Impact of a Residency Family Systems Curriculum on the Postresidency Practice of Family Physicians.

BACKGROUND AND OBJECTIVES: Training residents in family systems and family-oriented care holds the potential to increase empathy for patients and to grow self-awareness of how one's own family of origin affects clinical practice. Little has been studied about how training residents in family systems affects their clinical practice after they graduate residency. METHODS: We surveyed all the residency graduates (N=60) who completed the longitudinal family systems curriculum during their third year of residency, from 2016 to 2021. The former residents were emailed a survey and asked to respond to Likert-scale and qualitative questions regarding the effects of the family systems curriculum on their clinical practice. RESULTS: Thirty-five graduates (58.3%) returned completed surveys. Overall, 26 of 35 (74.3%) respondents felt that the family systems curriculum had helped them a fair amount or a great deal in the care of their patients. In particular, 29 of 35 (82.9%) felt that the curriculum helped them a fair amount or a great deal in maintaining empathy. Compared to other longitudinal courses, 32 of 35 (91.4%) respondents indicated that they liked the curriculum somewhat or a great deal.  Conclusions: More than half the respondents found all elements of the curriculum helpful in their clinical practice, especially in the areas of caring for patients and maintaining empathy. The responses will be used as a baseline for comparison to improve the training. Continued research, perhaps in the form of randomized controlled trials using several residencies, could help in developing elements for more standardized curriculum in family-oriented care training.

The Carbon Footprint and Cost of Virtual Residency Interviews.

Background: The shift from in-person to virtual residency interviews may impact greenhouse gas emissions (GHGE) and costs but the direction and amount of this change is not yet clear. Objective: To estimate GHGE and financial impacts of virtual interviews among applicants and programs. Methods: In 2020-2021 we sent a postinterview survey to 1429 applicants from 7 residency programs and 1 clinical psychology program at 1 institution. The survey collected origin of travel and transit type if in-person interviews had been held and excluded responses if the applicant would not have participated in an in-person interview, or if travel type or original city was missing. We used the International Civil Aviation Organization calculator to estimate flight-related GHGE in metric tons of carbon dioxide equivalent (MTCO2e) and Google Maps to estimate ground travel, with a standard CO2e per mile. Flight, hotel, and airport taxi costs were estimated using Expedia.com, Hotels.com, Uber, and Lyft. We aggregated these data and calculated median and interquartile ranges (IQRs) for applicant GHGE and cost savings, and assumed no cost or GHGE from virtual interviews. We used Wilcoxon signed rank sum tests to compare in-person 2019-2020 and virtual 2020-2021 GME program interview budgets. Results: The survey response rate was 565, or 40% of applicants; 543 remained after the exclusion criteria were applied. Reduction in applicant travel due to virtual interviews led to median estimated GHGE savings of 0.47 (IQR 0.30-0.61) MTCO2e and $490 (IQR $392-$544) per applicant, per interview. Programs savings ranged from $7,615 to $33,670 for the interview season. Conclusions: Virtual interviews in 8 GME programs were associated with lower estimated GHGE and costs, for applicants and programs, compared with in-person interviews.

Impact of the Affordable Care Act Medicaid Expansion on Weight Loss among Community Health Center Patients with Obesity.

