The Effectiveness and Flexibility of Practice-Based Teaching: A Long-term, Cross-disciplinary Evaluation.

OBJECTIVES: Schools of public health (SPHs) must train students through real-world situations. Practice-based teaching (PBT) uses immediate application for skill development through multiple modes of delivery including virtual collaborations. PBT provides short-term benefits but is less understood long term. We sought to understand the longer-term impacts of PBT on students, public health agencies, faculty, and SPH administration and determine if the reported benefits of PBT outweigh the challenges. METHODS: We used a mixed-methods pre-post-test evaluation to assess short-term outcomes in spring 2015 and long-term outcomes 3 years later using quantitative and qualitative assessments. The evaluation included 4 PBT courses spanning disciplines in 1 SPH. Participants included students (n = 56), collaborating agencies (n = 9), teaching faculty (n = 7), and SPH administrators (n = 8). RESULTS: Students reported acquisition of competencies, application at follow-up, and being workforce ready (91.0%) with greater appreciation 3 years post-semester (78.6%). Collaborating agencies reported successful implementation of deliverables (77.8%) and enhanced networks (88.7%) with cost savings and better outcomes for the communities served. Faculty recognized beneficial outcomes to students including workforce preparation (71.4%), and administration recognized the benefits and worth of PBT to the school for teaching (100%) and research opportunities (87.5%). CONCLUSIONS: Given the shifting higher education landscape as a result of the pandemic, public health courses are being redesigned to provide opportunities for skill development, regardless of delivery mode, and enhanced connections to the field are essential. PBT is a flexible pedagogy that results in lasting and innovative resources to agencies and prepares public health students with technical skills and professional competencies to be workforce ready.

Innovative Use Of Electronic Consultations In Preoperative Anesthesiology Evaluation At VA Medical Centers In New England.

Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experienced a rapid increase in the use of anesthesiology e-consults: 5,023 were sent in 2015, compared with 103 in 2012. Uptake across sites varied from near-universal use of e-consults for preoperative assessment to use for only selected low-risk patients or no use. Interviews with stakeholders revealed considerable differences in the perceived impact of e-consults on workflow and patient-centeredness. Clinicians at sites with high use of e-consults noted that they improved workflow efficiency. In comparison, clinicians at sites with low use preferentially valued face-to-face visits for some or all patients. The adoption of a health information technology innovation can alter the process of care delivery, depending on perceptions of its value by key stakeholders.

Patient navigation to improve diabetes outpatient care at a safety-net hospital: a retrospective cohort study.

BACKGROUND: Recent emphasis on value based care and population management, such as Accountable Care Organizations in the United States, promote patient navigation to improve the quality of care and reduce costs. Evidence supporting the efficacy of patient navigation for chronic disease care is limited. The objective of this study was to evaluate the effect of a patient navigation program on medical and administrative outcomes among patients with diabetes in an urban, safety-net hospital clinic setting. METHODS: A retrospective cohort study with pre- and post-intervention periods was conducted. Eligible patients were those with A1C ≥ 8.5% and at least one appointment no-show in the previous 12 months. The intervention and reference groups were balanced on observed characteristics and baseline outcome levels using propensity score matching. The effect of patient navigation was isolated using the difference-in-differences approach. Primary outcomes were A1C, low-density lipoprotein cholesterol, triglycerides, random urine microalbumin, the number of scheduled appointments, clinic visits, emergency visits, and inpatient stays, and the percentage of arrivals, cancellations, and no-shows to scheduled appointments. RESULTS: Of 797 eligible patients, 328 entered the navigation program. Matching reduced the sample size to 392 individuals (196 in each group). Patient navigation resulted in improved A1C (-1.1 percentage points; p < .001), more scheduled appointments (+ 5.3 per year; p < .001), more clinic visits (+6.4 per year; p < .001), more arrivals to scheduled appointments (+7.4 percentage points; p = .009) and fewer no-shows (-9.8 percentage points; p < .001). CONCLUSIONS: Navigation was associated with improved glycemic control and better clinic engagement among patients with diabetes. Further research is important to identify what features of navigation in diabetes care are critical to achieving success and to understand navigators' role in other settings.

Electronic Consultations (E-consults): Advancing Infectious Disease Care in a Large Veterans Affairs Healthcare System.

