Integration of Clinical Pharmacists in Family Medicine Residency Programs.

BACKGROUND AND OBJECTIVES: Clinical pharmacists are valued educators and practitioners within family medicine residency programs (FMRPs). Since the last survey of clinical pharmacists within FMRPs, there have been significant advancements to pharmacy education and training as well as growth of interprofessional education and collaborative practice within family medicine. The objective of this study is to describe the integration of clinical pharmacists within FMRPs. METHODS: All 480 Accreditation Council for Graduate Medical Education (ACGME)-approved FMRPs were contacted to identify clinical pharmacists involved with their programs. An electronic survey was distributed to these 253 pharmacists. Questions addressed educational, clinical, scholarly, and administrative activities. RESULTS: Of 396 FMRPs reached, 208 (52.5%) reported 253 clinical pharmacists within their programs. Survey responses were received from 142 (56.1%) pharmacists. Academic appointments in colleges/schools of pharmacy and medicine were held by 105 (75.5%) and 69 (50.0%) respondents, respectively. Eighty-nine (64.0%) pharmacists reported a single source of salary, 19.1% of which received full support from the FMRP. Clinical pharmacists dedicated an average of 50.4% of their overall time to the FMRP, and 14.5% of pharmacists dedicated all of their time to the FMRP. Time within the FMRP was spent on patient care (52.9%), teaching (31.6%), research/scholarship (7.5%), administrative activities (5.9%), and drug dispensing (0.7%). DISCUSSION: Prevalence of clinical pharmacists within FMRPs has increased since 2000, from 27.9% to 52.5%. However, the amount of time dedicated to the FMRPs has decreased. This shift from teaching to a more clinical role may reflect both a growth of patient-centered, interprofessional care and a needed mechanism to assist funding these positions.

Comparison of Alcohol Use Disorder Screens During College Athlete Pre-Participation Evaluations.

BACKGROUND AND OBJECTIVES: The US Preventive Services Task Force (USPSTF) recommends screening adults for alcohol misuse, a challenge among young adults who may not have regular primary care. The pre-participation evaluation (PPE) provides an opportunity for screening, but traditional screening tools require extra time in an already busy visit. The objective of this study was to compare the 10-item Alcohol Use Disorders Identification Test (AUDIT) with a single-question alcohol misuse screen in a population of college-aged athletes. METHODS: This cross-sectional study was performed during an athletic PPE clinic at a college in the Southeastern United States among athletes ages 18 years and older. Written AUDIT and single-question screen "How many times in the past year have you had X or more drinks in a day?" (five for men, four for women) asked orally were administered to each participant. Sensitivity, specificity, and positive and negative predictive values for the single-question screen were compared to AUDIT. RESULTS: A total of 225 athletes were screened; 60% were female; 29% screened positive by AUDIT; 59% positive by single-question instrument. Males were more likely to screen positive by both methods. Compared to the AUDIT, the brief single-question screen had 92% sensitivity for alcohol misuse and 55% specificity. The negative predictive value of the single-question screen was 95% compared to AUDIT. CONCLUSIONS: A single-question screen for alcohol misuse in college-aged athletes had a high sensitivity and negative predictive value compared to the more extensive AUDIT screen. Ease of administration of this screening tool is ideal for use within the pre-participation physical among college-aged athletes who may not seek regular medical care.

Clinical Pharmacists as Educators in Family Medicine Residency Programs: A CERA Study of Program Directors.

BACKGROUND AND OBJECTIVES: The clinical pharmacist's role within family medicine residency programs (FMRPs) is well established. However, there is limited information regarding perceptions of program directors (PDs) about clinical pharmacy educators. The study objectives were (1) to estimate the prevalence of clinical pharmacists within FMRPs and (2) to determine barriers and motivations for incorporation of clinical pharmacists as educators. METHODS: The Council of Academic Family Medicine Educational Research Alliance (CERA) distributed an electronic survey to PDs. Questions addressed formalized pharmacotherapy education, clinical pharmacists in educator roles, and barriers and benefits of clinical pharmacists in FMRPs. RESULTS: The overall response rate was 50% (224/451). Seventy-six percent (170/224) of the responding PDs reported that clinical pharmacists provide pharmacotherapy education in their FMRPs, and 57% (97/170) consider clinical pharmacists as faculty members. In programs with clinical pharmacists, 72% (83/116) of PDs reported having a systematic approach for teaching pharmacotherapy versus 22% (21/95) in programs without. In programs without clinical pharmacists, the top barrier to incorporation was limited ability to bill for clinical services 48% (43/89) versus 29% (32/112) in programs with clinical pharmacists. In both programs with and without clinical pharmacists, the top benefit of having clinical pharmacists was providing a collaborative approach to pharmacotherapy education for residents (35% and 36%, respectively). CONCLUSIONS: Less than half of FMRPs incorporate clinical pharmacists as faculty members. Despite providing collaborative approaches to pharmacotherapy education, their limited ability to bill for services is a major barrier.

