Ambulatory Care Experience Research Articles

Learning in Tension: A Case Study Examining What Internal Medicine Residents Learn in the Ambulatory Care Setting.

Medical care of patients with complex conditions has shifted to the ambulatory setting, whereas current knowledge of resident learning is primarily based on studies from inpatient settings. Preparing trainees to adapt to this shift necessitates an understanding of what internal medicine (IM) residents currently learn during ambulatory rotations. The aim of this study is to identify what residents learn during their ambulatory care experience. Using a qualitative instrumental case study design, the authors conducted separate focus groups with IM trainees (n = 15), supervisors (n = 16), and program directors (n = 5) from two IM programs in New York City, USA in 2019. Participants were invited via email, and focus group sessions were complemented by document analysis of ambulatory syllabi. Based on focus group commentary and document analysis, content learned in the ambulatory setting encompassed three domains; 1) patient needs, 2) the resident's role within a healthcare team, and 3) health system opportunities and limitations. Residents also learned about tensions within and between these domains including the skills needed to care for patients versus the skills acquired, a desire for ownership of patient care versus fragmented care, and time allotted versus time required. This study revealed two outcomes about what residents learn during their ambulatory care experience. First, learning content largely fell into three domains. Second, residents learned about the tensions between ideal care delivery and the realities of practice. These results highlight the imperative to better align curricula with clinical environments to meet the learning needs of residents.

Understanding Racial, Ethnic, and Socioeconomic Differences in the Ambulatory Care Experience.

Racial and ethnic and socioeconomic differences in patient experience are prevalent and can negatively impact health outcomes. Our objective was to examine differences in family experience of care in the pediatric ambulatory setting. We conducted interviews with parents of patients from different demographic groups who had received care at 1 of 3 clinics at a quaternary children's hospital. Multidisciplinary team conducted inductive and deductive thematic analysis of transcribed interviews. Sentiments and recurring themes were compared within and between racial and ethnic groups, insurance status, and language. Eighty parents were interviewed. Three primary themes were identified: (1) mitigation of system issues: parents' mixed experiences with staff or clinicians mitigating system issues impacted their overall perceptions of care; (2) pivotal role of personal interactions: clinicians' interactions positively influenced family-clinician relationships and offset negative experiences; (3) effective explanations: clinicians' clear and thorough explanations were crucial in enhancing parent confidence in care. As an overarching theme, discrimination and disrespect by staff undermined trust in care, affecting all aspects of experience. With the exception of explanations, a higher proportion of publicly-insured parents reported negative experiences across all themes compared to those with private insurance. Asian parents with public insurance had the highest proportion of interviews that were mainly negative in sentiment. Our findings offer nuanced insights into differences in the experience of ambulatory care. Insurance status emerged as an important marker of differential perceptions of care. Our study points to areas for improvement and highlights family-clinician interactions as vital to overall positive experience.

Veterans’ ambulatory care experience during COVID-19: veterans’ access to and satisfaction with primary care early in the pandemic

BackgroundThe COVID-19 pandemic caused widespread changes to healthcare, but few studies focus on ambulatory care during the early phase of the pandemic. We characterize veterans’ ambulatory care experience, specifically access and satisfaction, early in the pandemic.MethodsWe employed a semi-structured telephone interview to capture quantitative and qualitative data from patients scheduled with a primary care provider between March 1 – June 30, 2020. Forty veterans were randomly identified at a single large urban Veterans Health Administration (VHA) medical center. The interview guide utilized 56 closed and open-ended questions to characterize veterans’ perceptions of access to and satisfaction with their primary care experience at VHA and non-VHA primary care sources. We also explored the context of veterans' daily lives during the pandemic. We analyzed quantitative data using descriptive statistics and verbatim quotes using a matrix analysis.ResultsVeterans reported completing more appointments (mean 2.6 (SD 2.2)) than scheduled (mean 2.3 (SD 2.2)) mostly due to same-day or urgent visits, with a shift to telephone (mean 2.1 (SD 2.2)) and video (mean 1.5 (SD 0.6)). Among those who reported decreased access to care early in the pandemic (n = 27 (67%)), 15 (56%) cited administrative barriers (“The phone would hang up on me”) and 9 (33%) reported a lack of provider availability (“They are not reaching out like they used to”). While most veterans (n = 31 (78%)) were highly satisfied with their VHA care (mean score 8.6 (SD 2.0 on a 0–10 scale), 9 (23%) reported a decrease in satisfaction since the pandemic. The six (15%) veterans who utilized non-VHA providers during the period of interest reported, on average, higher satisfaction ratings (mean 9.5 (SD 1.2)).Many veterans reported psychosocial effects such as the worsening of mental health (n = 6 (15%)), anxiety concerning the virus (n = 12 (30%)), and social isolation (n = 8 (20%), “I stay inside and away from people”).ConclusionsWhile the number of encounters reported suggest adequate access and satisfaction, the comments regarding barriers to care suggest that enhanced approaches may be warranted to improve and sustain veteran perceptions of adequate access to and satisfaction with primary care during times of crisis.