Context: Obesity affects over 40% of the US population and is linked to multiple preventable health conditions which can cause premature morbidity and mortality. Weight loss of at least 5% in patients with obesity reduces their risk of comorbid conditions and leads to improvement in some conditions, such as diabetes. Patients with obesity from underserved populations are less likely to access primary and preventive care services. The Affordable Care Act (ACA) improved access to care, which may in turn improve access to obesity prevention and treatment and assist with weight loss. Objective: Assess whether the proportion of patients with a weight loss ≥5% was higher in states that expanded Medicaid relative to non-expansion states among patients with obesity receiving care in community health centers (CHCs) which provide health care to underserved patients. Study Design: Retrospective observational cohort study. Setting: Electronic health record data from the ADVANCE (Advancing Data Value Across a National Community Health Center) clinical research network, during years 2012-2017. Population Studied: Patients from 346 CHCs age 19-64 with a body mass index of ≥ 30 kg/m2 during the pre-ACA period (n=34,027). Outcome measures: Proportion of patients with weight loss >5% (WL5+) from pre- to post-ACA. Medicaid expansion status (expansion vs. non-expansion states) stratified by pattern of insurance (uninsured, continuously insured, newly insured, discontinuously insured) and race and ethnicity. Results: The proportion of patients with WL5+ for newly insured patients was greater in expansion (26%) than non-expansion states (20%) (χ2=9.75, p=0.002). Among newly insured patients, Hispanic (22%) and Black (29%) patients residing in expansion states, had larger proportion of patients with WL5+ than those in non-expansion states (20% and 18%, respectively). No differences were observed among non-Hispanic White patients (expansion 28% vs non-expansion 27%). Conclusions: The findings suggest greater improvement in weight management among patients residing in expansion states than those in non-expansion states, especially among racial and ethnic minorities receiving care in CHCs.

Effectiveness of Virtual Residency Interviews: Interviewer Perspectives.

BACKGROUND AND OBJECTIVES: Virtual residency interviews were widely utilized during the COVID-19 pandemic. Little is known about the effectiveness, advantages, barriers, and acceptability of virtual interviews, casting uncertainty about how interviews should be conducted after the pandemic. We conducted a survey of interviewers to inform future decisions. METHODS: We developed and implemented an online postinterview survey of interviewers representing seven residency programs and two clinical psychology programs at one midsized academic medical center. We analyzed results using descriptive statistics. RESULTS: Of 312 interviewers, 136 completed the survey (44% response rate). A majority rated virtual interviews as very or extremely effective in creating a comfortable setting (79%), answering interviewee questions (86%), establishing a sense of connection (59%), evaluating interviewee strengths (64%), and communicating program culture (51%). About half felt virtual interviews were not effective at all or only slightly effective for evaluating interviewee strengths via informal interactions (51%). A similar portion agreed or strongly agreed that virtual tours (44%) and social environment (50%) information were adequate. The most frequent advantages were time efficiency (81%), reduced carbon footprint (61%) and cost savings (56%). Frequent disadvantages included technological issues (21%) and caregiving duties (18%). Most interviewers (91%) thought some form of virtual interviews should be incorporated postpandemic. CONCLUSIONS: Interviewers found virtual interviews to be effective in most aspects, and identified more advantages than barriers. The vast majority preferred incorporation of virtual interviews in the future. Virtual tours and social activities were areas for improvement.

An Effective Gender-Affirming Care and Hormone Prescribing Standardized Patient Case for Residents.

Introduction: It is estimated that at least 700,000 individuals in the United States identify as transgender or gender expansive. Many have confronted marginalization within the health care system, leading to suboptimal care and inequitable health outcomes. Health sciences trainees do not receive adequate training in gender-affirming care. The authors therefore created, piloted, and evaluated a formative standardized patient case for gender-affirming care for family medicine resident learners that could be given with limited resources in primary care and health professional education. Methods: The curriculum for the case was developed with patient input and with family medicine physicians skilled in education, simulation, and gender-affirming care. The first case was held for 20 residents in a 4-year family medicine program in the Pacific Northwest. Nineteen participants completed pre/post case surveys delineating knowledge, awareness, attitudes, and intended behavior regarding providing gender-affirming care. Results: Self-reported knowledge and awareness increased after standardized patient case participation in multiple skill areas related to providing gender-affirming care. Faculty observers informally reported that the session increased their knowledge and comfort as well. Discussion: Implementation of this gender-affirming standardized patient case inclusive of community input was associated with successful improvements in self-reported measurements of resident knowledge and awareness of providing gender-affirming care. Additional institutions should consider such training to improve health care equity for this population.

