45267, USA
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Litofsky NS, Farooqui A, Tanaka T, Norregaard T. Use of the Electronic Health Record to Track Continuity of Care in Neurological Surgery Residency. J Grad Med Educ 2014; 6:507-11. [PMID: 26279776 PMCID: PMC4535215 DOI: 10.4300/jgme-d-13-00294.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 01/13/2014] [Accepted: 04/21/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Continuity of care in neurological surgery includes preoperative planning, technical and cognitive operative experience, and postoperative follow-up. Determining the extent of continuity of care with duty hour limits is problematic. OBJECTIVE We used electronic health record data to track continuity of care in a neurological surgery program and to assess changes in rotation requirements. METHODS The electronic health record was surveyed for all dictated resident-neurological surgery patient encounters (excluding progress notes), discharge summaries, and bedside procedures (July 2009-November 2011). Encounters were designated as preoperative, operative, or postoperative and were grouped by postgraduate year (PGY)-1 through PGY-6. RESULTS A total of 6382 dictations were reviewed, with 5231 (82.0%) pertinent to neurological surgery. Of the 1469 operative notes, 303 (20.6%) had a record of an encounter with the operating resident in either a postoperative or preoperative setting. Preoperative encounters totaled 10.1% (148 of 1469); postoperative, 5.1% (75 of 1469); and encounters with both were 5.4% (80 of 1469). Continuity of care was as follows: PGY-1, 13.8% (4 of 29); PGY-2, 17.4% (26 of 149); PGY-3, 29.0% (36 of 124); PGY-4, 24.8% (73 of 294); PGY-5, 28.8% (109 of 379); and PGY-6, 11.1% (55 of 494). One of the highest continuity rates was observed in a rotation specifically constructed to enhance continuity of care. CONCLUSIONS The electronic health record can be used to track resident continuity of care in neurological surgery. The primary operating resident saw the patient in nonoperative settings, such as general admission, clinic visitation, or consultation in 20.6% (303 of 1469) of cases.
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Mullins TLK, Griffioen AM, Glynn S, Zimet GD, Rosenthal SL, Fortenberry JD, Kahn JA. Human papillomavirus vaccine communication: perspectives of 11-12 year-old girls, mothers, and clinicians. Vaccine 2013; 31:4894-901. [PMID: 23916986 DOI: 10.1016/j.vaccine.2013.07.033] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 07/08/2013] [Accepted: 07/16/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Because little is known about the content of human papillomavirus (HPV) vaccine-related discussions with young adolescent girls in clinical settings, we explored communication between 11- and 12 year-old girls, mothers, and clinicians regarding HPV vaccines and concordance in reports of maternal and clinician communication. METHODS We conducted individual interviews with 33 girls who had received the quadrivalent HPV vaccine in urban and suburban clinical settings, their mothers, and their clinicians. Data were analyzed using qualitative methods. RESULTS From the perspectives of both girls and mothers, clinicians and parents were the preferred sources of HPV vaccine information for girls. Vaccine efficacy and risks/benefits of vaccination were the most commonly reported desired and actual topics of discussion by mothers, girls, and clinicians. Clinician recommendation of vaccination was reported by nearly one-fifth of girls and nearly half of mothers. The most common concordant messages were related to efficacy of the vaccine, with concordance in 70% of triads. The most common discordant messages were related to sexual health. Approximately half of clinicians (16) reported discussing sexual health, but only 5 mothers (15%) and 4 girls (12%) reported this. Triads recruited from suburban (vs. urban) practices had higher degrees of concordance in reported vaccination communication. CONCLUSIONS HPV vaccine efficacy and safety are important topics for clinicians to discuss with both girls and mothers; educating mothers is important because parents are a preferred source of vaccine-related information for girls. Because girls may be missing important vaccine-related messages, they should be encouraged to actively engage in vaccine discussions.
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Affiliation(s)
- Tanya L Kowalczyk Mullins
- Division of Adolescent Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 4000, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 3235 Eden Avenue, CARE/Crawley Building Suite E-870, Cincinnati, OH 45267, USA.
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Philibert I, Nasca T, Brigham T, Shapiro J. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Annu Rev Med 2012; 64:467-83. [PMID: 23121182 DOI: 10.1146/annurev-med-120711-135717] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Long hours are an accepted component of resident education, yet data suggest they contribute to fatigue that may compromise patient safety. A systematic review confirms that limiting duty hours increases residents' hours of sleep and improves objective measures of alertness. Most studies of operative experience for surgical residents found no effect, and there is evidence of a limited positive effect on residents' mood. We find a mixed effect on patient safety, although problems with supervision, rather than the limits, may be responsible or contibute; evidence of reduced continuity of care and reduced continuity in residents' clinical education; and evidence that increased workload under the limits has a negative effect on patient and resident outcomes. We highlight specific areas for research and offer recommendations for national policy.