Admitting what is needed: How the health system and society can reduce hospitalizations for children with medical complexity.

Admitting what is needed: How the health system and society can reduce hospitalizations for children with medical complexity.

A team-led remote ambulatory care rotation: Creating efficiency without sacrificing quality

Background and purposeAdvanced pharmacy practice experiences (APPEs) are a highly anticipated part of the doctor of pharmacy program. Traditionally, these rotations are offered as full-time, onsite experiences. However, there are situations in which geography, transportation, and housing requirements limit the accessibility of these experiences. Additionally, unexpected changes in rotation schedules or resource limitations may leave students in a difficult situation when completing their rotation hours. Having the ability to provide a remote APPE that results in similar student learning outcomes provides flexibility to experiential directors and ensures students' continued progression towards graduation. Educational activity and settingA group of faculty members and post-graduate trainees collaborated to create a remote, one-month ambulatory care experience for 18 students over three months. Students had access to the electronic health record (EHR) from their homes through a partnership with a local federally qualified health center. Access to the EHR enabled the students to participate in telehealth visits and have meaningful interactions with patients as if they were on-site. Students were also able to participate in topic discussions, answer drug information questions, complete a literature evaluation series, and work on projects remotely through this rotation. Findings and summaryThis remote rotation allowed preceptors to meet the educational needs of students while allowing them to provide patient care through telehealth. Data from summative student evaluations, student evaluations of preceptor and site, and a supplemental survey demonstrate that this remote rotation is a meaningful learning experience for students and is comparable to similar in-person rotations.

Factors associated with hospital admission and severe outcomes for older patients with COVID-19.

BackgroundMorbidity and death due to coronavirus disease 2019 (COVID‐19) experienced by older adults in nursing homes have been well described, but COVID‐19's impact on community‐living older adults is less studied. Similarly, the previous ambulatory care experience of such patients has rarely been considered in studies of COVID‐19 risks and outcomes.MethodsTo investigate the relationship of advanced age (65+), on risk factors associated with COVID‐19 outcomes in community‐living elders, we identified an electronic health records cohort of older patients aged 65+ with laboratory‐confirmed COVID‐19 with and without an ambulatory care visit in the past 24 months (n = 47,219) in the New York City (NYC) academic medical institutions and the NYC public hospital system from January 2020 to February 2021. The main outcomes are COVID‐19 hospitalization; severe outcomes/Intensive care unit (ICU), intubation, dialysis, stroke, in‐hospital death), and in‐hospital death. The exposures include demographic characteristics, and those with ambulatory records, comorbidities, frailty, and laboratory results.ResultsThe 31,770 patients with an ambulatory history had a median age of 74 years; were 47.4% male, 24.3% non‐Hispanic white, 23.3% non‐Hispanic black, and 18.4% Hispanic. With increasing age, the odds ratios and attributable fractions of sex, race–ethnicity, comorbidities, and biomarkers decreased except for dementia and frailty (Hospital Frailty Risk Score). Patients without ambulatory care histories, compared to those with, had significantly higher adjusted rates of COVID‐19 hospitalization and severe outcomes, with strongest effect in the oldest group.ConclusionsIn this cohort of community‐dwelling older adults, we provided evidence of age‐specific risk factors for COVID‐19 hospitalization and severe outcomes. Future research should explore the impact of frailty and dementia in severe COVID‐19 outcomes in community‐living older adults, and the role of engagement in ambulatory care in mitigating severe disease.

Resident Physician Experience and Duration of Electronic Health Record Use.