Virtual Residency Interviews: Applicant Perceptions Regarding Virtual Interview Effectiveness, Advantages, and Barriers.

Background: Studies of the virtual interview format are needed to inform medical residency program leaders as they plan for future virtual interview seasons. Objective: In the current study, completed in 2021, we sought to assess applicant perspectives of virtual interview effectiveness, advantages, and barriers, including factors that might impact equity and inclusion. Methods: Interviewees applying to 7 residency programs and 2 clinical psychology programs at an academic medical center in the Pacific Northwest completed a post-interview survey. Results: A total of 565 of 1429 interviewees (40%) completed the survey. A vast majority (83%-96%) agreed virtual interviews were effective in each measured domain, except for learning institutional culture (352 of 565, 62%). Many also found information regarding social/living environments inadequate. Participants selected advantages to virtual interviews more frequently than disadvantages. Commonly selected advantages included cost savings, time efficiency, reduced burden of travel, and reduced carbon footprint. Disadvantages included time zone differences, access to an appropriate interview setting, and reliable access to internet. The majority of interviewees (84%, 456 of 542) desired to keep a component of virtual interviews in the future. There were no significant disparities in results based on gender, rural/suburban/urban location, race, or underrepresented minority status. Conclusions: Virtual interviews were perceived as effective, more advantageous than burdensome, and widely acceptable, with no disparities in these findings by included demographic characteristics.

Depression and socioeconomic stressors in expectant parents with fetal congenital anomalies.

OBJECTIVE: Congenital anomalies are increasingly diagnosed before birth, which may lead to psychological distress in expectant parents. While the presence of significant symptoms of depression and stress in these parents is established, understanding their context within parents' other life stressors has not been fully investigated. We sought to characterize the socioeconomic profile and depression symptoms of expectant parents in a quaternary care academic hospital's fetal care clinic. METHODS: This prospective observational study enrolled pregnant persons and their partners in our fetal care clinic. The Edinburgh Postpartum Depression Scale (EPDS), Tool Assessing Patient Stress (TAPS), and a sociodemographic survey were utilized to assess parent psychological distress and socioeconomic stressors. Results were analyzed by the severity of the fetal anomaly. EPDS was repeated at two weeks postpartum. RESULTS: 21.7% of pregnant subjects and 25.0% of co-parents had a positive screen on the EPDS at enrollment during their pregnancy. Mothers' EPDS scores correlated with the severity of the fetal anomaly. Many parents reported socioeconomic stressors including: living remotely from the medical center, low household income, food insecurity, unemployment, or other employment concerns, and difficulty affording living expenses. Most also reported factors that can mitigate psychological distress including social support and participation in a religion or faith. CONCLUSIONS: Expectant parents with fetal anomalies should be screened for depression as well as social and economic risk factors that place them and their infants at higher risk for poor health outcomes. Further work is needed to determine the optimum interventions for addressing their depression symptoms and reducing socioeconomic stressors.

Associations of retention on buprenorphine for opioid use disorder with patient characteristics and models of care in the primary care setting.

INTRODUCTION: Buprenorphine, a medication for opioid use disorder (OUD), can be administered within primary care; however, little is known about characteristics associated with retention on buprenorphine in these settings. This study examines patient correlates of buprenorphine retention and whether an integrated, interdisciplinary treatment model (buprenorphine and behavioral health) is associated with higher odds of buprenorphine retention than a primarily medication-only treatment model. METHODS: Electronic health record data from adult patients with an OUD, ≥1 buprenorphine order and ≥1 visit to either of two primary care clinics between 9/2/2014-6/27/2018 were extracted (N = 494 patients). Two research team members reviewed the medication start and stop dates for each buprenorphine order and classified as retained (≥6 months of orders) or not retained (<6 months of orders). Logistic regressions estimated the odds of retention on buprenorphine by 1) patient characteristics and 2) timing of patient's engagement in buprenorphine treatment (pre- or post-implementation of an integrated treatment model). RESULTS: Of the study sample, 53% had ≥6 months of buprenorphine orders. Almost two times higher odds of retention were found among patients with ≥1 psychiatric comorbidity (versus none) and among those with buprenorphine orders in the post- versus pre-period. CONCLUSIONS: An integrated, interdisciplinary model of OUD treatment was associated with ≥6 months of buprenorphine orders among our study population. Continued research is needed in real-world primary care settings to understand the impact of OUD treatment models on patient outcomes. A more nuanced examination of the associations between psychiatric diagnoses and buprenorphine treatment retention is warranted.

