Care In Academic Medical Centers Research Articles

Exploring the Relationship Between Medication Adherence and Diabetes Disparities among Hispanic Patients in a Large Health System

BackgroundSub-optimal HbA1c control is a driver of disparities in diabetes outcomes among Hispanic patients. Differences in medication adherence may underlie racial/ethnic differences in HbA1c level.ObjectiveTo examine the relationship between medication adherence and disparities in HbA1c level among Hispanic patients, relative to other racial/ethnic groups, obtaining care in the University of California Health System (UC Health).DesignThis study used clinical, administrative, and prescription dispensing data (January–December 2021) derived from the electronic health records of 5 Academic Medical Centers in UC Health, and linear regression models (LRMs) to conduct a cross-sectional analysis of the association between medication adherence, race/ethnicity, and HbA1c level. Adjusted LRMs were run with and without the measure of medication adherence to assess this relationship.ParticipantsPatients with a UC Health primary care physician (PCP), with ≥ 1 PCP visit within the last 3 years, ages 18–75, reporting Asian, Hispanic, or White race/ethnicity, and who had ≥ 2 encounters with an ICD diagnosis of diabetes or had a prescription for a diabetes medication within the last 2 years, as of 12/31/21 (N = 27, 542; Asian = 6253, Hispanic = 7216, White = 14,073).Main MeasuresOur measure of medication adherence was the proportion of days covered (PDC) for diabetes medications in 2021. Our outcome was the most recent HbA1c value.Key ResultsIn the LRM excluding the PDC, Hispanic ethnicity was positively associated with HbA1c level (β = 0.31, p = < 0.001). In the LRM model including PDC, PDC was negatively associated with HbA1c level (β = − 0.18, p = < 0.001). However, the positive relationship between Hispanic ethnicity and HbA1c level did not change (β = 0.31, p = < 0.001).ConclusionsThe findings of this study suggest that the relationship between Hispanic ethnicity, HbA1c level, and factors outside of medication adherence should be explored among primary care patients receiving care in Academic Medical Centers.

Older adults perspectives on the potential for technology to enhance care in academic medical centers

Older adults perspectives on the potential for technology to enhance care in academic medical centers

"Patient Lost to Follow-up": Opportunities and Challenges in Delivering Primary Care in Academic Medical Centers.

Academic health centers (AHCs) face unique challenges in providing continuity to a medically and socially complex patient population. Little is known about what drives patient loss in these settings. Determine physician- and patient-based factors associated with patient loss in AHCs. Retrospective cohort study, embedded qualitative analysis. Academic health center. All visits from 7/1/2014 to 6/30/2019; 89 physicians (51%) participated in a qualitative analysis. Physician-based factors (gender, years of service, hours of practice per week, trainee status, and departure during the study period) and patient-based factors (age, gender, race, limited English proficiency, public health insurance, chronic illness burden, and severe psychiatric illness burden) and their association with patient loss to follow-up, defined as a lapse in provider visit greater than 3years. We identified 402,415 visits for 41,876 distinct patients. A total of 9332 (22.3%) patients were lost to follow-up. Patient factors associated with loss to follow-up included patient age < 40 (HR 3.12 (2.94-3.33)), identification as non-white (HR 1.07 (1.10-1.13)), limited English proficiency (HR 1.18 (1.04-1.33)), and use of public insurance (HR 1.12 (1.04-1.21)). Provider factors associated with patient loss included trainee status (HR 3.74 (2.43-5.75)) and having recently departed from the practice (HR 1.98, 1.66-2.35). Structured interviews with clinical providers revealed unfavorable relationships with providers and staff (35%), inconvenience accessing primary care (23%), unreliable health insurance (18%), difficulty accessing one's primary care provider (14%), and patient/provider transitions (10%) as reasons for patient loss. Younger patient age, markers of social vulnerability, and physician transiency are associated with patient loss at AHCs, providing targets to improve continuity of care within these settings.

Spanish-Speaking Parents' Experiences Accessing Academic Medical Center Care: Barriers, Facilitators and Technology Use.

Background and ObjectiveChildren of Spanish-speaking caregivers face multiple barriers to care in academic medical centers. This study identified barriers and facilitators of health care and described use of health information technology in order to guide interventions and optimize services.MethodsIn-depth, audiotaped interviews were conducted with monolingual Spanish-speaking caregivers (N = 28) of children receiving care in academic medical center clinics using a structured interview guide. Interviews were transcribed in Spanish, and key themes were identified using thematic analysis. Illustrative quotes for each theme were translated into English.ResultsLanguage-specific barriers included arrival/registration occurring in English, lack of bilingual personnel, heavy reliance on interpreters, long wait times, and challenging phone communication. Non–language-specific barriers included medical center size and complexity, distance to services, lack of convenient and coordinated appointments, missing work/school, and financial barriers including insurance coverage or lack of citizenship. Caregivers identified interpreters, bilingual physicians and staff, and written materials in Spanish as facilitators of care. Most caregivers had internet access and expressed interest in health information technology, including patient portals, to communicate about their children's health.ConclusionsCaregivers of Spanish-speaking children encounter many language-specific barriers, which are compounded by non–language-specific barriers arising from complex health systems and social needs. Caregivers with limited resources described working hard to meet children's complex health care needs despite these barriers. Most caregivers had internet access and interest in patient portals. Academic medical centers may need multifaceted interventions that improve the availability of bilingual staff and interpreters and also address caregivers' social and informational needs.

