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Integrating systematic chronic care for diabetes into an academic general internal medicine resident-faculty practice.

ABSTRACT: BACKGROUND: The quality of care for diabetes continues to fall short of recommended guidelines and results. Models for improving the care of chronic illnesses advocate a multidisciplinary team approach. Yet little is known about the effectiveness of such models in an academic setting with a diverse patient population and resident physicians participating in clinical care. OBJECTIVE: To implement a chronic illness management (CIM) practice within an academic setting with part-time providers, and evaluate its impact on the completion of diabetes-specific care processes and on the achievement of recommended outcomes for patients with diabetes mellitus. DESIGN: Retrospective cohort study SUBJECTS: Patients with the diagnosis of diabetes mellitus who receive their primary care in an academic general internal medicine resident-faculty practice. MEASUREMENTS: Process and outcomes measures in patients exposed to the CIM practice were compared with non-exposed patients receiving usual care. MAIN RESULTS: Five hundred and sixty-five patients met inclusion criteria. Patients in the CIM practice experienced a significant increase in completion of care processes compared to control patients for measurement of annual low-density lipoprotein (LDL) cholesterol (OR 3.1, 95% CI 1.7-5.7), urine microalbumin (OR 3.3, 95% CI 2.1-5.5), blood pressure (OR 1.8, 95% CI 1.1-2.8), retinal examination (OR 1.9, 95% CI 1.3-2.7), foot monofilament examination (OR 4.2, 95% CI 3.0-6.1) and administration of pneumococcal vaccination (OR 5.2, 95% CI 3.0-9.3). CIM-exposed patients were also more likely to achieve improvements in clinical outcomes of glycemic and blood pressure control reflected by hemoglobin A1c less than 7.0% (OR 1.7, 95% CI 1.02-3) and blood pressure less than 130/80 (OR 2.8, 95% CI 2.1-4.5) compared to controls. CONCLUSIONS: A systematic chronic care model can be successfully integrated into an academic general internal medicine practice and may result in improved processes of care and some clinical outcomes for diabetic patients. This study provides a model for further hypothesis generation and more rigorous testing of the quality benefits of structured chronic illness care in diverse outpatient practices.

SUBMITTER: DiPiero A

PROVIDER: S-EPMC2585684 | biostudies-other | 2008 Nov

REPOSITORIES: biostudies-other

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Project description:BackgroundGeneral internal medicine (GIM) careers are increasingly viewed as challenging and unsustainable.ObjectiveWe aimed to assess academic GIM worklife and determine remediable predictors of stress and burnout.DesignWe conducted an email survey.ParticipantsPhysicians, nurse practitioners, and physician assistants in 15 GIM divisions participated.Main measuresA ten-item survey queried stress, burnout, and work conditions such as electronic medical record (EMR) challenges. An open-ended question assessed stressors and solutions. Results were categorized into burnout, high stress, high control, chaos, good teamwork, high values alignment, documentation time pressure, and excessive home EMR use. Frequencies were determined for national data, Veterans Affairs (VA) versus civilian populations, and hospitalist versus ambulatory roles. A General Linear Mixed Model (GLMM) evaluated associations with burnout. A formal content analysis was performed for open-ended question responses.Key resultsOf 1235 clinicians sampled, 579 responded (47 %). High stress was present in 67 %, with 38 % burned out (burnout range 10-56 % by division). Half of respondents had low work control, 60 % reported high documentation time pressure, half described too much home EMR time, and most reported very busy or chaotic workplaces. Two-thirds felt aligned with departmental leaders' values, and three-quarters were satisfied with teamwork. Burnout was associated with high stress, low work control, and low values alignment with leaders (all p < 0.001). The 45 VA faculty had less burnout than civilian counterparts (17 % vs. 40 %, p < 0.05). Hospitalists described better teamwork than ambulatory clinicians and fewer hospitalists noted documentation time pressure (both p < 0.001). Key themes from the qualitative analysis were short visits, insufficient support staff, a Relative Value Unit mentality, documentation time pressure, and undervaluing education.ConclusionsWhile GIM divisions overall demonstrate high stress and burnout, division rates vary widely. Sustainability efforts within GIM could focus on visit length, staff support, schedule control, clinic chaos, and EMR stress.

Project description:INTRODUCTION:Although women have entered medical school and internal medicine residency programs in significant numbers for decades, women faculty remain underrepresented in senior and departmental leadership roles. How residents perceive this gender disparity is unknown. We sought to assess resident perception of gender parity among departmental leadership and teaching faculty in our internal medicine department, and to determine the actual gender distribution of those faculty roles. METHODS:An anonymous cross-sectional survey was distributed to evaluate resident perception of gender representation of various faculty roles. Using conference schedules, resident evaluations, and our department website, we determined the actual representation of women faculty in department leadership roles, and in clinical and educational activities. RESULTS:88 of 164 residents (54%) responded. Women residents were less likely than men to perceive that women faculty were equally represented in department leadership (45% men agreed vs. 13% women, p < 0.05), clinical teaching roles (55% men agreed vs. 28% women, p < 0.05), or facilitating educational conferences (45% men agreed vs. 28% women, p = 0.074). In 2017, the internal medicine department at our institution comprised 815 faculty members, 473 men (58%) and 342 women (42%). At that time, women faculty held 5% of senior departmental leadership positions and 21% of educational leadership positions. During the year preceding survey distribution, women faculty attended on internal medicine inpatient wards for 33% of the total number of weeks, staffed 20% of morning reports, and facilitated 28% of noon conferences. DISCUSSION:Women residents in our internal medicine training program perceived a gender disparity among faculty in leadership and educational positions to a greater extent than male residents. The perception of women trainees was accurate. In addition to disproportionate underrepresentation in leadership positions, women faculty were underrepresented in prominent educational positions, including attending on inpatient services and serving as discussants at educational conferences.

