High-Yield Birth-Cohort Hepatitis C Virus Screening and Linkage to Care Among Underserved African Americans, Atlanta, Georgia, 2012-2013.

OBJECTIVE: Hepatitis C virus (HCV) infection disproportionately affects certain populations, including those born between 1945 and 1965 (i.e., baby boomers) and African Americans. As part of the Hepatitis Testing and Linkage to Care initiative, which promoted hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites, we conducted routine HCV screening to identify previously undiagnosed, primarily African American baby boomers with chronic hepatitis C infection and link them to care. METHODS: We launched the Internal Medicine Trainees Identifying and Linking to Treatment for Hepatitis C (TILT-C) initiative at the Grady Memorial Hospital Primary Care Center and Grady Liver Clinic in Atlanta, Georgia, in October 2012, and present results from the first year. TILT-C faculty implemented an electronic medical record prompt and conducted educational sessions to boost HCV screening. A project coordinator tracked testing outcomes and linked HCV-positive patients to care. RESULTS: Of 2,894 patients tested for anti-HCV, 201 (6.9%) tested positive. Men had a significantly higher (p<0.001) prevalence of HCV infection than women, with 106 of 1,091 (9.7%) men compared with 95 of 1,803 (5.3%) women testing anti-HCV positive. A total of 174 of 201 (86.6%) anti-HCV-positive patients received HCV ribonucleic acid (RNA) testing. Of 124 patients with a positive HCV RNA test, 122 were referred to care and 120 attended the first appointment. CONCLUSION: The TILT-C screening program was feasible and effective in detecting previously undiagnosed HCV infection and linking patients to care. The unexpectedly high prevalence of HCV infection in this primarily African American, baby boomer population underscores the need for aggressive HCV screening efforts in similar populations.

What are internal medicine residents missing? A communication needs assessment of outpatient clinical encounters.

OBJECTIVE: In order to guide curricular innovation, we looked at the feasibility and utility of performing a targeted needs assessment of the communication skills of PGY2 internal medicine (IM) residents in their continuity clinic, utilizing faculty direct observation with a validated instrument for communication skills evaluation. METHODS: A convenience sample of PGY2 residents in the Emory University School of Medicine IM Residency Program was invited to participate. Using the SEGUE Framework, a checklist of medical communication tasks, faculty assessed residents during a clinic encounter. RESULTS: Thirty out of 53 (57%) PGY2 residents were assessed. SEGUE results indicate residents were most likely to "maintain patient's privacy" (100%), "greet patient appropriately" (97%) and "check/clarify information" (100%). Residents were least likely to "acknowledge waiting time" (7%), "explore psychosocial/emotional factors" (27%) and "outline agenda for visit" (33%). CONCLUSION: The SEGUE Framework is a feasible tool to evaluate the communication skills of IM residents in a clinic setting. Many PGY2 IM residents in a large, urban practice do not elicit important psychosocial information during outpatient clinic visits. PRACTICE IMPLICATIONS: More observation and evaluation of residents' communication skills are needed, with emphasis on building skills to "Understand the Patient's Perspective."

Does patient gender impact resident physicians' approach to the cardiac exam?

BACKGROUND: Physical examination remains an important part of the initial evaluation of patients presenting with chest pain but little is known about the effect of patient gender on physician performance of the cardiovascular exam. OBJECTIVE: To determine if resident physicians are less likely to perform five key components of the cardiovascular exam on female versus male standardized patients (SPs) presenting with acute chest pain. DESIGN: Videotape review of SP encounters during Objective Structured Clinical Examinations (OSCEs) administered by the Emory University Internal Medicine Residency Program in 2006 and 2007. Encounters were reviewed to assess residents' performance of five cardiac exam skills: auscultation of the aortic, pulmonic, tricuspid, and mitral valve areas and palpation for the apical impulse. PARTICIPANTS: One hundred forty-nine incoming residents. MAIN MEASURES: Residents' performance for each skill was classified as correct, incorrect, or unknown. KEY RESULTS: One hundred ten of 149 (74 %) of encounters were available for review. Residents were less likely to correctly perform each of the five skills on female versus male SPs. This difference was statistically significant for auscultation of the tricuspid (p = 0.004, RR = 0.62, 95 % CI 0.46-0.83) and mitral (p = 0.007, RR = 0.58, 95 % CI = 0.41-0.83) valve regions and palpation for the apical impulse (p < 0.001, RR = 0.27, 95 % CI = 0.16-0.47). Male residents were less likely than female residents to correctly perform each maneuver on female versus male SPs. The interaction of SP gender and resident gender was statistically significant for auscultation of the mitral valve region (p = 0.006) and palpation for the apical impulse (p = 0.01). CONCLUSIONS: We observed significant differences in the performance of key elements of the cardiac exam for female versus male SPs presenting with chest pain. This observation represents a previously unidentified but potentially important source of gender bias in the evaluation of patients presenting with cardiovascular complaints.

Older women's attitudes, behavior, and communication about sex and HIV: a community-based study.

OBJECTIVES: To examine the effects of race and marriage on the sexual attitudes, behavior, and patient-physician communication about sexuality and HIV/AIDS among older women. METHODS: This was a cross-sectional survey of 55 community-residing women aged 58-93. RESULTS: 57% of respondents had engaged in sexual activity since the 60th birthday. Nearly 60% of single women who had been sexually active in the previous 10 years reported that they had not used a condom; 21% of women with a current sexual partner agreed that condom use is not necessary "if you can no longer get pregnant." African American women were significantly more likely to report making changes in their sexual behavior due to HIV (53% vs. 19% white, p = 0.02). Married and African American women were more likely to discuss sex with a physician (80% vs. 47%; p = 0.03 and 75% vs. 46%, p = 0.05, respectively). African Americans were more likely to have had a physician initiate such a discussion (69% vs. 38%, p = 0.04). CONCLUSIONS: Older women in this sample were sexually active, engaged in potentially risky sexual behavior, and believed that physicians should address issues of sexuality. Older African American women were significantly more likely than white women to report HIV-related changes in their behavior and to discuss sex with a physician. This community-based study corroborates clinical research and suggests both a gap and a disparity in older women's dialogue with physicians. It also indicates the need for more broadly generalizable data on issues pertinent to older women's sexual health.