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Affiliation(s)
- Ingrid Philibert
- Accreditation Council for Graduate Medical Education, Chicago, Illinois 60654, USA.
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Augustine S, Lawrence RH, Raghavendra P, Watts B. Benefits and costs of pay for performance as perceived by residents: a qualitative study. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2010; 85:1888-1896. [PMID: 20978422 DOI: 10.1097/acm.0b013e3181fa7aec] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
PURPOSE To describe and interpret pay-for-performance (P4P) systems as perceived by internal medicine residents to develop curricula that relate P4P measures to quality improvement initiatives. METHOD In 2008-2009, the authors conducted a qualitative study in which 97 internal medicine residents completed a mandatory survey soliciting their views of the advantages and disadvantages of P4P. The authors analyzed responses to identify and categorize emergent themes. RESULTS Eighty-two residents (85%) noted advantages, from which 13 themes emerged. Two were general themes: P4P improves overall delivery of quality care by enabling quality care and by motivating providers to improve or provide quality care. The other themes formed three categories: P4P enables contemplation and knowledge enhancement (e.g., by promoting reflection) and has potential impacts both on physicians' delivery of better care (e.g., by facilitating vigilance and closer follow-up) and on the care delivery process (e.g., by increasing pay/satisfaction). Eighty-seven residents (90%) indicated disadvantages, from which 16 themes emerged. The four categories of the themes reflected P4P's impacts on patient perceptions (e.g., by decreasing patient satisfaction and access), on clinical care (e.g., by fostering abuse/gaming and compromising focus, care, and safety), on resources and efficiency, and on providers that may undermine morale. CONCLUSIONS Residents' reported advantages and disadvantages were often in direct opposition to each other (e.g., P4P enables quality care but also compromises focus, care, and safety). These opposing responses form a continuum that the authors believe will require providers to perform a balancing act to practice successfully in a P4P environment.
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Affiliation(s)
- Sarah Augustine
- Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio 44106, USA.
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Rodriguez H, Turner JP, Speicher P, Daskin MS, Darosa D. A model for evaluating resident education with a focus on continuity of care and educational quality. JOURNAL OF SURGICAL EDUCATION 2010; 67:352-358. [PMID: 21156291 DOI: 10.1016/j.jsurg.2010.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 06/09/2010] [Accepted: 09/13/2010] [Indexed: 05/30/2023]
Affiliation(s)
- Heron Rodriguez
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Lerner CF, Chung PJ. Continuity of care in fixed-day versus variable-day resident continuity clinics. Acad Pediatr 2010; 10:119-23. [PMID: 20206910 DOI: 10.1016/j.acap.2009.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 11/03/2009] [Accepted: 11/13/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Since the introduction of resident work-hour standards, pediatric residency programs have struggled to preserve robust continuity clinic experiences. Many programs have resorted to more flexible approaches to resident scheduling. We know little regarding the impact of such changes. We compared 2 continuity clinic scheduling models: a traditional fixed-day clinic and a variable-day clinic in which resident clinic days vary each week to accommodate resident schedules. METHODS The setting for our study was a large university resident continuity clinic. We analyzed 111 resident schedules and 1113 visits by children aged younger than 1 year during 2 periods: July 2007 to December 2007, when residents were scheduled by using a variable-day clinic model, and July 2008 to December 2008, when a fixed-day model was used. We compared the number of clinic sessions per resident and continuity of care. We used the usual provider of care definition of continuity: the proportion of visits in which a patient is seen by his or her primary resident. A multivariable logistic regression was used to model the relationship between patient continuity of care and clinic structure (fixed-day vs variable-day), resident level, patient age, and appointment type. RESULTS The number of clinics per resident during a 6-month period was higher using variable-day scheduling (19.6 vs 16.2; P < .01), whereas continuity of care was lower (0.54 vs 0.61; P = .01) In the multivariate model, continuity of care was significantly higher under the fixed-day model (odds ratio 1.40; P < .01). CONCLUSIONS Scheduling residents for continuity clinic on variable days results in lower patient continuity of care despite increased resident time in clinic.
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Affiliation(s)
- Carlos F Lerner
- David Geffen School of Medicine, University of California, Los Angeles, Calif, USA.
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