Cost and Utilization: Hospitalized Patients on a Family Medicine Service.

OBJECTIVES: The cost of hospitalizations contributes to the rising expense of medical care in the United States. Providing health insurance to uninsured Americans is a strategy to reduce these costs, but only if costs for uninsured patients are disproportionately high. This study examined hospitalization use patterns for uninsured patients compared with those with Medicaid and commercial insurance. METHODS: We performed a retrospective chart review to analyze inpatient admissions to a family medicine teaching service in a 290-bed, for-profit community hospital during a 2-year period based on insurance status of the patient. Outcome variables investigated were length of stay, emergency department visits, and readmission rates to the hospital and/or emergency department. Secondary outcome variables were mean charges. RESULTS: A total of 1102 admissions to a family medicine teaching service were evaluated. Length of stay, readmission rates to the hospital and the emergency department after hospital discharge, and average length of stay compared with diagnosis-related groups were significantly higher in the Medicaid population than for insured and uninsured individuals. Variable costs also were significantly higher. CONCLUSIONS: Insurance status was found to be a significant factor in hospital charges and utilization data, with Medicaid patients having the highest costs. This suggests that moving uninsured patients to Medicaid may not significantly reduce hospitalization costs.

Discrepancies in cardiovascular disease risk calculation affect aspirin use recommendations in patients with diabetes.

OBJECTIVES: Aspirin is recommended for cardiovascular disease (CVD) prevention in patients who are at high risk for CVD. The objective of this study was to compare agreement between two American Diabetes Association-endorsed CVD risk calculators in identifying candidates for aspirin therapy. METHODS: Adult patients with diabetes mellitus (n = 238) were studied for 1 year in a family medicine clinic. Risk scores were calculated based on the United Kingdom Prospective Diabetes Study Risk Engine and the Atherosclerosis Risk in Communities Coronary Heart Disease Risk Calculator. Analyses included χ(2), κ scores, and logistic regressions. RESULTS: The Atherosclerosis Risk in Communities Coronary Heart Disease Risk Calculator identified 50.4% of patients as high risk versus 23.5% by the United Kingdom Prospective Diabetes Study Risk Engine. κ score for agreement identifying high-risk status was 0.3642. Among patients at high risk, African Americans (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.24-0.86) and those with uncontrolled diabetes (OR 0.30, 95% CI 0.16-0.56) had lower odds of disagreement, whereas nonsmokers had higher odds (OR 2.98, 95% CI 1.57-5.69). Among patients at low risk, women (OR 3.83, 95% CI 1.64-8.91), African Americans (OR 5.96, 95% CI 3.07-11.59), and those with high high-density lipoprotein (OR 2.82, 95% CI 1.48-5.37) showed greater odds of disagreement. CONCLUSIONS: Improved risk assessment methods are needed to identify patients with diabetes mellitus who benefit from aspirin for the primary prevention of CVD. Prospective trials are needed to provide additional evidence for aspirin use in this population.

Education in quality improvement for practice in primary care during residency training and subsequent activities in practice.

