A Review of Continuous Quality Improvement Processes at Ten Medical Schools.

The Liaison Committee on Medical Education now expects all allopathic medical schools to develop and adhere to a documentable continuous quality improvement (CQI) process. Medical schools must consider how to establish a defensible process that monitors compliance with accreditation standards between site visits. The purpose of this descriptive study is to detail how ten schools in the Association of American Medical Colleges' (AAMC) Southern Group on Educational Affairs (SGEA) CQI Special Interest Group (SIG) are tackling practical issues of CQI development including establishing a CQI office, designating faculty and staff, charging a CQI committee, choosing software for data management, if schools are choosing formalized CQI models, and other considerations. The information presented is not meant to certify that any way is the correct way to manage CQI, but simply present some schools' models. Future research should include defining commonalities of CQI models as well as seeking differences. Furthermore, what are components of CQI models that may affect accreditation compliance negatively? Are there "worst practices" to avoid? What LCME elements are most commonly identified for CQI, and what are the successes and struggles for addressing those elements? What are identifiable challenges relating to use of standard spreadsheet software and engaging information technology for support? How can students be more engaged and involved in the CQI process? Finally, how do these major shifts to a formalized CQI process impact the educational experience?

Swollen toes.

A 15-month-old black male was brought to the pediatric emergency department by his grandmother because she was concerned about his 2 swollen big toes. The patient's grandmother said that the swelling began 36 hours prior and that her grandson's big toes had continued to increase in size. She denied trauma, bites, or unusual exposures and said that although her grandson had been fussier than usual that day, he was eating and drinking normally and had normal urine output. What is your diagnosis? How would you treat this patient?

Training family medicine residents in HIV primary care: a national survey of program directors.

BACKGROUND AND OBJECTIVES: As the number of people living with HIV steadily increases, severe shortages in the HIV provider workforce in the United States are projected. With an increased emphasis on HIV education during residency, family physicians could play a major role in meeting this need. METHODS: A nationwide survey of family medicine residency program directors (PDs) was conducted to determine their attitudes toward training residents in HIV care. RESULTS: Of 440, 224 (51%) PDs responded to the electronic survey. Teaching HIV care was a high priority for 20% of PDs. Twenty percent of PDs reported residents in their program were providing care to at least five HIV-infected patients. Twenty-five percent of PDs felt that their graduates had the skills to be HIV care providers. Fewer than 25% of PDs reported having a formal HIV curriculum or faculty with adequate HIV expertise. The most favored approaches to strengthen the HIV curriculum by PDs were: (1) a half-day mini-course (30%) and (2) developing a faculty member's expertise in HIV care (17%). A total of 79% of directors saw a need to modify their existing curriculum. CONCLUSIONS: Despite growing numbers of HIV-infected patients, only 25% of family medicine PDs felt that their graduates were adequately trained in HIV primary care, and most saw a need to modify their HIV curricula. Family medicine residency training programs have an important opportunity to develop residency curricula and increase faculty competence to train the next generation of clinicians in HIV care.

STFM's National Clerkship Curriculum: CERA reveals impact, clerkship director needs.

BACKGROUND AND OBJECTIVES: Consistency is needed in family medicine clerkships nationwide. The Society of Teachers of Family Medicine's (STFM) National Clerkship Curriculum (NCC) and supporting NCC website have been developed to address this need. A survey was used to measure these tools' effect and guide future improvements. METHODS: The Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) 2012 survey of clerkship directors (CD) was used to answer two research questions: (1) To what extent are clerkships teaching the minimum core curriculum? and (2) What resources do clerkship directors identify as important in their role? RESULTS: The survey response rate was 66% (88/134). Ninety-two percent of these CDs are aware of the NCC, 74% report having visited the NCC website, and 71% plan to visit it more than once per year in the future. A total of 21.6% strongly agree that their clerkship content matches the NCC. CDs rate the quality of materials on the website as high and place greatest value on materials that can be downloaded and adapted to their clerkships. CONCLUSIONS: STFM's NCC website and materials are familiar to CDs although only one in five state their clerkship curriculum matches the NCC minimum core curriculum. The NCC editorial board needs to better understand why so few teach curriculum that closely matches the minimum core. Continued outreach to CDs can answer this question and improve our ability to support CDs as they incorporate the NCC into family medicine clerkships.

