Improving Timely Resident Follow-Up and Communication of Results in Ambulatory Clinics Utilizing a Web-Based Audit and Feedback Module

Interventions to improve timely cancer diagnosis: an integrative review

Cancer will affect more than one in three U.S. residents in their lifetime, and although the diagnosis will be made efficiently in most of these cases, roughly one in five patients will experience a delayed or missed diagnosis. In this integrative review, we focus on missed opportunities in the diagnosis of breast, lung, and colorectal cancer in the ambulatory care environment. From a review of 493 publications, we summarize the current evidence regarding the contributing factors to missed or delayed cancer diagnosis in ambulatory care, as well as evidence to support possible strategies for intervention. Cancer diagnoses are made after follow-up of a positive screening test or an incidental finding, or most commonly, by following up and clarifying non-specific initial presentations to primary care. Breakdowns and delays are unacceptably common in each of these pathways, representing failures to follow-up on abnormal test results, incidental findings, non-specific symptoms, or consults. Interventions aimed at 'closing the loop' represent an opportunity to improve the timeliness of cancer diagnosis and reduce the harm from diagnostic errors. Improving patient engagement, using 'safety netting,' and taking advantage of the functionality offered through health information technology are all viable options to address these problems.

Resident Perceptions of Continuity Clinic Patient Metrics Differ From EHR Data: Pilot Use of Population Health Dashboards

BACKGROUND AND OBJECTIVES

Population health management (PHM) dashboards using electronic health record (EHR) data can teach trainees about the population they serve while also delivering data on their clinical practice. Yet, few studies have demonstrated their use. In this pilot study, we assessed baseline resident perceptions of population health metrics for continuity clinic panels by comparing resident estimates with EHR-reported values delivered by individualized PHM dashboards.

METHODS

A descriptive, comparative study was conducted at a primary continuity clinic site for pediatric residents in January 2018. Residents were surveyed about population health metrics for their patient panels, including demographics, utilization, and medical diagnoses. We compared resident estimates to corresponding EHR-reported values using 2-tailed paired t tests.

RESULTS

A total of 42 out of 55 eligible residents (76%) completed the survey. Compared with EHR-reported values, residents estimated higher percentages of emergency department utilization (22.1% vs 10.3%, P < .01) and morbidity, including medical complexity (15.6% vs 5.9%, P < .01), overweight (38.1% vs 11.7%, P < .01), obesity (20.5% vs 15.8%, P = .02), and asthma (34.6% vs 21.4%, P < .01).

CONCLUSIONS

In this pilot study of PHM dashboards, resident perceptions of continuity clinic population health metrics did not align with EHR data. Estimates were higher for measures of utilization and morbidity. PHM dashboards may help trainees better understand their patient populations and serve as a consistent source of objective practice data. However, further research and investment is needed to evaluate dashboard implementation and impact on trainee and patient outcomes.

Introduction of Otolaryngology Outpatient Examination Training Program for junior residents as part of rural regional medical support in Japan

Background

Nagasaki Prefecture is located in the most western part of Japan, and there are a considerable number of clinics in its many remote islands and rural areas. Thus, the Regional Medical Support Center in Nagasaki Prefecture dispatches doctors to rural hospitals to provide medical support. We introduced an outpatient training program at these rural hospitals for all residents to improve their clinical training in the field of otorhinolaryngology, whereby one otolaryngologist trains one resident.

Methods

This otolaryngology outpatient training program is randomly assigned, and conducted for 4-5 days a year, transported by a helicopter in Nagasaki Prefecture, which is a 30-minute one-way trip. We used a case checklist that included the 35 items that should be experienced and are defined as frequent by the Ministry of Health, Labor and Welfare. We also conducted a survey using an anonymous questionnaire.

Results

The survey response rate was 100%. Comparing the experience rate of symptoms between the pre-introduction resident and the post-introduction resident who underwent the otolaryngology outpatient training program, the experience rates of common diseases, including vertigo and otolaryngologic symptoms such as nasal bleeding and hoarseness, significantly increased after the program was introduced (p ≤ .001). Notably, the experience rate of headache, cough/sputum, and vertigo was 100%.

Conclusion

Our training program provides a suitable medical environment for the resident and secures a doctor who can provide secondary medical service support. Furthermore, the program will improve the level of primary care provided by the residents in remote island and rural area hospitals.