The impact of e-consults on total consultative services was evaluated. After implementing infectious diseases e-consults within an electronically integrated healthcare system, consultation volume increased. As compared with face-to-face consultations, e-consults were more often related to antimicrobial guidance and were requested by off-site providers. E-consults increased the breadth and volume of total consults.

Women's Pathways to Abortion Care in South Carolina: A Qualitative Study of Obstacles and Supports.

CONTEXT: Women seeking timely and affordable abortion care may face myriad challenges, including high out-of-pocket costs, transportation demands, scheduling difficulties and stigma. State-level regulations may exacerbate these burdens and impede women's access to a full range of care. Women's reports of their experiences can inform efforts to improve pathways to abortion care. METHODS: In 2014, semistructured qualitative interviews were conducted with 45 women obtaining abortions in South Carolina, which has a restrictive abortion environment. Interviews elicited information about women's pathways to abortion, including how they learned about and obtained care, whether they received professional referrals, and the supports and obstacles they experienced. Transcripts were examined using thematic analysis to identify key themes along the pathways, and a process map was constructed to depict women's experiences. RESULTS: Twenty participants reported having had contact with a health professional or crisis pregnancy center staff for pregnancy confirmation, and seven of them received an abortion referral. Women located abortion clinics through online searches, previous experience, and friends or family. Financial strain was the most frequently cited obstacle, followed by transportation challenges. Women reported experiencing emotional strain, stress and stigma, and described the value of receiving social support. Because of financial pressures, the regulation with the greatest impact was the one prohibiting most insurance plans from covering abortion care. CONCLUSIONS: Further research on experiences of women seeking abortion services, and how these individuals are affected by evolving state policy environments, will help shape initiatives to support timely, affordable and safe abortion care in a climate of increasing restrictions.

Radiology Residency Quality Improvement Curriculum: Lessons Learned.

Quality improvement (QI) skills in radiology are required as part of the Accreditation Council for Graduate Medical Education Diagnostic Radiology Milestones competencies. Although feasibility of QI curricula has been demonstrated in radiology before, there are still barriers to widespread implementation. Here, we share our experience with designing the curriculum structure and selecting content. We describe the QI projects that have been performed and discuss lessons learned, including successes, challenges, and future directions. This information is relevant for many radiology programs currently planning to implement or revise existing QI curricula.

Disruptive Innovation: Implementation of Electronic Consultations in a Veterans Affairs Health Care System.

BACKGROUND: Electronic consultations (e-consults) offer rapid access to specialist input without the need for a patient visit. E-consult implementation began in 2011 at VA Boston Healthcare System (VABHS). By early 2013, e-consults were available for all clinical services. In this implementation, the requesting clinician selects the desired consultation within the electronic health record (EHR) ordering menu, which creates an electronic form that is pre-populated with patient demographic information and allows free-text entry of the reason for consult. This triggers a message to the requesting clinician and requested specialty, thereby enabling bidirectional clinician-clinician communication. OBJECTIVE: The aim of this study is to examine the utilization of e-consults in a large Veterans Affairs (VA) health care system. METHODS: Data from the electronic health record was used to measure frequency of e-consult use by provider type (physician or nurse practitioner (NP) and/or physician assistant), and by the requesting and responding specialty from January 2012 to December 2013. We conducted chart reviews for a purposive sample of e-consults and semi-structured interviews with a purposive sample of clinicians and hospital leaders to better characterize the process, challenges, and usability of e-consults. RESULTS: A total of 7097 e-consults were identified, 1998 from 2012 and 5099 from 2013. More than one quarter (27.56%, 1956/7097) of the e-consult requests originated from VA facilities in New England other than VABHS and were excluded from subsequent analysis. Within the VABHS e-consults (72.44%, 5141/7097), variability in frequency and use of e-consults across provider types and specialties was found. A total of 64 NPs requested 2407 e-consults (median 12.5, range 1-415). In contrast, 448 physicians (including residents and fellows) requested 2349 e-consults (median 2, range 1-116). More than one third (37.35%, 1920/5141) of e-consults were sent from primary care to specialists. While most e-consults reflected a request for specialist input to a generalist's question in diagnosis or management in the ambulatory setting, we identified creative uses of e-consults, including requests for face-to-face appointments and documentation of pre-operative chart reviews; moreover, 7.00% (360/5141) of the e-consults originated from our sub-acute and chronic care inpatient units. In interviews, requesting providers reported high utility and usability. Specialists recognized the value of e-consults but expressed concerns about additional workload. CONCLUSIONS: The e-consult mechanism is frequently utilized for its initial intended purpose. It has also been adopted for unexpected clinical and administrative uses, developing into a "disruptive innovation" and highlighting existing gaps in mechanisms for provider communication. Further investigation is needed to characterize optimal utilization of e-consults within specialty and the medical center, and what features of the e-consult program, other than volume, represent valid measures of access and quality care.