Shots by STFM: value of immunization software to family medicine residency directors: a CERA study.

BACKGROUND AND OBJECTIVES: The Group on Immunization Education (GIE) of the Society of Teachers of Family Medicine (STFM) has developed Shots by STFM immunization software, which is available free of charge for a variety of platforms. It is routinely updated with the Center for Disease Control and Prevention's (CDC's) most recent immunization schedules. Successful development and marketing of teaching resources requires periodic evaluation of their use and value to their target audience. This study was undertaken to evaluate the 2011 version of Shots by STFM. METHODS: Family medicine residency directors were surveyed about their use of Shots by STFM for teaching residents and their ratings of its features. RESULTS: The response rate for the survey was 38% (172/452). While awareness of Shots by STFM among responding residency directors was low (57%), ratings by those using the resource were excellent. Thirty percent of respondents recommend or require their residents to use Shots by STFM. CONCLUSIONS: Better marketing of Shots by STFM to family medicine residency directors seems to be indicated.

Health and turnover of working mothers after childbirth via the work-family interface: an analysis across time.

This study examined organizational levers that impact work-family experiences, participant health, and subsequent turnover. Using a sample of 179 women returning to full-time work 4 months after childbirth, we examined the associations of 3 job resources (job security, skill discretion, and schedule control) with work-to-family enrichment and the associations of 2 job demands (psychological requirements and nonstandard work schedules) with work-to-family conflict. Further, we considered subsequent impact of work-to-family conflict and enrichment on women's health (physical and mental health) 8 months after women returned to work and the impact of health on voluntary turnover 12 months after women returned to work. Having a nonstandard work schedule was directly and positively related to conflict, whereas schedule control buffered the effect of psychological requirements on conflict. Skill discretion and job security, both job resources, directly and positively related to enrichment. Work-to-family conflict was negatively related to both physical and mental health, but work-to-family enrichment positively predicted only physical health. Physical health and mental health both negatively influenced turnover. We discuss implications and opportunities for future research.

Maternal depressive symptomatology: 16-month follow-up of infant and maternal health-related quality of life.

PURPOSE: The purpose of this study was to document risk factors for depressive symptoms during the postpartum period among working mothers and to determine longitudinal effects of depressive symptoms on maternal health-related quality of life and infant health and development. METHODS: Mother-infant dyads from a community-based cohort study of working mothers were recruited when infants were 4 months old and were interviewed every 4 months until infants were 16 months old. Depressive symptoms and health-related quality of life were assessed using the Center for Epidemiologic Studies Depression Scale and the Short Form-12 Health Survey, respectively. Infant development and health-related quality of life were measured with the Ages and Stages Questionnaire and the Infant-Toddler Quality of Life Questionnaire, respectively. RESULTS: Depressive symptoms were elevated among mothers who were younger, less educated, African American, unmarried, and impoverished. Mothers with significant depressive symptoms had significantly poorer physical and mental health-related quality of life, reported greater pain for their infant, and had more health-related concerns about their child. Maternal depressive symptoms at 4 months predicted infant poorer health-related quality of life at 8, 12, and 16 months. CONCLUSIONS: Several characteristics, including age, education level, race, marital status, and poverty, can help primary care physicians identify working mothers at risk for depressive symptoms. Identification of these symptoms is important; they are correlated with poorer maternal health-related quality of life and they predict poorer children's health-related quality of life.

Return to work, economic hardship, and women's postpartum health.

This study followed a sample of 217 new mothers in a North Carolina county as they returned to work full-time, measuring their mental and physical health-related quality of life through 16 months postpartum. In general, working mothers of infants had mental health scores that were comparable to the general population of U.S. women, and physical health that was slightly better than women in general. Using ANCOVA and controlling for important demographic characteristics, health-related quality of life was compared between mothers experiencing low and high levels of economic hardship. Across the study period, women with high economic hardship, who constituted 30.7% of the sample, had levels of mental and physical health below those of women with low economic hardship. Mothers with high economic hardship also had less stable health trajectories than mothers with low economic hardship. The findings highlight the importance of reconsidering the traditionally accepted postpartum recovery period of six weeks and extending benefits, such as paid maternity and sick leave, as well as stable yet flexible work schedules.