Effects of Implementing an Interactive Substance Use Disorders Workshop on a Family Medicine Clerkship.

BACKGROUND AND OBJECTIVES: Substance use disorders (SUD) remain a public health crisis and training has been insufficient to provide the skills necessary to combat this crisis. We aimed to create and study an interactive, destigmatizing, skills-based workshop for medical students to evaluate if this changes students' self-reported knowledge, skills, and attitudes toward patients with SUD. METHODS: We surveyed students on a required family medicine outpatient rotation at a Pacific Northwest medical school during clerkship orientation on their views regarding SUDs utilizing the validated Drug and Drug Problems Perceptions Questionnaire containing a 7-point Likert scale. After attending a substance use disorder workshop, they repeated the survey. We calculated differences between the paired pre- to postsurveys. RESULTS: We collected the pre- and postdata for 118 students who attended the workshop and showed statistically significant positive differences on all items. CONCLUSIONS: The positive change in the medical students' reported attitudes suggests both necessity and feasibility in teaching SUD skills in a destigmatizing way in medical training. Positive changes also suggest a role of exposing students to family medicine and/or primary care as a strategy to learn competent care for patients with substance use disorders.

A Family Systems Curriculum: Evaluating Skills and Empathy.

BACKGROUND AND OBJECTIVES: Training residents in family-centered approaches offers an opportunity to investigate how learners translate skills to real clinical encounters. Previous evaluations of a family systems curriculum have relied on self-assessment and narrative reflection to assess resident learning. Assessment of learning using encounter observation and objective tools, including evaluation of empathy, allows for a deeper understanding of how residents transform curricular education into clinical practice. METHODS: We evaluated resident learning from a longitudinal family systems curriculum delivered during the third year of a four-year residency training program. Using the Family-Centered Observation Form (FCOF), we analyzed seven pre- and postcurriculum videotaped encounters for changes in family-centered interviewing skills. We assessed changes in empathy before and after the curriculum using the Jefferson Empathy Scale. RESULTS: There was a trend toward improvement in all family-centered skills, as measured by the FCOF, though the improvements were only statistically significant in the area of rapport building. Statistically significant improvement in empathy occurred for all participants. Narrative reflection demonstrated that residents found the curriculum valuable in ways that we were unable to objectively measure. CONCLUSIONS: Training in family systems can enhance patient interactions and may improve empathy. Evaluation of family-centered skills is challenging and takes a significant amount of time and planning. The FCOF can help learners identify how to use family-centered concepts and skills in a typical family medicine outpatient visit. Further study is needed to determine whether patients seen by doctors who use family-oriented skills have better experiences or outcomes.

Hospitalist Perceptions of Fall Prevention: A Comparison of Two Health Care Systems.

Inpatient falls are common, but little is known about hospitalist perceptions regarding their exact role in fall prevention. The authors conducted a cross-sectional analysis of hospitalists' attitudes and perceived barriers to fall prevention practices in 2 different hospital systems in Portland, Oregon. A total of 42 responses were collected. Although hospitalists in both groups agreed that all patients admitted should undergo fall risk assessments (FRAs), both groups disagreed that hospitalists should be responsible for performing them. Neither group felt that they had the time to complete FRAs and were either neutral or felt the lack of expertise to conduct them. These findings suggest that the hospitalist role in inpatient fall prevention multidisciplinary teams may be unclear to physician providers and that health care systems may benefit from examining this further.