No Quick Fixes: Integrating Population Health Education and Quality Improvement in a Large Residency Program

ABSTRACT

The intersection of population health (PH), quality improvement (QI), and health disparities is increasingly a focus in graduate medical education. However, it remains unclear how trainees may best improve disparities within clinical training environments. We integrated PH education for residents participating in a practical QI experience in a continuity clinic serving an underserved population. We analyzed whether PH education increased confidence in creating care plans and implementing team-based care strategies after selection of one of three QI metrics with known health disparities led to improvement. Posteducational session, attendees had odds of confidence in creating care plans 10.0 (95% confidence interval [CI] 4.6-21.7) times the presession period, whereas nonattendees' confidence was unchanged (OR 1.63, 95% CI 0.78-3.4). Residents participating in the QI project did not have higher confidence in creating a care plan at baseline (20% vs. 9.6%, p = .09) nor any additional shift in confidence versus other residents (p = .57). There were no differences in QI metric performance rate trends for residents choosing a specific QI metric versus those that did not (p > .33 for all comparisons). PH didactics can increase resident confidence around PH topics. However, translating such learning into outcomes and improved health equity may require dedicated efforts across residency training.

A Mixed-Methods Program Evaluation of a Self-directed Learning Panel Management Curriculum in an Internal Medicine Residency Clinic

BACKGROUND

Panel management (PM) curricula in internal medicine (IM) residency programs often assign performance measures which may not address the varied interests or needs of resident-learners.

AIM

To evaluate a self-directed learning (SDL)-based PM curriculum.

SETTING

University-based primary care practice in Burlington, Vermont.

PARTICIPANTS

Thirty-five internal medicine residents participated.

PROGRAM DESCRIPTION

Residents completed a PM curriculum that integrated SDL, electronic health record (EHR)-driven performance feedback, mentorship, and autonomy to set learning and patient care goals.

PROGRAM EVALUATION

Pre/post-curricular surveys assessed EHR tool acceptability, weekly curricular surveys and post-curricular focus groups assessed resident perceptions and goals, and an interrupted time series analysis of care gap closure rates was used to compare the pre-intervention and intervention periods. Majority of residents (28-32 or 80-91%) completed the surveys and focus groups. Residents found the EHR tools acceptable and valued protected time, mentorship, and autonomy to set goals. A total of 13,313 patient visits were analyzed. There were no significant differences between rates between the pre-intervention period and the first intervention period (p=0.44).

DISCUSSION

A longitudinal PM curriculum that incorporated SDL and goal setting with EHR-driven performance feedback was well-received by residents, however did not significantly impact the rate of care gap closure.

OUP accepted manuscript

Objectives

(1) Systematically review the literature on computerized audit and feedback (e-A&F) systems in healthcare. (2) Compare features of current systems against e-A&F best practices. (3) Generate hypotheses on how e-A&F systems may impact patient care and outcomes.

Methods

We searched MEDLINE (Ovid), EMBASE (Ovid), and CINAHL (Ebsco) databases to December 31, 2020. Two reviewers independently performed selection, extraction, and quality appraisal (Mixed Methods Appraisal Tool). System features were compared with 18 best practices derived from Clinical Performance Feedback Intervention Theory. We then used realist concepts to generate hypotheses on mechanisms of e-A&F impact. Results are reported in accordance with the PRISMA statement.

Results

Our search yielded 4301 unique articles. We included 88 studies evaluating 65 e-A&F systems, spanning a diverse range of clinical areas, including medical, surgical, general practice, etc. Systems adopted a median of 8 best practices (interquartile range 6–10), with 32 systems providing near real-time feedback data and 20 systems incorporating action planning. High-confidence hypotheses suggested that favorable e-A&F systems prompted specific actions, particularly enabled by timely and role-specific feedback (including patient lists and individual performance data) and embedded action plans, in order to improve system usage, care quality, and patient outcomes.

Conclusions

e-A&F systems continue to be developed for many clinical applications. Yet, several systems still lack basic features recommended by best practice, such as timely feedback and action planning. Systems should focus on actionability, by providing real-time data for feedback that is specific to user roles, with embedded action plans.

Protocol Registration

PROSPERO CRD42016048695.