BACKGROUND: Quality improvement (QI) is an integral aspect of graduate medical education and an important competence for physicians. OBJECTIVE: We examined the QI activities of recent family medicine residency graduates and whether a standardized curriculum in QI during residency resulted in greater self-reported participation in QI activities in practice after graduation. METHODS: The family medicine residency programs affiliated with the South Carolina Area Health Education Consortium (N  =  7) were invited to participate in this study. Following completion of introductory educational activities, each site implemented regularly occurring (at least monthly) educational and patient care activities using QI principles and tools. Semiannually, representatives from each participating site met to review project aims and to provide updates regarding the QI activities in their program. To examine the impact of this project on QI activities, we surveyed graduates from participating programs from the year prior to and 2 years after the implementation of the curriculum. RESULTS: Graduates in the preimplementation and postimplementation cohorts reported participating in periodic patient care data review, patient care registries, QI projects, and disease-specific activities (57%-71% and 54%-63%, respectively). There were no significant differences in QI activities between the 2 groups except in activities associated with status of their practice as a patient-centered medical home. CONCLUSIONS: Most but not all family medicine graduates reported they were actively involved in QI activities within their practices, independent of their exposure to a QI curriculum during training.

Satisfaction, early removal, and side effects associated with long-acting reversible contraception.

BACKGROUND AND OBJECTIVES: Although intrauterine devices (IUDs) and subdermal implants (SDI) are recommended as first-line contraception for the majority of women by the American College of Obstetrics and Gynecology, these methods of long-acting reversible contraception (LARC) are underutilized. Some concerns regarding their use include cost of placement, side effects, and perception of frequent early removal. This study evaluated satisfaction with LARC, frequency, and reasons behind early removal in a family medicine setting. METHODS: Women > 18 years seen for placement of removal of an IUD or SDI were identified from billing data and surveyed via telephone to determine satisfaction and side effects with LARC. Additional demographic information was extracted from the electronic health record. RESULTS: Of the 132 respondents (response rate 61.4%), 58.3% had IUDs and 41.7% had SDIs placed. Early removal occurred in 24.2% of women, and 72.7% were satisfied with their contraceptive choice. Younger and nulliparous women were more likely to have an SDI placed, whereas older and multiparous women chose the IUD. Younger nulliparous women were less likely to have LARC removed early. Pain (more commonly reported with the IUD) and increased frequency in bleeding (more commonly reported with the SDI) were associated with early removal rates. CONCLUSIONS: Most women who received LARC were satisfied with their contraceptive choice, and only one in four had the LARC removed early. This is significantly better than continuation rates with other contraceptive methods. Younger, nulliparous women were good candidates for LARC, continuing their use more than older, multiparous women. Improved counseling regarding pain and changes in menstrual bleeding patterns may impact early removal of IUDs and SDIs, respectively.

On track for success: an innovative behavioral science curriculum model.

This article describes the behavioral science curriculum currently in place at the Trident/MUSC Family Medicine Residency Program. The Trident/MUSC Program is a 10-10-10 community-based, university-affiliated program in Charleston, South Carolina. Over the years, the Trident/MUSC residency program has graduated over 400 Family Medicine physicians. The current behavioral science curriculum consists of both required core elements (didactic lectures, clinical observation, Balint groups, and Resident Grand Rounds) as well as optional elements (longitudinal patient care experiences, elective rotations, behavioral science editorial experience, and scholars project with a behavioral science focus). All Trident/MUSC residents complete core behavioral science curriculum elements and are free to participate in none, some, or all of the optional behavioral science curriculum elements. This flexibility allows resident physicians to tailor the educational program in a manner to meet individual educational needs. The behavioral science curriculum is based upon faculty interpretation of existing "best practice" guidelines (Residency Review Committee-Family Medicine and AAFP). This article provides sufficient curriculum detail to allow the interested reader the opportunity to adapt elements of the behavioral science curriculum to other residency training programs. While this behavioral science track system is currently in an early stage of implementation, the article discusses track advantages as well as future plans to evaluate various aspects of this innovative educational approach.

Recent family medicine residency graduates' perceptions of resident duty hour restrictions.