Project description:BackgroundIdentifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors.MethodsWe conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more.ResultsWe screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit.InterpretationOur prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.

Project description:BackgroundThe use of telemedicine has increased dramatically through the COVID-19 pandemic. Although data are available about patient satisfaction with telemedicine, little is known about immigrant patients' experience.ObjectiveWe sought to investigate patients' experiences with telehealth compared to in- person visits between immigrants and nonimmigrants. We wanted to identify and describe next visit preferences within the Farmington University of Connecticut Internal Medicine practice to ultimately guide suggestions for more equitable use and accessibility of visit options.MethodsA total of 270 patients including 122 immigrants and 148 nonimmigrants were seen by 4 Internal Medicine providers in an in-person (n=132) or telemedicine (n=138) university practice setting. Patients were queried between February and April 2021, using an adaptation of a previously validated patient satisfaction survey that contained standard questions developed by the Consumer Assessment of Healthcare Providers and Systems Program. Patients seen via in-person visits completed a paper copy of the survey. The same survey was administered by a follow-up phone call for telemedicine visits. Patients surveyed spoke English, Spanish, or Arabic and were surveyed in their preferred language. For televisits, the same survey was read to the patient by a certified translator. The survey consisted of 10 questions on a Likert scale of 1-5. Of them, 9 questions assessed patient satisfaction under the categories of access to care, interpersonal interaction, and quality of care. An additional question asked patients to describe and explain the reasons behind next visit preferences. Survey question responses were compared by paired t tests.ResultsAcross both immigrant and nonimmigrant patient populations, satisfaction with perceived quality of care was high, regardless of visit type (P=.80, P=.60 for televisits and P=.76, P=.37 for in-person visits). During televisits, immigrants were more likely to feel providers spent sufficient time with them (P<.001). Different perceptions were noted among nonimmigrant patients. Nonimmigrants tended to perceive more provider time during in-person visits (P=.006). When asked to comment on reasons behind next televisit preference, nonimmigrant patients prioritized convenience, whereas immigrants noted not having to navigate office logistics. For those who chose in-person visits, both groups prioritized the need for a physical exam.ConclusionsAlthough satisfaction was high for both telemedicine and in-person visits across immigrant and nonimmigrant populations, significant differences in patient priorities were identified. Immigrants found televisits desirable because they felt they spent more time with providers and were able to avoid additional office logistics that are often challenging barriers for non-English speakers. This suggests opportunities to use information technology to provide cultural and language-appropriate information throughout immigrants' in-person and telemedicine visit experience. A focus on diminishing these barriers will help reduce health care inequities among immigrant patients.

Project description:Background:Assessment of trainees' competency is challenging; the predictive power of traditional evaluations is debatable especially in regard to noncognitive traits. New assessments need to be sought to better understand affective areas like personality. Grit, defined as "perseverance and passion for long-term goals," can assess aspects of personality. Grit predicts educational attainment and burnout rates in other populations and is accurate with an informant report version. Self-assessments, while useful, have inherent limitations. Faculty's ability to accurately assess trainees' grit could prove helpful in identifying learner needs and avenues for further development. Objective:This study sought to determine the correlation between EM resident self-assessed and faculty-assessed Grit Scale (Grit-S) scores of that same resident. Methods:Subjects were PGY-1 to -4 EM residents and resident-selected faculty as part of a larger multicenter trial involving 10 EM residencies during 2017. The Grit-S Scale was administered to participating EM residents; an informant version was completed by their self-selected faculty. Correlation coefficients were computed to assess the relationship between residents' self-assessed and the residents' faculty-assessed Grit-S score. Results:A total of 281 of 303 residents completed the Grit-S, for a 93% response rate; 200 of 281 residents had at least one faculty-assessed Grit-S score. No correlation was found between residents' self-assessed and faculty-assessed Grit-S scores. There was a correlation between the two faculty-assessed Grit-S scores for the same resident. Conclusion:There was no correlation between resident and faculty-assessed Grit-S scores; additionally, faculty-assessed Grit-S scores of residents were higher. This corroborates the challenges faculty face at accurately assessing aspects of residents they supervise. While faculty and resident Grit-S scores did not show significant concordance, grit may still be a useful predictive personality trait that could help shape future training.

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Integrating systematic chronic care for diabetes into an academic general internal medicine resident-faculty practice.

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