Together We Learn: Analyzing the Interprofessional Internal Medicine Residents' and Master of Public Health Students' Quality Improvement Education Experience.

Although the value of interprofessional collaborative education has been promoted, it is unclear how teams of clinical and nonclinical learners perceive this experience. The authors studied an interprofessional quality improvement (QI) curriculum implemented in 2013 integrating internal medicine residents (n = 90) and Master of Public Health (MPH) students (n = 33) at an urban safety net academic medical center. Pre and post curriculum surveys assessed attitudes toward QI and interprofessional education and team performance. Resident attitudes toward learning and engaging in QI work improved at the end of the curriculum. Overall, MPH students demonstrated significantly more positive attitudes about interprofessional learning and work than residents. They also agreed more strongly than residents that patients would benefit if residents and public health students worked together. As health care organizations evolve to become more integrated, it is crucial that interprofessional educational opportunities be developed and evaluated to help encourage a culture of collaboration among health care providers.

Electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis.

BACKGROUND: We define electronic consultations ("e-consults") as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was to systematically review and summarize the literature describing the use and effects of e-consults. METHODS: We searched PubMed, EMBASE, the Cochrane Library, and CINAHL for studies related to e-consults published between 1990 through December 2014. Three reviewers identified empirical studies and system descriptions, including articles on systems that used a shared EHR or web-based platform, connected providers in the same health system, were used for two-way provider communication, and were text-based. RESULTS: Our final review included 27 articles. Twenty-two were research studies and five were system descriptions. Eighteen originated from one of three sites with well-developed e-consult programs. Most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. E-consultations are used in a variety of ways within and across medical centers. They provide timely access to specialty care and are well-received by primary care providers. DISCUSSION: E-consults are feasible in a variety of settings, flexible in their application, and facilitate timely specialty advice. More extensive and rigorous studies are needed to inform the e-consult process and describe its effect on access to specialty visits, cost and clinical outcomes.

Using lean methodology to teach quality improvement to internal medicine residents at a safety net hospital.

The overall objective of this initiative was to develop a quality improvement (QI) curriculum using Lean methodology for internal medicine residents at Boston Medical Center, a safety net academic hospital. A total of 90 residents and 8 School of Public Health students participated in a series of four, 60- to 90-minute interactive and hands-on QI sessions. Seventeen QI project plans were created and conducted over a 4-month period. The curriculum facilitated internal medicine residents' learning about QI and development of positive attitudes toward QI (assessed using pre- and post-attitude surveys) and exposed them to an interprofessional team structure that duplicates future working relationships. This QI curriculum can be an educational model of how health care trainees can work collaboratively to improve health care quality.

International medical graduates and health information technology use in the United States.

PURPOSE: Health information technology (HIT) holds promise for improving the quality of health care and reducing health care system inefficiencies. Numerous studies have examined HIT availability, specifically electronic health records (EHRs), and utilization among physicians in individual countries. However, no one has examined EHR use among physicians who train in one country and move to practice in another country. In the United States, physicians who complete medical school outside the country but practice within the United States are commonly referred to as International Medical Graduates (IMGs). IMGs have a growing presence in the United States, yet little is known about the availability and use of HIT among these physicians. The purpose of this study is to explore the availability and use of HIT among IMGs practicing in United States. DESIGN/METHODOLOGY/APPROACH: The Health Tracking Physician Survey (2008) was used to examine the relationship between availability and use of HIT and IMG status controlling for several physician and practice characteristics. Our analysis included responses from 4,720 physicians, 20.7% of whom were IMGs. FINDINGS: Using logistic regression, controlling for physician gender, specialty, years in practice, practice type, ownership status and geographical location, we found IMGs were significantly less likely to have a comprehensive EHR in their practices (OR = 0.84; p = 0.005). In addition, findings indicate that IMGs are more likely to have and use several so-called first generation HIT capabilities, such as reminders for clinicians about preventive services (OR = 1.31; p = 0.001) and other needed patient follow-up (OR = 1.26; p = 0.007). ORIGINALITY/VALUE: This study draws attention to the need for further research regarding barriers to HIT adoption and use among IMGs.