BACKGROUND: Resident duty hour limits, new requirements for supervision, and an enhanced focus on patient safety have shown mixed effects on resident quality of life, patient safety, and resident competency. Few studies have assessed how recent graduates feel these changes have affected their education. OBJECTIVE: We assessed recent graduates' perceptions about the effects of duty hour and supervision requirements on their education. METHODS: We conducted a cross-sectional survey of graduates from South Carolina Area Health Education Consortium-affiliated family medicine residency programs from 2005 to 2009 by using logistic regression to determine associations between participant characteristics and survey responses. RESULTS: Graduates (N  =  136) completed the survey with a 51.3% response rate. Nearly all (96%) reported that residency prepared them for their current work hours; 97% reported they felt adequately supervised; 81% worked fewer hours in practice than in residency; 20% believed the limits had restricted their clinical experience; and 3% felt duty hour limits were more important than supervision. Graduates who practiced in a mid-sized communities were more likely to report duty hour limits restricted their clinical experience than individuals practicing in communities of <10 000 (OR  =  6.30; 95% CI, 1.38-28.72). CONCLUSIONS: Most graduates who responded to the survey felt supervision was equally or more important than limits on resident duty hours. However, 20% of respondents felt that the duty hour standards limited their education. The duty hour and supervision requirements challenge educators to ensure quality education.

Preparation for practice in family medicine: before and after duty hours.

BACKGROUND AND OBJECTIVES: In July of 2003, the Accreditation Council for Graduate Medical Education (ACGME) adopted requirements limiting the duty hours of resident physicians. The impact of these restrictions on education and patient care activities is not clear. The purpose of this study is to examine the perception of graduates of family medicine residency programs immediately prior to and following implementation of duty hours regarding preparedness to practice and board certification status, as well as current patient care activities. METHODS: Surveys of graduates of family medicine residency programs in South Carolina were conducted. Preparation for practice and professional activities of program graduates prior to (1999--2003) and following (2005--2009) implementation of duty hours were compared. RESULTS: Response rates were 54.4% and 53.1%, respectively. No significant differences by survey years in the average age, gender, or race was noted. Recent graduates felt as well prepared for practice in most curricular areas except surgery (OR=0.50 [0.27, 0.91]) and performed similar procedures with the following exceptions: central line placement (OR=0.32 [0.11, 0.95]), flexible sigmoidoscopy (OR=0.12 [0.02, 0.80]), ICU care (OR=0.39 [0.22, 0.70]), and ventilator management (OR=0.54 [0.29, 0.99]). Higher proportion of recent graduates do not take after hours call (22.3% versus 8.6%). Similarly, fewer recent graduates care for patients in nursing homes (22.0% versus 44.9%) and hospitals (46.2% versus 68.0%). CONCLUSIONS: Implementation of resident duty hours appears to have little overall association with self-reported preparedness for practice. An association was noted in the patient care services and procedures performed.

Clinician knowledge about use of intrauterine devices in adolescents in South Carolina AHEC.

BACKGROUND AND OBJECTIVES: Intrauterine devices (IUDs) are recommended as first-line choices for both nulliparous and parous adolescents by the American College of Obstetrics and Gynecology (ACOG). This study describes use of IUDs and knowledge regarding IUD use in adolescents in South Carolina family medicine residency programs. METHODS: Faculty and residents in South Carolina Area Health Education Consortium (SC AHEC) Family Medicine Residency Programs received an anonymous survey including questions about current use of IUDs and scenarios where they were asked whether they would recommend an IUD. Proportions were compared using chi-square or Fisher's Exact Test. Modified Wald method was utilized to calculate 95% confidence intervals. RESULTS: The survey response rate was 53.8% (n=133). Most respondents (78%) prescribed IUDs and 42% inserted them, but ≥ 90% reported only prescribing or inserting ≤ 10 yearly. In scenarios where IUD recommendation was appropriate, only 27% (95% CI: 20.2-35.2) recommended IUDs for a sexually active adolescent, whereas 60% (95% CI: 51.7-68.1) recommended use for a postpartum adolescent. For similar scenarios in non-adolescents, a statistically significant higher proportion recommended IUDs, with 50% (95% CI: 42.0-58.7) recommending use in a 21-year-old nulliparous woman and 77% (95% CI: 68.8-83.1) in a breast-feeding mother. Women were more likely to recommend IUD use than men in non-adolescents, but not adolescents. There was no difference in recommendations by level of training. CONCLUSIONS: Knowledge regarding IUD use in nulliparous women and adolescents is limited in this sample of family physicians. Increasing appropriate IUD recommendations may increase IUD use and improve contraceptive counseling for adolescents.

Addressing the Scholarly Activity Requirements for Residents: One Program's Solution.

