Leadership Development in Academic Health Science Centers: Towards a Paradigm Shift.

PROBLEM: In an era of increasing complexity, leadership development is an urgent need for academic health science centers (AHSCs). The Association of American Medical Colleges (AAMC) and others have described the need for a focus on organizational leadership development and more rigorous evaluation of outcomes. Although the business literature notes the importance of evaluating institutional leadership culture, there is sparse conversation in the medical literature about this vital aspect of leadership development. Defining the leadership attributes that best align with and move an AHSC forward must serve as the foundational framework for strategic leadership development. APPROACH: In 2015, the Medical University of South Carolina (MUSC) began a systematic process to approach strategic leadership development for the organization. An interprofessional group completed an inventory of our leadership development programs and identified key drivers of a new institutional strategic plan. A strategic leadership advisory committee designed a series of leadership retreats to evaluate both individual and collective leadership development needs. OUTCOMES: Three key drivers were identified as critical attributes for the success of our institutional strategy. Four specific areas of focus for the growth of the institution's ideal leadership culture were identified, with specific action items or behaviors developed for our leaders to model. As a result of this foundational work, we have now launched the MUSC Leadership Institute. NEXT STEPS: Knowledge of our current leadership culture, key drivers of strategy and our desired collective leadership attributes are the basis for building our institutional leadership development strategy. This will be a longitudinal process that will start with senior leadership engagement, organizational restructuring, new programming and involve significant experimentation. Disciplined, thoughtful evaluation will be required to find the right model. In addition to individual transformation with leadership development, MUSC will measure specifically identified strategic outcomes and performance metrics for the institution.

Chaos to complexity: leveling the playing field for measuring value in primary care.

RATIONALE, AIMS AND OBJECTIVES: Develop a risk-stratification model that clusters primary care patients with similar co-morbidities and social determinants and ranks 'within-practice' clusters of complex patients based on likelihood of hospital and emergency department (ED) utilization. METHODS: A retrospective cohort analysis was performed on 10 408 adults who received their primary care at the Medical University of South Carolina University Internal Medicine clinic. A two-part generalized linear regression model was used to fit a predictive model for ED and hospital utilization. Agglomerative hierarchical clustering was used to identify patient subgroups with similar co-morbidities. RESULTS: Factors associated with increased risk of utilization included specific disease clusters {e.g. renal disease cluster [rate ratio, RR = 5.47; 95% confidence interval (CI; 4.54, 6.59) P < 0.0001]}, low clinic visit adherence [RR = 0.33; 95% CI (0.28, 0.39) P < 0.0001] and census measure of high poverty rate [RR = 1.20; 95% CI (1.11, 1.28) P < 0.0001]. In the cluster model, a stable group of four clusters remained regardless of the number of additional clusters forced into the model. Although the largest number of high-utilization patients (top 20%) was in the multiple chronic condition cluster (1110 out of 4728), the largest proportion of high-utilization patients was in the renal disease cluster (67%). CONCLUSIONS: Risk stratification enhanced with disease clustering organizes a primary care population into groups of similarly complex patients so that care coordination efforts can be focused and value of care can be maximized.

Sustained Improvement in Blood Pressure Control for a Multiracial Cohort: Results of a Patient-centered Medical Home Quality Improvement Initiative.

BACKGROUND: Patient-centered medical homes incorporate strategies to increase healthcare access as a means of improving health at the patient and population level. We hypothesized that quality improvement initiatives based in a patient-centered medical home would improve hypertension control for adult patients, regardless of race. METHODS: This prospective cohort study included patients of a hospital-based Internal Medicine practice in the southeastern U.S. whose systolic blood pressure was uncontrolled (criteria ≥140mmHg) prior to patient-centered medical home certification. Mean systolic blood pressure and hypertension control rates were calculated from the average of the four quarterly means prior to patient-centered medical home designation and again from the last 4 quarters of the five-year study period (final). Quality improvement interventions included patient identification, multidisciplinary team meetings, targeted outreach, and dedicated office visits for addressing hypertension. Primary outcomes included the change in systolic blood pressure and the change in the proportion of the cohort with hypertension control. Chi-square, two sample t-tests, and ANOVA were used for comparison (SAS 9.3). RESULTS: The inception cohort had 1,702 patients (64% nonwhite, 36% white) with systolic blood pressure ≥140mmHg. Mean systolic blood pressure significantly decreased while hypertension control rates increased in both races after patient-centered medical home certification. White adults had lower mean systolic blood pressure and higher control rates at baseline and study conclusion compared to nonwhite adults. Similar trends persisted regardless of the number of office visits. CONCLUSIONS: The analysis of blood pressure before and after designation of an Internal Medicine clinic as a patient-centered medical home reveals disparities in rates of chronic disease control. Team-based outreach improves hypertension control for patients regardless of race or visit number. These findings suggest that patient-centered medical homes and a multidisciplinary care approach, not limited to increased access, improve chronic disease control and should be considered for diverse outpatient clinics.