Electronic health records (EHRs) demand a significant amount of physician time for documentation, orders, and communication during care delivery. Resident physicians already work long hours as they gain experience and develop both clinical and socio-technical skills. Measure how much time resident physicians spend in the EHR during clinic hours and after-hours, and how EHR usage changes as they gain experience over a 12-month period. Longitudinal descriptive study where participants were 622 resident physicians across postgraduate year cohorts (of 948 resident physicians at the institution, 65.6%) working in an ambulatory setting from July 2017 to June 2018. Time spent in the EHR per patient, patients records documented per day, and proportion of EHR time spent after-hours were the outcome, while the number of months of ambulatory care experience was the predictor. Resident physicians spent an average of 45.6 minutes in the EHR per patient, with 13.5% of that time spent after-hours. Over 12 months of ambulatory experience, resident physicians reduced their EHR time per patient and saw more patients per day, but the proportion of EHR time after-hours did not change. Resident physicians spend a significant amount of time working in the EHR, both during and after clinic hours. While residents improve efficiency in reducing EHR time per patient, they do not reduce the proportion of EHR time spent after-hours. Concerns over the impact of EHRs on physician well-being should include recognition of the burden of EHR usage on early-career physicians.

The Impact of an Early Clinical Experience on Pharmacy Student Learning About Ambulatory Care Practice

Objective. To determine whether student confidence in their knowledge of ambulatory care pharmacy and ability to contribute to patient care in this setting increased after participating in an ambulatory care introductory pharmacy practice experience (IPPE), and whether it changed student interest in pursuing a career in ambulatory care pharmacy.Methods. Second-year pharmacy students (n=86) completed a required ambulatory care experience which included four hours of didactic work and 13.5 hours of clinic experience with an ambulatory care pharmacist. Before and after the experience, students completed an eight-question survey in which they rated their confidence in their knowledge of ambulatory care practice and in providing patient care in this setting, as well as their interest in a career in ambulatory care. A five-point Likert scale was used to assess student confidence (1=not at all confident, 5=very confident) and interest in ambulatory care (1=not at all interested, 5=extremely interested). The Wilcoxon signed rank test was used to compare pre-post survey responses.Results. Eighty-five pharmacy students completed both the pre- and post-survey. Median scores on the post-intervention test increased from 3 to 4 in seven of the domains assessed. Student interest in a career in ambulatory care remained unchanged.Conclusion. An ambulatory care IPPE increased student confidence in their understanding of ambulatory care pharmacy practice and caring for patients in this setting.

Ambulatory Care Preferences of Older People Age 80 and Over: A Systematic Review of Qualitative Studies

According to the United Nations, the number of people aged 80 and over is expected to treble by 2050 globally. But research on the preferences for care of this age group grows slowly. To achieve high-quality patient-centered care, we need to understand the oldest people’s specific living circumstances, care preferences and goals. The aim of the study was to synthesize findings about ambulatory care preferences, experiences and expectations of people aged 80 and over. We systematically searched Medline, CINAHL, PsycInfo, Web of Science Core Collection and Google Scholar for qualitative studies published until October 2019 and additionally conducted forward and backward citation search for included studies. Two independent reviewers assessed studies for eligibility criteria and quality. We performed a thematic synthesis of study findings as developed by Thomas and Harden using MAXQDA-20 content analysis software. Twenty-three studies were included. They were mainly conducted in Europe, used face-to-face interviews, reported on ambulatory home care and used qualitative content or thematic analysis. The meta-synthesis revealed two fundamental themes from the perspective of older people: feeling safe and feeling valued in their relationships with caregivers and in their care environment. This was shown, for instance, in preferences for coordinated care, high continuity of caregivers, personal attention and interactions based on trust and respect. In practice, the older persons’ preferences should be integrated into care planning and policies to ensure patient-centered care.

Effect of hospital interventions to improve patient flow on emergency department clinical quality indicators

IntroductionThe Royal College of Emergency Medicine highlights poor flow through hospitals as a major challenge to improving emergency department flow. We describe the effect of several hospital-wide flow interventions on...

University of Nevada, Reno School of Medicine

University of Nevada, Reno School of Medicine

Training in the Era of EHR: Examining the Experience of Medical Student Documentation in the Ambulatory Care Setting.