BACKGROUND: Scholarly activity as a component of residency education is becoming increasingly emphasized by the Accreditation Council for Graduate Medical Education. "Limited or no evidence of resident or faculty scholarly activity" is a common citation given to family medicine residency programs by the Review Committee for Family Medicine. OBJECTIVE: The objective was to provide a model scholarly activity curriculum that has been successful in improving the quality of graduate medical education in a family medicine residency program, as evidenced by a record of resident academic presentations and publications. METHODS: We provide a description of the Clinical Scholars Program that has been implemented into the curriculum of the Trident/Medical University of South Carolina Family Medicine Residency Program. RESULTS: During the most recent 10-year academic period (2000-2010), a total of 111 residents completed training and participated in the Clinical Scholars Program. This program has produced more than 24 presentations during national and international meetings of medical societies and 15 publications in peer-reviewed medical journals. In addition, many of the projects have been presented during meetings of state and regional medical organizations. CONCLUSIONS: This paper presents a model curriculum for teaching about scholarship to family medicine residents. The success of this program is evidenced by the numerous presentations and publications by participating residents.

Measuring diabetes care in the national interdisciplinary primary care practice-based research network (NIPC-PBRN).

STUDY OBJECTIVE: To assess diabetes care in a network of primary care practices that include pharmacist support by using a scoring system designed for the National Committee for Quality Assurance (NCQA) Diabetes Recognition Program (DRP) measures. DESIGN: Retrospective medical record review. DATA SOURCE: Subset of the National Interdisciplinary Primary Care Practice-Based Research Network (NIPC-PBRN). PATIENTS: A total of 1309 adults who were seen at 17 practices for an outpatient diabetes mellitus visit between January 1 and June 30, 2008. MEASUREMENTS AND MAIN RESULTS: Patient demographic data and NCQA DRP process and outcome measures (hemoglobin A(1c) [A1C], blood pressure, and low-density lipoprotein cholesterol [LDL] level measurements; eye and foot examinations; nephropathy assessment; and smoking status and cessation advice or treatment) were recorded. Points for each measure were compiled, and practices achieving a sufficient score for NCQA recognition (≥ 75.0 points) were identified. Pharmacists were also surveyed regarding their services, participation in quality improvement initiatives, use of electronic medical records, and methods of data extraction. The relationships between DRP measures and quality improvement activities, pharmacist involvement in diabetes care, and use of electronic medical records were analyzed. The DRP outcome measures were satisfactory: mean ± SD A1C 7.6% ± 1.9%, LDL level 99.1 ± 35.1 mg/dl, and systolic and diastolic blood pressures 130.2 ± 18.1 and 74.4 ± 10.8 mm Hg, respectively. Five practices (29%) achieved a sufficient score for NCQA recognition. No significant relationships were noted between DRP measures and participation in quality improvement, type of clinical pharmacy services, or use of electronic medical records (p>0.05). In a regression analysis, only electronic medical record use was significantly related to DRP measures (p=0.02). CONCLUSION: Diabetes care in the NIPC-PBRN appears satisfactory, but improvements are necessary if NCQA recognition is the goal. Use of electronic medical records was associated with better DRP measures.

Dizziness: a diagnostic approach.

Dizziness accounts for an estimated 5 percent of primary care clinic visits. The patient history can generally classify dizziness into one of four categories: vertigo, disequilibrium, presyncope, or lightheadedness. The main causes of vertigo are benign paroxysmal positional vertigo, Meniere disease, vestibular neuritis, and labyrinthitis. Many medications can cause presyncope, and regimens should be assessed in patients with this type of dizziness. Parkinson disease and diabetic neuropathy should be considered with the diagnosis of disequilibrium. Psychiatric disorders, such as depression, anxiety, and hyperventilation syndrome, can cause vague lightheadedness. The differential diagnosis of dizziness can be narrowed with easy-to-perform physical examination tests, including evaluation for nystagmus, the Dix-Hallpike maneuver, and orthostatic blood pressure testing. Laboratory testing and radiography play little role in diagnosis. A final diagnosis is not obtained in about 20 percent of cases. Treatment of vertigo includes the Epley maneuver (canalith repositioning) and vestibular rehabilitation for benign paroxysmal positional vertigo, intratympanic dexamethasone or gentamicin for Meniere disease, and steroids for vestibular neuritis. Orthostatic hypotension that causes presyncope can be treated with alpha agonists, mineralocorticoids, or lifestyle changes. Disequilibrium and lightheadedness can be alleviated by treating the underlying cause.