Effects of Clinic First Educational Interventions on Resident Wellness and Engagement.

BACKGROUND AND OBJECTIVES: Tensions between clinical and hospital training, along with dysfunctional family medicine training clinics, have resulted in continuity clinic being the least favorite part of training for some residents. These factors are all contributors to burnout. We hypothesized that following Clinic First action steps to prioritize and enhance outpatient clinic would positively affect resident wellness and clinic engagement. This study describes our interventions and their effects within the Oregon Health & Science University (OHSU) Family Medicine 4-year Portland residency program. METHODS: In July 2017 the Oregon Health & Science University Family Medicine Portland residency program implemented scheduling and curricular interventions inspired by the Clinic First model. We conducted a mixed-methods cross-sectional study using focus groups and surveys to understand the effects of these interventions on resident wellness and engagement. RESULTS: Clinic First-inspired interventions, particularly a 2+2 scheduling model, decreased transitions within the day, and a clinic immersion month were associated with improved residents' perception of wellness. These interventions had variable effects on clinic engagement. Eighty-eight percent of interns surveyed about the month-long clinic orientation in the beginning of residency reported that they felt prepared managing continuity patients in the clinic setting and their upcoming rotations. CONCLUSIONS: This study demonstrates that Clinic First-inspired structural changes can be associated with improvement in resident perceptions of wellness and aspects of clinic engagement. This can give educators a sense of hope as well as tangible steps to take to improve these difficult and important issues.

Nonclinical Factors in Autism Diagnosis: Results From a National Health Care Provider Survey.

OBJECTIVE: The prevalence of autism spectrum disorder (ASD) has increased 10-fold in the past 40 years, and disparities have been noted by race/ethnicity and socioeconomic status, prompting concern about diagnostic accuracy. Provider perceptions of ASD diagnostic accuracy are not known. We conducted a survey of providers who diagnose ASD assessing how nonclinical factors might affect ASD diagnostic rates. METHODS: The mixed-mode survey was sent to the members of the Society of Developmental and Behavioral Pediatrics with clinical interest in ASD (n = 400). Respondents used a Likert-type scale to address how often they and their colleagues overdiagnosed or underdiagnosed ASD. They were also asked how families grouped by race/ethnicity, education, socioeconomic status, and urbanicity perceived an ASD diagnosis. RESULTS: Sixty-three percent of providers completed the survey. Eight point seven percent of providers self-reported that they overdiagnose ASD at least sometimes. However, 58% of providers reported that local colleagues overdiagnose ASD at least sometimes. Seven point eight percent of providers self-reported underdiagnosing ASD at least sometimes and cited parents not wanting a diagnosis as one of the most common reasons they may underdiagnose. Providers reported that non-white and rural families were more likely to think that ASD diagnosis was "a bad thing" than "a good thing" than white and urban and suburban families, respectively. CONCLUSION: Providers report moderate rates of ASD misdiagnosis and perceive differences in diagnostic preferences according to family characteristics. The study results may help explain the trends and disparities in ASD diagnosis.

Cervical and colorectal cancer screening prevalence before and after Affordable Care Act Medicaid expansion.

Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an increase in insured visits after the 2014 Affordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs. Electronic health record data on 624,601 non-pregnant patients aged 21-64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using difference-in-difference methodology. Female patients had 19% increased odds of receiving cervical cancer screening post- relative to pre-ACA in expansion states [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.09-1.31] and 23% increased odds in non-expansion states (aOR = 1.23, 95% CI = 1.05-1.46): the greatest increase was among uninsured patients in expansion states (aOR = 1.36, 95% CI = 1.16-1.59) and privately-insured patients in non-expansion states (aOR = 1.43, 95% CI = 1.11-1.84). Colorectal cancer screening prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states. For most outcomes, the observed changes were not significantly different between expansion and non-expansion states. Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.