This article was migrated. The article was marked as recommended. Purpose: Documenting clinical encounters in the electronic health record has become an important component of medical student training. Reflecting this trend, recent rule changes by the Centers for Medicare and Medicaid services now permit billing for medical student notes. We sought to investigate the educational value of student note-writing following implementation of these changes. Methods: We surveyed medical students at a private research university who participated in longitudinal ambulatory care experiences. Survey questions assessed the incorporation of student note-writing into clinic workflow, as well as the benefits and disadvantages of note-writing. Results: Thirty-six students completed the survey. A majority of students perceived benefits in regards to residency preparedness, engagement with the clinical team, and clinical reasoning ability as a result of writing notes in clinic. While some students reported seeing fewer patients as a result of note-writing, most felt that use of the electronic health record did not negatively impact patient interaction. Barriers cited included a lack of knowledge regarding billing requirements and preceptor apprehension toward student note-writing. Conclusion: The results of this study indicate that student note-writing continues to be a valuable part of medical training following recent billing changes. Our results also identify areas for improvement, including clarifying billing requirements and assuaging preceptor concerns.

Impact of Student Pharmacists Teaching a Diabetes Self-Management Education and Support Class

Objective. To evaluate student pharmacists' knowledge of diabetes and self-perceptions of aptitude and confidence before and after teaching a diabetes self-management education and support (DSMES) class. Methods. Students enrolled in an advanced pharmacy practice experience (APPE) in ambulatory care were randomly assigned to the intervention group (taught a DSMES class) or control group (did not teach a DSMES class) between June 2016 to April 2018. Students self-assessed their aptitude and confidence using a 14-item pre- and post-intervention survey instrument. Additionally, participants completed a 10-item diabetes knowledge evaluation at baseline and during week three or four of the APPE. Results. Forty-six students participated in the study (26 students in the intervention group and 20 in the control group). Students in the intervention cohort demonstrated a significant improvement in their knowledge score (81.8% post-intervention vs 68.4% pre-intervention). Students in the control cohort did not experience a significant change in knowledge scores from pre- to post-intervention evaluation (70.0% vs 74.1%). The intervention cohort achieved a significantly greater improvement in confidence scores compared to the control group (11.8 vs 6.7 increase in scores, respectively). Conclusion. A student pharmacist team-taught DSMES class resulted in significant improvement in diabetes knowledge, aptitude, and confidence. Student pharmacist participation in a DSMES class may improve knowledge and enhance confidence, while offering an opportunity to advance the pharmacy practice model in ambulatory care.

Ambulatory Care Training Within Postgraduate Year 2 Pediatric Pharmacy Residency Programs.

This study evaluates pediatric ambulatory care training opportunities for postgraduate year 2 (PGY2) pediatric pharmacy residents. An online survey was disseminated to PGY2 pediatric pharmacy residency directors. The questions involved the number and type of pediatric ambulatory care rotations offered; number of preceptors who practice in pediatric ambulatory care; whether or not a pediatric ambulatory care rotation is a requirement of the program; length and format of the rotations; amount of time residents spend in the pediatric ambulatory care setting; and the resident's role during pediatric ambulatory care rotations. The survey yielded an 85% response rate (n = 41/48). Most residency programs offer at least 1 pediatric ambulatory care rotation (n = 38; 93%), most of which are longitudinal experiences, and two thirds of programs require their resident(s) to complete a pediatric ambulatory care rotation (n = 27; 66%). These experiences involve a variety of specialty clinics, and residents assume diverse roles and responsibilities. Few programs offer residents the opportunity to practice under a collaborative drug therapy management agreement (n = 6; 15%) or develop new clinical services (n = 6; 15%). Most residency program directors (n = 39; 95%) reported that less than 25% of their residency graduates work in the pediatric ambulatory care setting. Ambulatory care experiences in PGY2 pediatric pharmacy residency programs are diverse in number and scope. There is an opportunity to expand pediatric ambulatory care rotation offerings, particularly with respect to collaborative drug therapy management and the establishment of new clinical services.

Patient Experience with Primary Care Physician and Risk for Hospitalization in Hispanics with CKD.