Promoting resident scholarship through a statewide symposium.

BACKGROUND AND OBJECTIVES: Literature on integration and assessment of a research curriculum into family medicine residency training programs is limited. The objectives of this paper are to describe the development, implementation, and evaluation of a state-wide resident scholarship symposium. METHODS: In 2003, the South Carolina Area Health Education Consortium (SC AHEC) and residency program directors developed an annual resident scholarship symposium. Abstracts are submitted in the categories of case presentation, quality improvement, or clinical research. Subsequently, two half days are devoted to residents' presentation of their research, which is evaluated by a panel of three judges, and awards are given in each category. RESULTS: A total of 238 residents have presented 176 research projects. Fifteen projects have been presented during the Annual Spring Conference of the Society of Teachers of Family Medicine (STFM), seven projects have been presented during the Annual Meeting of the North American Primary Care Research Group (NAPCRG), and nine projects have been published in peer-reviewed journals. Resident evaluations have rated the conference overall as good to outstanding. CONCLUSIONS: A state-wide symposium has provided family medicine residents an opportunity to present their scholarly works to a larger audience and is associated with resident projects that have been presented or published on a national level.

Comparison of chronic systolic heart failure guideline adherence for two ambulatory clinics / Comparación del cumplimiento de las guías para fallo cardíaco crónico sistólico en dos clínicas ambulatorias

Guidelines have been published for management of chronic systolic heart failure to reduce patient morbidity and mortality. Objective: A quality review of the heart failure medical therapy for a community family medicine residency program clinic and a multidisciplinary heart failure specialty clinic was performed to compare adherence to ACC/AHA heart failure guidelines, with regard to medications and in titrating to recommended target doses. Methods: The study was a retrospective chart review and data collected included name and dose of any ACEI, beta-blocker, ARB, or other medication addressed in the guidelines. Results: Specialty clinic patients had significantly lower systolic blood pressures and ejection fractions. Significantly more patients were prescribed beta-blockers in the specialty clinic population (98% vs 80%, p<0.05). Both patient populations had very low rates of reaching target beta-blocker doses (15% vs 21%, p=0.27). More patients in the family medicine clinic reached target doses of ACEI (64% vs 49%, p<0.05) and ARBs (67% vs 35%, p<0.05). Conclusions: This study revealed the vast majority of patients in either a community family medicine residency program or heart failure specialty clinic were prescribed ACEI or ARB, and beta-blockers. However, achieving target doses should continue to be an important goal for practitioners (AU)

Se han publicado guías para el manejo del fallo cardiaco sistólico crónico para reducir la morbilidad y mortalidad de los pacientes. Objetivo: Se realizó una revisión de la calidad del tratamiento del fallo cardíaco en un programa de residencia en una clínica de medicina familiar y en una clínica multidisciplinaria especializada en fallo cardiaco para comparar el cumplimiento de las guías de fallo cardiaco ACC/AHA en relación a la medicación y en la reducción de dosis hacia las dosis recomendadas. Métodos: El estudio fue una revisión retrospectiva de historiales y una recogida de datos que incluyó nombre y dosis de cualquier IECA, betabloqueante, ARA u otra medicación mencionada en las guías. Resultados: La clínica especializada tuvo presiones sistólicas y fracciones de eyección significativamente más bajas. Se prescribió betabloqueantes significativamente a más pacientes en la clínica especializada (98% vs 80%, p<0.05). Ambos grupos de pacientes tuvieron tasa muy bajas de alcanzar los valores objetivo de dosis de betabloqueantes (15% vs 21%, p=0.27). Más pacientes en la clínica de medicina familiar alcanzaron las dosis objetivo de IECA (64% vs 49%, p<0.05) y ARA (67% vs 35%, p<0.05). Conclusiones: Este estudio revela que la gran mayoría de pacientes, tanto en un programa de medicina familiar y comunitaria como en una clínica especializada en fallo cardiaco tenían prescritos IECA o ARA y betabloquenates. Sin embargo, alcanzar las dosis objetivo debería continuar a ser una meta para los facultativos (AU)

Comparison of chronic systolic heart failure guideline adherence for two ambulatory clinics.