Signed, Sealed, Delivered: Increasing Patient Notification of Test Results in an Internal Medicine Resident Continuity Clinic

OBJECTIVES

Informing patients of their test results is an important patient safety issue, yet many physicians perform dismally in this regard. Residents often face additional barriers to communicating test results to patients. We wanted to determine whether streamlining the notification process, communicating expectations, and having residents audit their performance would increase result notification rates.

METHODS

We used a quasi-experimental design, and a single-group before-and-after intervention. Our multifold intervention consisted of development and standardization of a notification process in the electronic medical record, an education component, and a self-audit component. During a 15-minute session, we educated residents on the use of the new process. We also restated expectations regarding notifying patients of their results. Residents audited their own charts for a period before the intervention and during a second, postintervention period. An independent review of notification rates took place simultaneously as well as during an additional period several months later.

RESULTS

In total, 87 residents were eligible for participation. All 87 completed the project, giving a 100% participation rate. Resident-reported laboratory test notification rates increased from 16% to 91%; other test result rates increased from 33% to 84%. The three independent reviews showed laboratory test notification rates increased from 18.5% to 71.7% to 87.1%, and notification of other test results increased from 23.5% to 66.7% to 91.7%.

CONCLUSIONS

Baseline rates of notification for diagnostic tests results were low, but streamlining the notification process, clearly stating expectations for using it, and using resident self-audit can improve notification rates.

Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review: BEME Guide No. 56

Background: Clinical teachers often struggle to report unsatisfactory trainee performance, partly because of a lack of evidence-based remediation options. Objectives: To identify interventions for undergraduate (UG) and postgraduate (PG) medical learners experiencing academic difficulties, link them to a theory-based framework and provide literature-based recommendations around their use. Methods: This systematic review searched MEDLINE, CINAHL, EMBASE, ERIC, Education Source and PsycINFO (1990-2016) combining these concepts: medical education, professional competence/difficulty and educational support. Original research/innovation reports describing intervention(s) for UG/PG medical learners with academic difficulties were included. Data extraction employed Michie's Behavior Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraisal used the Mixed Methods Appraisal Tool (MMAT). The authors synthesized extracted evidence by adapting the GRADE approach to formulate recommendations. Results: Sixty-eight articles met the inclusion criteria, most commonly addressing knowledge (66.2%), skills (53.9%) and attitudinal problems (26.2%), or learner personal issues (41.5%). The most common BCTs were Shaping knowledge, Feedback/monitoring, and Repetition/substitution. Quality appraisal was variable (MMAT 0-100%). A thematic content analysis identified 109 interventions (UG: n = 84, PG: n = 58), providing 24 strong, 48 moderate, 26 weak and 11 very weak recommendations. Conclusion: This review provides a repertoire of literature-based interventions for teaching/learning, faculty development, and research purposes.

Continuity Clinic Practice Feedback Curriculum for Residents: A Model for Ambulatory Education

BACKGROUND

There is an unmet need for formal curricula to deliver practice feedback training to residents.

OBJECTIVE

We developed a curriculum to help residents receive and interpret individual practice feedback data and to engage them in quality improvement efforts.

METHODS

We created a framework based on resident attribution, effective metric selection, faculty coaching, peer and site comparisons, and resident-driven goals. The curriculum used electronic health record-generated resident-level data and disease-specific ambulatory didactics to help motivate quality improvement efforts. It was rolled out to 144 internal medicine residents practicing at 1 of 4 primary care clinic sites from July 2016 to June 2017. Resident attitudes and behaviors were tracked with presurveys and postsurveys, completed by 126 (88%) and 85 (59%) residents, respectively. Data log-ins and completion of educational activities were monitored. Group-level performance data were tracked using run charts.

RESULTS

Survey results demonstrated significant improvements on a 5-point Likert scale in residents' self-reported ability to receive (from a mean of 2.0 to 3.3, P < .001) and to interpret and understand (mean of 2.4 to 3.2, P < .001) their practice performance data. There was also an increased likelihood they would report that their practice had seen improvements in patient care (13% versus 35%, P < .001). Run charts demonstrated no change in patient outcome metrics.

CONCLUSIONS

A learner-centered longitudinal curriculum on ambulatory patient panels can help residents develop competency in receiving, interpreting, and effectively applying individualized practice performance data.