Clinical inquiries. What is the best approach to benign paroxysmal positional vertigo in the elderly?

A canalith repositioning maneuver (CRM), such as the Epley or Semont maneuver, should be the first-line treatment for benign paroxysmal positional vertigo (BPPV) in the elderly. Following the Epley maneuver with self-treatment at home using a modified Epley procedure improves outcomes. Postural restrictions are not necessary after CRM treatment. Medications do not work as well as a CRM, but studies comparing treatments are limited.

Individual and job-related variation in infant feeding practices among working mothers.

OBJECTIVE: To document working mothers' infant feeding practices and delineate factors that may shape infant feeding. METHODS: Cross-sectional data were obtained from a community sample of working women with 8-month old infants (n=199). RESULTS: Nearly all working mothers used commercially prepared foods like infant cereals, fruits, and vegetables. Approximately one-fifth fed infants french fries, sweetened beverages, and sweetened desserts. Unhealthy infant feeding was elevated among unmarried mothers, those with less education, and those with a nonstandard work schedule. CONCLUSIONS: Working mothers use commercially prepared foods for infant feeding. Socially disadvantaged working mothers' infant feeding may pose health and developmental risks.

Characteristics of mother-provider interactions surrounding postpartum return to work.

BACKGROUND: Many mothers with infants work full-time, yet little is known about communication between women and health care providers regarding returning to work (RTW). METHODS: Survey data were obtained from a community-based sample of mothers returning to full-time employment within 4 months postpartum. Bivariate analyses (chi(2) and independent sample t tests) and multivariate logistic regressions were specified. RESULTS: Eighty-three percent of mothers believed prenatal providers should discuss RTW, yet only 60% had such a discussion; 58% discussed RTW with their infants' provider. Black women (odds ratio, 2.6) and women in poverty (odds ratio, 3.6) more often reported having an RTW discussion with a prenatal provider whereas mothers with college degrees or higher (odds ratio, 2.7) more often had RTW discussions with their infant's provider. RTW discussions occurred < or =3 times and were felt to be only somewhat useful. RTW discussions infrequently centered on maternal health (19.5%) or infant health or development (35.5%). CONCLUSIONS: Women want providers to initiate RTW discussions. Providers should be aware that race, poverty status, and level of maternal education impact a mother's odds of having an RTW discussion. Additional research is required to further delineate the content of RTW discussions and to determine the clinical value of RTW discussions.

Impact of a multifaceted intervention on cholesterol management in primary care practices: guideline adherence for heart health randomized trial.

BACKGROUND: Physician adherence to National Cholesterol Education Program clinical practice guidelines has been poor. METHODS: We recruited 68 primary care family and internal medicine practices; 66 were randomly allocated to a study arm; 5 practices withdrew, resulting in 29 receiving the Third Adult Treatment Panel (ATP III) intervention and 32 receiving an alternative intervention focused on the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7). The ATP III providers received a personal digital assistant providing the Framingham risk scores and ATP III-recommended treatment. All practices received copies of each clinical practice guideline, an introductory lecture, 1 performance feedback report, and 4 visits for intervention-specific academic detailing. Data were abstracted at 61 practices from random samples of medical records of patients treated from June 1, 2001, through May 31, 2003 (baseline), and from May 1, 2004, through April 30, 2006 (follow-up). The proportion screened with subsequent appropriate decision making (primary outcome) was calculated. Generalized estimating equations were used to compare results by arm, accounting for clustering of patients within practices. RESULTS: We examined 5057 baseline and 3821 follow-up medical records. The screening rate for lipid levels increased from 43.6% to 49.0% (ATP III practices) and from 40.1% to 50.8% (control practices) (net difference, -5.3% [P = .22]). Appropriate management of lipid levels decreased slightly (73.4% to 72.3%) in ATP III practices and more markedly (79.7% to 68.9%) in control practices. The net change in appropriate management favored the intervention (+9.7%; 95% confidence interval [CI], 2.8%-16.6% [P < .01]). Appropriate drug prescription within 4 months decreased in both arms (38.8% to 24.8% in ATP III practices and 45.3% to 24.1% in control practices; net change, +7.2% [P = .37]) Overtreatment declined from 6.6% to 3.9% in ATP III and rose from 4.2% to 6.4% in control practices (net change, -4.9% [P = .01]). CONCLUSIONS: A multifactor intervention including personal digital assistant-based decision support may improve primary care physician adherence to the ATP III guidelines. Trial Registration clinicaltrials.gov Identifier: NCT00224848.