Personal characteristics associated with the effect of childhood trauma on health.

Objective This article will describe a pilot study to explore associations between adult attachment style, resilience, Adverse Childhood Experiences, and adult health. Method A self-report survey was mailed to 180 randomly selected primary care patients and linked to a retrospective chart review. The patients met the following criteria: (1) enrolled for at least the previous year at their primary care clinic, (2) 21 years of age or greater, (3) English as their primary language, and (4) were seen by their provider on selected dates of the study. The survey was made up of three instruments: (1) the Adverse Childhood Experiences Questionnaire which consists of 10 questions about the respondent's adverse experiences during their first 18 years of life; (2) the Relationship Scales Questionnaire which measures adult attachment style; and (3) the Connor-Davidson Resilience Scale, a self-report scale that measures individual's perceptions of their resilience. For each returned questionnaire, we calculated a measure of medical complexity using the Elixhauser Comorbidity Index. Results Of the 180 randomly selected patients from four clinic sites, 84 (46.6%) returned completed questionnaires. We found that Adverse Childhood Experience scores were significantly correlated with health and attachment style and trended toward association with resilience. Conclusion This pilot study revealed expected relationships of the complex associations between Adverse Childhood Experiences, attachment style, and resiliency. Further research with more subjects is warranted in order to continue to explore these relationships.

Quantification of nutritive sucking among preterm and full-term infants.

PURPOSE: We developed summaries of oral bottle-feeding skills among preterm (<37 gestational weeks) and full-term (≥37 gestational weeks) infants using a mechanical device (Orometer) to measure intraoral pressure changes, with accompanying automated software and analytics. We then compared the rates of change in feeding skills over several weeks (feeding trends) between preterm and full-term infants. We also compared group means at 40 weeks post menstrual age (PMA). PATIENTS AND METHODS: Healthy full-term and preterm infants capable of oral feeding were recruited from the Pediatric Outpatient Clinic at University of California San Francisco, Fresno, and from the Oregon Health & Science University Doernbecher Neonatal Critical Care Unit, respectively. Feeding skill was quantified using an Orometer and automated suck-analysis software. Factor analysis reduced the >40 metrics produced by the Orometer system to the following seven factors that accounted for >99% of the sample covariance: suck vigor, endurance, resting, irregularity, frequency, variability, and bursting. We proposed that these factors represent feeding skills and they served as the dependent variables in linear models estimating trends in feeding skills over time for full-term and preterm infants (maturation). At approximately 40 weeks PMA we compared mean feedings skills between infants born preterm and those born full-term using predictions from our models. RESULTS: Feeding skills for 117 full-term infants and 82 preterm infants were first captured at mean PMA of 42.3 and 36.0 weeks, respectively. For some feeding skills, preterm and full-term infants showed different trends over time. At 37-40 weeks PMA, preterm infants took approximately 15% fewer sucks than infants born full-term (p=0.06) and generally had weaker suck vigor, greater resting, and less endurance than full-term babies. Preterm infant-feeding skills appeared similar to those of full-term infants upon reaching ≥40 weeks PMA, although preterm infants showed greater variability for all factors. CONCLUSION: The Orometer device, accompanying software, and analytic methods provided a framework for describing trends in oral feeding, thereby allowing us to characterize differences in maturation of feeding between healthy preterm and full-term infants.

The Electronic Health Record Objective Structured Clinical Examination: Assessing Student Competency in Patient Interactions While Using the Electronic Health Record.

