Ambulatory Training Program to Expand Procedural Skills in Primary Care.

INTRODUCTION: Outpatient procedures are an important component of primary care, yet few programs incorporate procedural training into their curriculum. We examined a 4-year procedural curriculum to improve understanding of ambulatory procedures and increase the number of procedures performed. METHODS: A total of 56 resident and 8 faculty physicians participated in a procedural curriculum directed at joint injections (knee, shoulder, elbow, trochanteric bursa, carpal tunnel, wrist, and ankle), subdermal contraceptive insertion/removal, skin biopsies, and ultrasound use in primary care. We administered annual surveys and used generalized estimating equations to model changes. RESULTS: Across the 4 years, there was an average 96% response rate. Mean comfort level with the indications for procedures increased for both resident (62.5 to 78.8; P < .0001) and faculty physicians (61.5 to 94.8; P < .0001). Similarly, mean comfort with performing procedures increased for both resident (32.1 to 62.3; P < .0001) and faculty physicians (42.2 to 85.4; P < .0001). Residents' comfort level performing procedures increased for all individual procedures measured. The mean number of procedures performed per year increased for resident (1.9 to 8.2; P < .0001) and faculty physicians (14.7 to 25.2; P = .087). CONCLUSIONS: A longitudinal ambulatory-based procedural curriculum can increase resident and faculty physician understanding and comfort performing primary-care-based procedures. This, in turn, increased the total number of procedures performed.

TRANSFER FROM PEDIATRIC TO ADULT ENDOCRINOLOGY.

OBJECTIVE: Adult and pediatric endocrinologists share responsibility for the transition of youth with type 1 diabetes from pediatric to adult healthcare. This study aimed to increase successful transfers to adult care in subspecialty practices by establishing a systematic health care transition (HCT) process. METHODS: Providers from the adult and pediatric endocrinology divisions at the University of Rochester Medical Center met monthly to customize and integrate the Six Core Elements (6CEs) of HCT into clinical workflows. Young adult patients with type 1 diabetes having an outpatient visit during a 34-month pre-post intervention period were eligible (N = 371). Retrospective chart review was performed on patients receiving referrals to adult endocrinology (n = 75) to obtain (1) the proportion of patients explicitly tracked during transfer from the pediatric to adult endocrinology practice, (2) the providers' documentation of the use of the 6CEs, and (3) the patients' diabetes control and healthcare utilization during the transition period. RESULTS: The percent of eligible patients with type 1 diabetes who were explicitly tracked in their transfer more than doubled compared to baseline (11% vs. 27% of eligible patients; P<.01). Pediatric providers started to use transition readiness assessments and create medical summaries, and adult providers increased closed-loop communication with pediatric providers after a patient's first adult visit. Glycemic control and healthcare utilization remained stable. CONCLUSION: Successful implementation of the 6CEs into pediatric and adult subspecialty practices can result in improvements of planned transfers of pediatric patients with type 1 diabetes to adult subspecialty providers. ABBREVIATIONS: 6CEs = six core elements; AYA = adolescent and young adult; DKA = diabetic ketoacidosis; ED = emergency department; HbA1c = hemoglobin A1c; HCT = health care transition.

Factors Associated With Resident Continuity in Ambulatory Training Practices.