In the general population, the quality of the patient experience with their primary care physician may influence health outcomes but this has not been evaluated in CKD. This is relevant for the growing Hispanic CKD population, which potentially faces challenges to the quality of the patient experience related to language or cultural factors. We evaluated the association between the patient experience with their primary care physician and outcomes in Hispanics with CKD. This prospective observational study included 252 English- and Spanish-speaking Hispanics with entry eGFR of 20-70 ml/min per 1.73 m2, enrolled in the Hispanic Chronic Renal Insufficiency Cohort study between 2005 and 2008. Patient experience with their primary care physician was assessed by the Ambulatory Care Experiences Survey subscales: communication quality, whole-person orientation, health promotion, interpersonal treatment, and trust. Poisson and proportional hazards models were used to assess the association between the patient experience and outcomes, which included hospitalization, ESKD, and all-cause death. Participants had a mean age of 56 years, 38% were women, 80% were primary Spanish speakers, and had a mean eGFR of 38 ml/min per 1.73 m2. Over 4.8 years (median) follow-up, there were 619 hospitalizations, 103 ESKD events, and 56 deaths. As compared with higher subscale scores, lower scores on four of the five subscales were associated with a higher adjusted rate ratio (RR) for all-cause hospitalization (communication quality: RR, 1.54; 95% confidence interval [95% CI], 1.25 to 1.90; health promotion: RR, 1.31; 95% CI, 1.05 to 1.62; interpersonal treatment: RR, 1.50; 95% CI, 1.22 to 1.85; and trust: RR, 1.57; 95% CI, 1.27 to 1.93). There was no significant association of subscales with incident ESKD or all-cause death. Lower perceived quality of the patient experience with their primary care physician was associated with a higher risk of hospitalization.

Effect of application score strategy on interviews offered to postgraduate year 1 pharmacy residency applicants

ObjectivesResidency programs may need to spend a large amount of time on the application review process in order to invite the best candidates for interviews. By using a different scoring strategy, this process could be made more efficient while still resulting in selection of the most appropriate candidates to interview. The objective of this study was to explore hypothetical scoring strategies for past residency applicants and to determine the percentage of these applicants that would have received an interview offer compared with the program’s standard scoring strategy. MethodsTwo years of residency applications to a postgraduate year 1 (PGY1) program providing the majority of clinical experience in ambulatory care were analyzed. Four models were explored: 1) standard model (original method); 2) simplified model (derived from statistical methods); 3) intuition model (criteria thought to best exemplify program success); and 4) objective model (criteria easy to objectively record, e.g., grade point average). All 3 new models were compared with the standard model to determine the percentage of candidates who would have received an interview if their applications had been scored according to the new model. ResultsA total of 110 applications were reviewed (42 interviews offered). After a multivariable analysis, academics, leadership, interest in ambulatory care, and professionalism were included in the simplified model, which predicted 81% of the interviews offered through the standard model. The intuition and objective models predicted 71% and 48% of interviews offered through the standard model, respectively. ConclusionModels scoring only 4 of the initial 12 criteria would have likely predicted 71% to 81% of original interview offers. Residency programs should consider periodically reviewing their application review processes to determine areas for improved efficiency.

Correlating Preclinical Ambulatory Care Specialty Exposure with First-Year Medical Student Performance on an Objective Structured Clinical Examination

Preclinical Ambulatory Care exposure offers medical students early opportunities to improve clinical performance; however, it is unknown whether exposure to generalist care rather than specific specialties results in variable performances on standardized patient examinations (SPEs). We intend to compare mean objective structured clinical examination (OSCE) scores for students by ambulatory specialty exposure. One hundred ninety-seven first-year medical students were exposed to one of ten outpatient specialties before taking a two-station OSCE. Performance was assessed in the domains of communication, elicitation of patient concerns, and history-taking. OSCE scores were measured and compared by specialty and on the basis of generalist versus specialist preceptors. By specialty, student performances in all domains did not significantly differ. Students with generalist preceptors outperformed peers with specialist preceptors in eliciting concerns from patients in their first case (1.00 vs. 0.98; p = 0.03), but results did not significantly differ in the second case or in the total score for that domain. No other scores significantly differed. Our results allow for the recruitment of preceptors from a variety of outpatient specialties to provide preclinical students with a longitudinal ambulatory care experience without concern for significant differences in clinical development or performance communicating, attaining clinical histories, or eliciting patient concerns on an OSCE.