PROBLEM: Because many medical students do not have access to electronic health records (EHRs) in the clinical environment, simulated EHR training is necessary. Explicitly training medical students to use EHRs appropriately during patient encounters equips them to engage patients while also attending to the accuracy of the record and contributing to a culture of information safety. APPROACH: Faculty developed and successfully implemented an EHR objective structured clinical examination (EHR-OSCE) for clerkship students at two institutions. The EHR-OSCE objectives include assessing EHR-related communication and data management skills. OUTCOMES: The authors collected performance data for students (n = 71) at the first institution during academic years 2011-2013 and for students (n = 211) at the second institution during academic year 2013-2014. EHR-OSCE assessment checklist scores showed that students performed well in EHR-related communication tasks, such as maintaining eye contact and stopping all computer work when the patient expresses worry. Findings indicated student EHR skill deficiencies in the areas of EHR data management including medical history review, medication reconciliation, and allergy reconciliation. Most students' EHR skills failed to improve as the year progressed, suggesting that they did not gain the EHR training and experience they need in clinics and hospitals. NEXT STEPS: Cross-institutional data comparisons will help determine whether differences in curricula affect students' EHR skills. National and institutional policies and faculty development are needed to ensure that students receive adequate EHR education, including hands-on experience in the clinic as well as simulated EHR practice.

Patient-Provider Communication: Does Electronic Messaging Reduce Incoming Telephone Calls?

PURPOSE: Internet-based patient portals are increasingly being implemented throughout health care organizations to enhance health and optimize communication between patients and health professionals. The decision to adopt a patient portal requires careful examination of the advantages and disadvantages of implementation. This study aims to investigate 1 proposed advantage of implementation: alleviating some of the clinical workload faced by employees. METHODS: A retrospective time-series analysis of the correlation between the rate of electronic patient-to-provider messages-a common attribute of Internet-based patient portals-and incoming telephone calls. The rate of electronic messages and incoming telephone calls were monitored from February 2009 to June 2014 at 4 economically diverse clinics (a federally qualified health center, a rural health clinic, a community-based clinic, and a university-based clinic) related to 1 university hospital. RESULTS: All 4 clinics showed an increase in the rate of portal use as measured by electronic patient-to-provider messaging during the study period. Electronic patient-to-provider messaging was significantly positively correlated with incoming telephone calls at 2 of the clinics (r = 0.546, P < .001 and r = 0.543, P < .001). The remaining clinics were not significantly correlated but demonstrated a weak positive correlation (r = 0.098, P = .560 and r = 0.069, P = .671). CONCLUSIONS: Implementation and increased use of electronic patient-to-provider messaging was associated with increased use of telephone calls in 2 of the study clinics. While practices are increasingly making the decision of whether to implement a patient portal as part of their system of care, it is important that the motivation behind such a change not be based on the idea that it will alleviate clinical workload.

Randomized Controlled Trial of Home-Based Hormonal Contraceptive Dispensing for Women At Risk of Unintended Pregnancy.

CONTEXT: Women frequently experience barriers to obtaining effective contraceptives from clinic-based providers. Allowing nurses to dispense hormonal methods during home visits may be a way to reduce barriers and improve -effective contraceptive use. METHODS: Between 2009 and 2013, a sample of 337 low-income, pregnant clients of a nurse home-visit program in Washington State were randomly selected to receive either usual care or enhanced care in which nurses were permitted to provide hormonal contraceptives postpartum. Participants were surveyed at baseline and every three months postpartum for up to two years. Longitudinal Poisson mixed-effects regression analysis was used to examine group differences in gaps in effective contraceptive use, and survival analysis was used to examine time until a subsequent pregnancy. RESULTS: Compared with usual care participants, enhanced care participants had an average of 9.6 fewer days not covered by effective contraceptive use during the 90 days following a first birth (52.6 vs. 62.2). By six months postpartum, 50% of usual care participants and 39% of enhanced care participants were using a long-acting reversible contraceptive (LARC). In analyses excluding LARC use, enhanced care participants had an average of 14.2 fewer days not covered by effective contraceptive use 0-3 months postpartum (65.0 vs. 79.2) and 15.7 fewer uncovered days 4-6 months postpartum (39.2 vs. 54.9). CONCLUSION: Home dispensing of hormonal contraceptives may improve women's postpartum contraceptive use and should be explored as an intervention in communities where contraceptives are not easily accessible.