BACKGROUND: Continuity of care is a critical element of residents' educational experience in primary care programs. OBJECTIVE: We examined how continuity in resident practices compares to nonteaching practices, identified factors associated with increased continuity, and explored the association between continuity and quality measures. METHODS: We analyzed 117 235 patient visits to 4 resident practices (26 resident teams in internal medicine, pediatrics, family medicine, and medicine-pediatrics) and 270 242 visits to nonteaching community practices between July 2013 and May 2014. We defined continuity from both clinician and patient perspectives, and used logistic regression models to examine the influence of factors on continuity while controlling for postgraduate year, patient age, gender, race, and insurance. RESULTS: Continuity was greater at nonteaching sites compared to resident practices (87.3% versus 56.2%, P < .001). Resident continuity ranged from 33.1% to 83.7% among resident sites. Factors associated with improved resident continuity included absence of advanced practice providers (71.5% versus 52.3%); consistent use of scheduling protocols (77.5% versus 33.1%); rescheduling policies (71.5% versus 41.3%); increased faculty clinical time (71.5% versus 46.3%); and dismissal policies for excessive missed appointments (71.5% versus 62.5%, P < .001 for all). Increased continuity was associated with improved rates of diabetic control (62.8% versus 54.6%); hypertension control (82.8% versus 57.5%); screening colonoscopy (69.2% versus 31.9%); and mammography (74.8% versus 38.2%, P < .001 for all). CONCLUSIONS: Increased clinical faculty time, scheduling protocols, and absence of advanced practice providers were most strongly associated with increasing continuity. Increased continuity was associated with improved quality measures.

The impact of neighborhood socioeconomic status and race on the prescribing of opioids in emergency departments throughout the United States.

BACKGROUND: Racial and ethnic disparities in opioid prescribing in the emergency department (ED) are well described, yet the influence of socioeconomic status (SES) remains unclear. OBJECTIVES: (1) To examine the effect of neighborhood SES on the prescribing of opioids for moderate to severe pain; and (2) to determine if racial disparities in opioid prescribing persist after accounting for SES. DESIGN: We used cross-sectional data from the National Hospital Ambulatory Medical Care Survey between 2006 and 2009 to examine the prescribing of opioids to patients presenting with moderate to severe pain (184 million visits). We used logistic regression to examine the association between the prescribing of opioids, SES, and race. Models were adjusted for age, sex, pain-level, injury-status, frequency of emergency visits, hospital type, and region. MAIN MEASURES: Our primary outcome measure was whether an opioid was prescribed during a visit for moderate to severe pain. SES was determined based on income, percent poverty, and educational level within a patient's zip code. RESULTS: Opioids were prescribed more frequently at visits from patients of the highest SES quartile compared to patients in the lowest quartile, including percent poverty (49.0 % vs. 39.4 %, P<0.001), household income (47.3 % vs. 40.7 %, P<0.001), and educational level (46.3 % vs. 42.5 %, P=0.01). Black patients were prescribed opioids less frequently than white patients across all measures of SES. In adjusted models, black patients (AOR 0.73; 95 % CI 0.66­0.81) and patients from poorer areas (AOR 0.76; 95 % CI 0.68­0.86) were less likely to receive opioids after accounting for pain-level, age, injury-status, and other covariates. CONCLUSIONS: Patients presenting to emergency departments from lower SES regions were less likely to receive opioids for equivalent levels of pain than those from more affluent areas. Black and Hispanic patients were also less likely to receive opioids for equivalent levels of pain than whites, independent of SES.

Delayed transition of care: a national study of visits to pediatricians by young adults.

OBJECTIVE: Despite numerous policy statements and an increased focus on transition of care, little is known about young adults who experience delayed transition to adult providers. METHODS: We used cross-sectional data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey between 1998 and 2008 to examine delayed transition among young adults ages 22 to 30. We defined delayed transition as continuing to visit a pediatrician after the age of 21 years. RESULTS: Overall, we found that 1.3% (95% confidence interval [CI] 1.1-1.7) of visits by young adults to primary care physicians were seen by pediatricians, approximately 445,000 visits per year. We did not find a significant change in delayed transition during the past decade (ß = -.01; P = .77). Among young adults, visits to pediatricians were more likely than visits to adult-focused providers to be for a chronic disease (25.7% vs 12.6%; P = .002) and more likely to be billed to public health insurance (23.5% vs 14.1%; P = .01). In adjusted models, visits by young adults to pediatric healthcare providers were more likely associated with chronic disease (adjusted relative risk [ARR] 2.2; 95% CI 1.5-3.4), with public health insurance (ARR 1.9; 95% CI 1.3-2.9), or with no health insurance (ARR 1.9; 95% CI 1.1-3.4). CONCLUSIONS: Although most young adult visits were to adult providers, a considerable number of visits were to pediatricians, indicating delayed transition of care. There has been no substantial change in delayed transition during the past decade. Visits by young adults with chronic disease, public health insurance, or no health insurance were more likely to experience delayed transition of care.