Faculty and resident perspectives on ambulatory care education: A collective case study of family medicine, psychiatry, and surgery

Ambulatory care (AC) experiences within medical education are garnering increasing attention. We sought to understand how faculty and residents' describe their experiences of AC and ambulatory care education (ACEduc) within, between, and across disciplinary contexts. We designed a Stakian collective case study, applying constructivist grounded theory analytic methods. Using purposive and snowball sampling, we interviewed 17 faculty and residents across three instrumental cases: family medicine, psychiatry, surgery. Through constant comparative analysis, we identified patterns within, between, and across cases. Family medicine and psychiatry saw AC as an inherent part of continuous, longitudinal care; surgery equated AC with episodic experiences in clinic, differentiating it from operating. Across cases, faculty and residents cautiously valued ACEduc, and in particular, considered it important to develop non-medical expert competencies (e.g., communication). However, surgery residents described AC and ACEduc as less interesting and a lower priority than operating. Educational structures mediated these views. Differences between cases highlight a need for further study, as universal assumptions about ACEduc's purposes and approaches may need to be tempered by situated, contextually-rich perspectives. How disciplinary culture, program structure, and systemic structure influence ACEduc warrant further consideration as does the educational potential for explicitly framing learners' perspectives.

Development of a direct observation of procedural skills rubric for fourth-year pharmacy students in ambulatory care rotations.

The development and implementation of a pilot program requiring direct observation of procedural skills (DOPS) assessments of fourth-year pharmacy students during ambulatory care rotations are described. All fourth-year pharmacy students at the University of Texas at Austin College of Pharmacy who engaged in a required advanced pharmacy practice experience (APPE) in ambulatory care during the period January-May 2015 participated in a DOPS pilot program. The DOPS process required students to select a patient for a medication-focused "workup," evaluate the selected patient case, present the results to a preceptor, and conduct a preceptor-supervised patient interview. Preceptors used a DOPS rubric to rate students' performance in 12 domains. At the time of submission of DOPS evaluation forms, program participants were invited to complete online surveys soliciting feedback on the effectiveness of the DOPS evaluation process and other aspects of the program. A total of 81 students and preceptors participated in the DOPS pilot program, with 47 DOPS evaluation forms submitted; the median ± S.D. score was 90.4% ± 29.7%. Results of the online surveys indicated that the overall perception of the DOPS program was positive, with majorities of both students and preceptors supporting DOPS incorporation into the curriculum for fourth-year pharmacy students. The DOPS rubric was a useful tool for evaluating clinical skills of APPE students on ambulatory care rotations.

24-Month pharmacotherapy residency: The what and how behind these programs

PurposeTo describe available 24-month pharmacotherapy residency programs. MethodsEligible residency programs were identified using the American Society of Health-System Pharmacy (ASHP) and American College of Clinical Pharmacy (ACCP) online directory of postgraduate programs. Initial information was gathered via a program description search on the World Wide Web. Following the initial search, program directors were contacted to verify current information and complete missing data. Descriptive statistics were utilized to report the data. ResultsThirteen programs were identified and all programs responded. The majority of programs had multiple practice sites (n = 7; 54%) and an affiliation with a college or school of pharmacy (n = 11; 85%). Additionally, 62% (n = 8) receiving some funding for the residency program through a college or school of pharmacy. Although most programs had a primarily acute care focus, all programs required both acute care and ambulatory care experiences. Overall, 62% (n = 8) of programs offered a rotation coupling strategy. All programs required completion of a research project, allowing flexibility for a large two year project as appropriate. Academic experiences were available in all programs; however, experience was more prevalent in programs with academic funding. When combined, programs report the following average residency time allocations: 61% patient care, 15% research, 15% teaching, and 9% leadership/service. ConclusionsMinimal information is available comparing 24-month pharmacotherapy programs, providing a barrier to interested students, student mentors, and potential residency program directors. While diversity exists between required and elective experiences, all offer a mix of acute and ambulatory care clinical experiences. Graduates are equipped with diverse experiences, allowing versatility in the delivery of patient care. Additionally, residents are often afforded the opportunity to participate in teaching, service, and scholarship. Utilizing knowledge of the characteristics of currently available programs may help future programs structure diverse 24-month pharmacotherapy residencies and enhance student understanding of what these programs have to offer.