Acute Care Utilization in Patients With Concurrent Mental Health and Complex Chronic Medical Conditions.

OBJECTIVES: Patients with coexisting mental health disorder and chronic disease are more at risk for poor outcomes, including increased acute care utilization. This study was performed to assess the association of mental health disorders on acute care utilization (emergency department [ED] use, hospitalization, and rehospitalization within 30 days) using disease clustering. METHODS: A retrospective cohort analysis was performed on 10 408 patients. Adult patients >18 years of age were included in the study if they were seen at least twice in University Internal Medicine primary care clinic at the Medical University of South Carolina from October 10, 2010 through September 30, 2013. The main outcome measure was a count of acute care use (hospital or ED). A linear regression model was used to fit a predictive model for ED and hospital utilization, and agglomerative hierarchical clustering was used to identify patients with similar comorbidities. RESULTS: Covariates associated with increased risk of ED and hospital utilization include non-white race (rate ratio [RR] = 1.35, P < .0001), resident physician (RR = 1.30, P < .0001), and public insurance (RR = 1.56, P < .0001). Patients within the multiple chronic conditions (MCC), chronic obstructive pulmonary disease (COPD)/asthma, or renal disease clusters had 1.80 (P < .0001), 1.50 (P < .0001), and 2.57 (P < .0001) times, respectively, the amount of predicted utilization compared with healthy patients, whereas patients with a mental health diagnosis had 1.41 (P < .0001) times the predicted utilization. There was a significant association with increased utilization in patients with coexisting mental health disorder and chronic disease within the COPD/asthma (RR = 1.20, P = .0038), renal disease (RR = 1.27, P < .0001), and MCC (RR = 1.34, P < .0001) clusters. CONCLUSIONS: Patients with co-occurring chronic medical conditions and mental health disorders have higher rates of acute care utilization compared with patients with chronic medical conditions alone. Improving access to mental health care at the primary care clinic may have a positive impact on utilization.

Point of care experience with pneumococcal and influenza vaccine documentation among persons aged ≥65 years: high refusal rates and missing information.

Missed opportunities to vaccinate and refusal of vaccine by patients have hindered the achievement of national health care goals. The meaningful use of electronic medical records should improve vaccination rates, but few studies have examined the content of these records. In our vaccine intervention program using an electronic record with physician prompts, paper prompts, and nursing standing orders, we were unable to achieve national vaccine goals, due in large part to missing information and patient refusal.

Impact of the foundations of clinical medicine course on USMLE scores.

BACKGROUND: The synthesis of basic and clinical science knowledge during the clerkship years has failed to meet educational expectations. OBJECTIVES: We hypothesized that a small-group course emphasizing the basic science underpinnings of disease, Foundations of Clinical Medicine (FCM), could be integrated into third year clerkships and would not negatively impact the United States Medical Licensure Examination (USMLE) step 2 scores. DESIGN: In 2001-2002, all third year students met weekly in groups of 8-12 clustered within clerkships to discuss the clinical and basic science aspects of prescribed, discipline-specific cases. PARTICIPANTS: Students completing USMLE step 2 between 1999 and 2004 (n = 743). MEASUREMENTS: Course evaluations were compared with the overall institutional average. Bivariate analyses compared the mean USMLE steps 1 and 2 scores across pre- and post-FCM student cohorts. We used multiple linear regression to assess the association between USMLE step 2 scores and FCM cohort controlling for potential confounders. RESULTS: Students' average course evaluation score rose from 66 to 77 (2001-2004) compared to an institutional average of 73. The unadjusted mean USMLE step 1 score was higher for the post-FCM cohort (212.9 vs 207.5, respectively, p < .001) and associated with step 2 scores (estimated coefficient = 0.70, p < .001). Post-FCM cohort (2002-2004; n = 361) mean step 2 scores topped pre-FCM (1999-2001; n = 382) scores (215.9 vs 207.7, respectively, p < .001). FCM cohort remained a significant predictor of higher step 2 scores after adjustment for USMLE step 1 and demographic characteristics (estimated coefficient = 4.3, p = .002). CONCLUSIONS: A curriculum integrating clinical and basic sciences during third year clerkships is feasible and associated with improvement in standardized testing.