Evaluation of the immunogenicity of liposome encapsulated HVR1 and NS3 regions of genotype 3 HCV, either singly or in combination.

BACKGROUND: Hepatitis C virus displays a high rate of mutation and exists as a quasispecies in infected patients. In the absence of an effective universal vaccine, genotype-specific vaccine development represents an alternative. We have attempted to develop a genotype 3 based, liposome encapsulated HCV vaccine with hypervariable region-1 (HVR1) and non-structural region-3 (NS3) components. RESULTS: HCV RNA extracted from serum samples of 49 chronically infected patients was PCR amplified to obtain HVR1 region. These amplified products were cloned to obtain 20 clones per sample in order to identify the quasispecies pattern. The HVR1 consensus sequence, along with three variants was reverse transcribed to obtain peptides. The peptides were checked for immunoreactivity individually, as a pool or as a single peptide tetramer interspersed with four glycine residues. Anti-HCV positivity varied from 42.6% (tetramer) to 92.2% (variant-4) when 115 anti-HCV positive sera representing genotypes 1, 3, 4 and 6 were screened. All the 95 anti-HCV negatives were scored negative by all antigens. Mice were immunized with different liposome encapsulated or Al(OH)3 adjuvanted formulations of HVR1 variants and recombinant NS3 protein, and monitored for anti-HVR1 and anti-NS3 antibody titres, IgG isotypes and antigen specific cytokine levels. A balanced Th1/Th2 isotyping response with high antibody titres was observed in most of the liposome encapsulated antigen groups. The effect of liposomes and aluminium hydroxide on the expression of immune response genes was studied using Taqman Low Density Array. Both Th1 (IFN-gamma, Il18) and Th2 (Il4) genes were up regulated in the liposome encapsulated HVR1 variant pool-NS3 combination group. In-vitro binding of the virus to anti-HVR1 antibodies was demonstrated. CONCLUSION: The optimum immunogen was identified to be combination of peptides of HVR1 consensus sequence and its variants along with pNS3 encapsulated in liposomes, which could generate both cellular and humoral immune responses in mice deserving further evaluation in a suitable cell culture system/non-human primate model.

Complete genome sequences of hepatitis C virus subtype 3i and 3a subtype isolates from India.

AIM: Hepatitis C virus (HCV), a major causative agent of chronic hepatitis, is classified into six major genotypes. Genotype 3 HCV infection is more sensitive to interferon therapy. In India, genotype 3, particularly subtype 3a, HCV infections are common. Three novel HCV subtypes i.e., 3g, 3j, and 3i were identified from India based on partial genomic sequences. This report provides full genome sequences of one isolate each of subtypes 3i and 3a. METHODS: Serum samples positive for subtype 3i and 3a HCV RNA based on core region genomic sequences were studied. Complete HCV genomes were amplified as 11 overlapping PCR fragments and sequenced. RESULTS: The complete genomic sequence of Indian HCV 3i isolate clustered with other genotype 3 sequences, and was closer to subtypes 3b and 3a (80.5% and 79.1% [SD 0.4%] nucleotide identity). Nucleotide similarities were the highest in the core region (86.1-88.7%), and the least in the E2 region (69.4-70.7%). Phylogenetic tree analysis confirmed the existence of a separate subtype 3i. The Indian HCV 3a isolate's complete genomic sequences clustered with previously known genotype 3a sequences with a nucleotide similarity of 91.1% (SD 0.2%). Neither isolates showed evidence of recombination of different HCV genotypes. CONCLUSION: The information on complete genomic sequences of the genotype 3 HCV isolates should be helpful in future studies on HCV evolution and classification, and for development of newer therapeutic and preventive strategies against this infection.