Graduating med-peds residents' interest in part-time employment.

OBJECTIVE: As part-time work is becoming more popular among the primary care specialties, we examined the demographic descriptors of med-peds residents seeking and finding part-time employment upon completion of residency training. METHODS: As part of the 2006 annual American Academy of Pediatrics (AAP) Graduating Med-Peds Residents Survey, we surveyed the graduating residents of all med-peds programs about their interest in and plans for part-time employment. A total of 199 (60%) of the residents responded. RESULTS: Of the resident respondents applying for nonfellowship jobs, 19% sought part-time positions and 10% actually accepted a part-time position. Female residents were significantly more likely than male residents to apply for part-time jobs (26% vs. 7%, P = .034). Sixty percent of female residents immediately seeking work and 58% of those going on to fellowship reported an interest in arranging a part-time or reduced-hours position at some point in the next 5 years. CONCLUSIONS: Part-time employment among med-peds residents applying for nonfellowship positions after graduation is similar to the current incidence of part-time employment in other fields of primary care. A much higher percentage of med-peds residents are interested in arranging part-time work within 5 years after graduation. This strong interest in part-time work has many implications for the primary care workforce.

Prescribing of controlled medications to adolescents and young adults in the United States.

OBJECTIVE: The nonmedical use of prescription drugs by adolescents and young adults has surpassed all illicit drugs except marijuana, yet little is known about prescribing patterns. We examined the prescribing of controlled medications to adolescents aged 15 to 19 and young adults aged 20 to 29. METHODS: We used cross-sectional data from the National Ambulatory Medical Care Survey (N = 4304 physicians) and the National Hospital Ambulatory Medical Care Survey (N = 2805 clinics; N = 1051 emergency departments) between 2005 and 2007. We also used consecutive data from 1994 to describe trends. RESULTS: A controlled medication was prescribed at 2.3 million visits by adolescents and 7.8 million visits by young adults in 2007. Between 1994 and 2007, controlled medications were prescribed at an increasing proportion of visits from adolescents (6.4%-11.2%) and young adults (8.3%-16.1%) (P < .001 for trend). This increase was seen among males and females, in ambulatory offices and emergency departments, and for injury-related and non-injury-related visits (all P < .001). A controlled medication was prescribed during 9.6% of all adolescent visits and 13.8% of young-adult visits for non-injury-related indications and at 14.5% of adolescent visits and 27.0% of young-adult visits for injury-related reasons. Controlled medications were prescribed at a substantial proportion of visits for common conditions, such as back pain, to both adolescents (23.4%) and young adults (36.9%). CONCLUSIONS: Controlled medications are prescribed at a considerable proportion of visits from adolescents and young adults, and prescribing rates have nearly doubled since 1994. This trend and its relationship to misuse of medications warrants further study.

Dependence on emergency care among young adults in the United States.

BACKGROUND: Young adults have a high prevalence of many preventable diseases and frequently lack a usual source of ambulatory care, yet little is known about their use of the emergency department. OBJECTIVE: To characterize care provided to young adults in the emergency department. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of visits from young adults age 20 to 29 presenting to emergency departments (N = 17,048) and outpatient departments (N = 14,443) in the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey. MAIN MEASURES: Visits to the emergency department compared to ambulatory offices. RESULTS: Emergency department care accounts for 21.6% of all health care visits from young adults, more than children/adolescents (12.6%; P < 0.001) or patients 30 years and over (8.3%; P < 0.001). Visits from young adults were considerably more likely to occur in the emergency department for both injury-related and non-injury-related reasons compared to children/adolescents (P < 0.001) or older adults (P < 0.001). Visits from black young adults were more likely than whites to occur in the emergency department (36.2% vs.19.2%; P < 0.001) rather than outpatient offices. The proportion of care delivered to black young adults in the emergency department increased between 1996 and 2006 (25.9% to 38.5%; P = 0.001 for trend). In 2006, nearly half (48.5%) of all health care provided to young black men was delivered through emergency departments. The urgency of young adult emergency visits was less than other age groups and few (4.7%) resulted in hospital admission. CONCLUSIONS: A considerable amount of care provided to young adults is delivered through emergency departments. Trends suggest that young adults are increasingly relying on emergency departments for health care, while being seen for less urgent indications.