UNLABELLED: Guidelines have been published for management of chronic systolic heart failure to reduce patient morbidity and mortality. OBJECTIVE: A quality review of the heart failure medical therapy for a community family medicine residency program clinic and a multidisciplinary heart failure specialty clinic was performed to compare adherence to ACC/AHA heart failure guidelines, with regard to medications and in titrating to recommended target doses. METHODS: The study was a retrospective chart review and data collected included name and dose of any ACEI, beta-blocker, ARB, or other medication addressed in the guidelines. RESULTS: Specialty clinic patients had significantly lower systolic blood pressures and ejection fractions. Significantly more patients were prescribed beta-blockers in the specialty clinic population (98% vs 80%, p<0.05). Both patient populations had very low rates of reaching target beta-blocker doses (15% vs 21%, p=0.27). More patients in the family medicine clinic reached target doses of ACEI (64% vs 49%, p<0.05) and ARBs (67% vs 35%, p<0.05). CONCLUSIONS: This study revealed the vast majority of patients in either a community family medicine residency program or heart failure specialty clinic were prescribed ACEI or ARB, and beta-blockers. However, achieving target doses should continue to be an important goal for practitioners.

Teaching quality improvement in a primary care residency.

BACKGROUND: Several organizations emphasize that medical education should include how to improve patient outcomes effectively using quality improvement (QI) methods. In spite of the importance of teaching QI principles, limited literature exists on the implementation and evaluation of these in residency programs. METHODS: The Clinical Scholars Program was established in 1996 to provide residents an opportunity to participate in a scholarly activity. The program, fully integrated into a community-based, university-affiliated family medicine residency program, is currently structured as a longitudinal educational experience, with specific time lines in which all second- and third-year residents are required to participate in and successfully complete a project before graduation. Factors influencing project success are also presented. RESULTS: During the five-year period evaluated, 61 residents completed 53 Scholars projects, 39.6% of which were QI projects. Residents have delivered 86 local presentations, 50 state presentations, 11 national presentations, and 8 international presentations. Nine resident projects have been published in peer-reviewed journals. Factors associated with successful interventions include focus on a topic relevant and common in primary care practice, change in the system of patient care (for example, use of group visits, providing patient education directly to the patient prior to his or her visit), use of the electronic medical record to provide relevant clinical information during office visits, and interdisciplinary team participation in the project. CONCLUSION: This program is an example of the successful integration of scholarly activity and QI education into a residency program. It serves as a potential model for other residency programs to meet the needs of residency training and to promote QI and research in primary care practices.

Pharmacotherapy for the obese patient.

The long-term safety of many antiobesity pharmacologic regimens has not been adequately evaluated. If recommended and prescribed, pharmacologic agents should be an adjunct to a structured diet and exercise regimen. Unfortunately, weight gain after discontinuation of antiobesity agents is common. In addition, the effect of weight loss obtained through the use of pharmacotherapeutic agents on overall morbidity and mortality has not been established.

A limited effect on performance indicators from resident-initiated chart audits and clinical guideline education.

BACKGROUND AND OBJECTIVES: Clinical practice guidelines are useful as tools to reduce variation and improve clinical outcomes in performance-improvement initiatives. The aim of this study is to examine, in a family medicine residency practice, the effect of incorporating education about clinical practice guidelines for specific medical conditions and services on specific quality of care indicators. METHODS: An educational intervention regarding the implementation of clinical practice guidelines and the use of quality indicators for selected disease states or medical services was developed and implemented into a family medicine residency program. Residents completed a review of the records of selected patients who either were affected by the selected medical condition or were eligible for the medical service being provided, before and after participating in a specific seminar addressing guidelines addressing that condition. RESULTS: Based upon the comparison between the chart reviews, some quality indicators significantly improved following the presentations (ie, documentation of oral examination in children and in patients with chronic illnesses, attempts to decrease medications in patients with anxiety disorders, compliance with measuring HgbA1C in patients with diabetes mellitus), while others did not. CONCLUSIONS: The effect of an organized approach through presentation and chart review of specific quality indicators regarding medical problems frequently encountered in family medicine had a modest and inconsistent effect on the practice behaviors of family medicine residents.