A multifaceted intervention to improve blood pressure control: The Guideline Adherence for Heart Health (GLAD) study.

BACKGROUND: Although high blood pressure is associated with significant morbidity and mortality, the proportion reaching the goal blood pressures as outlined in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, Treatment of High Blood Pressure (JNC 7) is low. We conducted a randomized trial in primary care practices of a multifactorial intervention targeted to improve providers' adherence to hypertension guidelines. METHOD: A total of 61 primary care practices in North Carolina were randomized to receive either a multifactorial intervention (guideline dissemination via a continuing medical education session, academic detailing sessions, audit and feedback on preintervention rates of adherence, and automated blood pressure machines) or an attention control of similar magnitude but targeted at a different guideline. Outcomes were determined through review of patient charts conducted by an independent masked quality assurance organization. RESULTS: We found no difference between the 2 groups in any of the adherence measures including no difference in the percentage of patients at goal (intervention 49.2%, control 50.6%), with undiagnosed hypertension (18.1% vs 13.6%), average systolic (126 vs 125.1 mm Hg), or diastolic blood pressure (73.1 vs 73.4 mm Hg). Similarly, there was no difference in provider adherence to treatment recommendations (use of thiazide-type diuretic as first-line therapy: 32% vs 29.5%; use of 2-drug therapy in stage 2 hypertension: 11.3% vs 10.4%). CONCLUSION: An intensive, multifactorial intervention did not improve adherence to national hypertension guidelines among community-based primary care. Efforts should be focused on other types of interventions to improve rates of control of hypertension.

The impact of patient participation on physicians' information provision during a primary care medical interview.

This study investigated the impact of patients' participation on physicians' information provision during a primary care medical interview. When communicating with high-participation patients, physicians provided significantly more information overall, more information in response to patients' questions, and volunteered more information than when interacting with low-participation patients. The most significant differences with respect to volunteered information involved communication about treatment and tests or procedures. These results were interpreted to suggest that high-participation patients' communication style promotes better alignment of patients' and physicians' goals and agendas. Overall, the results suggest that patients' style of participation during a medical interview significantly influenced the extent and type of information physicians provided. Given that patients' biggest complaint about physicians often is a lack of desired information, this study has important implications for physician-patient communication.

Value of recruitment strategies used in a primary care practice-based trial.

PURPOSE: "Physicians-recruiting-physicians" is the preferred recruitment approach for practice-based research. However, yields are variable; and the approach can be costly and lead to biased, unrepresentative samples. We sought to explore the potential efficiency of alternative methods. METHODS: We conducted a retrospective analysis of the yield and cost of 10 recruitment strategies used to recruit primary care practices to a randomized trial to improve cardiovascular disease risk factor management. We measured response and recruitment yields and the resources used to estimate the value of each strategy. Providers at recruited practices were surveyed about motivation for participation. RESULTS: Response to 6 opt-in marketing strategies was 0.40% (53/13290), ranging from 0% to 2.86% by strategy; 33.96% (18/53) of responders were recruited to the study. Of those recruited from opt-out strategies, 8.68% joined the study, ranging from 5.35% to 41.67% per strategy. A strategy that combined both opt-in and opt-out approaches resulted in a 51.14% (90/176) response and a 10.80% (19/90) recruitment rate. Cost of recruitment was $613 per recruited practice. Recruitment approaches based on in-person meetings (41.67%), previous relationships (33.33%), and borrowing an Area Health Education Center's established networks (10.80%), yielded the most recruited practices per effort and were most cost efficient. Individual providers who chose to participate were motivated by interest in improving their clinical practice (80.5%); contributing to CVD primary prevention (54.4%); and invigorating their practice with new ideas (42.1%). CONCLUSIONS: This analysis provides suggestions for future recruitment efforts and research. Translational studies with limited funds could consider multi-modal recruitment approaches including in-person presentations to practice groups and exploitation of previous relationships, which require the providers to opt-out, and interactive opt-in approaches which rely on borrowed networks. These approaches can be supplemented with non-relationship-based opt-out strategies such as cold calls strategically targeted to underrepresented provider groups.