Ambulatory care among young adults in the United States.

BACKGROUND: Young adults are the most likely age group to be uninsured and have the highest prevalence of substance abuse, motor vehicle accidents, and sexually transmitted diseases, yet little is known about their use of ambulatory care. OBJECTIVE: To characterize ambulatory care of young adults. DESIGN: Cross-sectional data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. SETTING: Community and hospital-based clinics. PATIENTS: Nonpregnant young adults age 20 to 29 years. MEASUREMENTS: Ambulatory care utilization, types of visits, and preventive care. RESULTS: Insured young adults had more visits (2.16 [95% CI, 2.14 to 2.19] annual visits per capita) than those without insurance (0.59 [CI, 0.54 to 0.67] annual visits per capita). Young men utilized ambulatory medical care less than adolescents age 15 to 19 years or older adults age 30 to 39 years (1.10, 1.65, and 1.73 annual visits per capita, respectively) and had lower rates of utilization than young women (1.10 vs. 2.31 annual visits per capita). Young black and Hispanic men had considerably fewer annual visits per capita (0.75 and 0.65, respectively) than did young white men (1.21). Young men had nearly one half the preventive care visits compared with male adolescents or older men (0.11, 0.24, and 0.19 annual visits per capita, respectively) and less than one quarter the visits compared with young women (0.11 vs. 0.48 annual visits per capita). Only 30.6% of visits by young adults included any preventive counseling, and few encounters included counseling directed toward injury prevention (2.4%), mental health (4.1%), or sexually transmitted diseases (2.7%). LIMITATION: School-based clinics were not included, and counseling may be underreported. CONCLUSION: Young adults use less ambulatory medical care relative to other groups and infrequently receive preventive care directed at the greatest threats to their health. Efforts to ensure appropriate preventive care are needed. PRIMARY FUNDING SOURCE: None.

Could our pretest probabilities become evidence based? A prospective survey of hospital practice.

OBJECTIVE: We sought to measure the proportion of patients on our clinical service who presented with clinical problems for which research evidence was available to inform estimates of pretest probability. We also aimed to discern whether any of this evidence was of sufficient quality that we would want to use it for clinical decision making. DESIGN: Prospective, consecutive case series and literature survey. SETTING: Inpatient medical service of a university-affiliated Veterans' Affairs hospital in south Texas. PATIENTS: Patients admitted during the 3 study months for diagnostic evaluation. MEASUREMENTS: Patients' active clinical problems were identified prospectively and recorded at the time of discharge, transfer, or death. We electronically searched medline and hand-searched bibliographies to find citations that reported research evidence about the frequency of underlying diseases that cause these clinical problems. We critically appraised selected citations and ranked them on a hierarchy of evidence. RESULTS: We admitted 122 patients for diagnostic evaluation, in whom we identified 45 different principal clinical problems. For 35 of the 45 problems (78%; 95% confidence interval [95% CI], 66% to 90%), we found citations that qualified as disease probability evidence. Thus, 111 of our 122 patients (91%; 95% CI, 86% to 96%) had clinical problems for which evidence was available in the medical literature. CONCLUSIONS: During 3 months on our hospital medicine service, almost all of the patients admitted for diagnostic evaluation had clinical problems for which evidence is available to guide our estimates of pretest probability. If confirmed by others, these data suggest that clinicians' pretest probabilities could become evidence based.