Pediatric Quality Improvement Engagement In The Community Setting

Providing safe, high quality care to pediatric patients is a core goal for all healthcare systems. To this end, robust quality improvement and patient safety methodologies have been developed to improve pediatric patient care in academic medical centers. However, given that the majority of pediatric patients are first seen in emergency departments (EDs) in community hospitals rather than academic pediatric medical centers, there is an urgent need to adapt these methodologies to the community ED environment. In this review, we begin to address these issues by looking to successful quality improvement and patient safety initiatives for lessons that can be adapted to the unique challenges and opportunities encountered in community healthcare settings.

Effect of Modest Pay-for-Performance Financial Incentive on Time-to-Discharge Summary Dictation Among Medical Residents

Evaluate the effect of a modest financial incentive on time-to-discharge summary dictation among medicine residents. Pay-for-performance incentives are used in a number of health care settings. Studies are lacking on their use with medical residents and other trainees. Timely completion of discharge summaries is necessary for effective follow-up after hospitalization, and residents perform the majority of discharge summary dictations in academic medical centers. Medicine residents with the lowest average discharge-to-dictation time during their 1-month inpatient medicine ward rotation were rewarded with a $50 gift card. Discharge data were captured using an autopopulating electronic database. The average discharge-to-dictation time was reduced from 7.44 to 1.84 days, representing a 75.3% decrease. Almost 90% of discharge summary dictations were performed on the day of discharge. A modest financial incentive resulted in a marked improvement in the time-to-discharge summary dictation by medicine residents. Pay-for-performance programs may be an effective strategy for improving the quality and efficiency of patient care in academic medical centers.

The Physician???Hospital Team: A Successful Approach To Improving Care in a Large Academic Medical Center

Initiatives to improve the quality and efficiency of care in academic medical centers (AMCs, teaching hospitals) can benefit the performance of academic departments as well as the hospital. However, the value of performance improvement programs in an AMC is often challenging. At Jefferson Medical College, clinical efficiency and bed availability are important priorities to the Department of Medicine. To this end, a multidisciplinary program was designed to (1) improve the quality and consistency of care by adapting and adopting national guidelines for patients with heart failure and acute coronary syndrome; (2) identify and improve hospital operational supports and maximize resource utilization; (3) increase hospital functional capacity to make way for increased volume; and (4) improve housestaff education and practice by using evidence-based approaches and by optimizing teaching relationships between housestaff and attending faculty. The eight-month project (November 2002 to July 2003) resulted in improvement in several quality measures including increased use of beta blockers and angiotensin converting enzyme inhibitors for heart failure patients, reduced length of stay for heart failure and acute coronary syndrome patients, and increased satisfaction of the clinicians involved in caring for these patients. However, the project was not without barriers including individual physician's unwillingness to embrace change and an inability to incentivize change. Development of faculty leadership skills and enhanced physician accountability helped in overcoming the challenges of change.

Legal standards of conduct for students and residents: implications for health professions educators.

Students and residents are responsible for providing much of the patient care in academic medical centers. Though experiential learning has been central to equipping students with the professional knowledge and skills needed in their careers, it raises significant medicolegal questions. One such question addresses the standard of care being provided by health care practitioners in training. Referred to as "standard of conduct" in a legal setting, the applicable standard for students and residents has been addressed by the courts on several occasions. Some early cases supported the notion that there is a special standard of conduct for students and interns, one that is lesser than that expected of fully licensed, certified practitioners. Cases since the late 1970s, however, indicate a trend away from that view, generally finding that any persons holding themselves to be practitioners, including students and residents, should be held to the standard of conduct of a practicing professional. Further, providers are being held to a national rather than a community-based standard of care, heightening the extent of the duty that all providers, including those still in training, have to their patients. A significant reason that students and residents are being held by the courts to the same standard of conduct as practicing professionals is that they are providing care under the supervision of licensed, experienced faculty. Case law indicates that while personnel in training have a duty to their patients to render care of a nationally recognized standard, supervising faculty have a parallel duty to those patients to provide adequate levels of supervision to ensure that such a standard be met, as well as to ensure that the care be in compliance with relevant policies and statutes. The findings discussed in this paper hold several implications for educators and administrators. First, faculty have a duty to maintain their knowledge bases and skill levels in accordance with nationally recognized standards in their professions in order to adequately fulfill their teaching and patient care responsibilities. Second, faculty have a duty to maintain an appropriate level of supervision during the provision of patient care. Administrators and educators also have supervisory responsibilities regarding the monitoring of pertinent policies and statutes to ensure the continued appropriateness of those documents and to foster compliance of all involved. Finally, alternative modes of education that would provide opportunities for students to develop competence in technical skills before using them on real patients (such as patient simulators) should be explored.

Restructuring VA ambulatory care and medical education: the PACE model of primary care.

The Veterans Health Administration (VHA) Western Region and associated medical schools formulated a set of recommendations for an improved ambulatory health care delivery system during a 1988 strategic planning conference. As a result, the Department of Veterans Affairs (VA) Medical Center in Sepulveda, California, initiated the Pilot (now Primary) Ambulatory Care and Education (PACE) program in 1990 to implement and evaluate a model program. The PACE program represents a significant departure from traditional VA and non-VA academic medical center care, shifting the focus of care from the inpatient to the outpatient setting. From its inception, the PACE program has used an interdisciplinary team approach with three independent global care firms. Each firm is interdisciplinary in composition, with a matrix management structure that expands role function and empowers team members. Emphasis is on managed primary care, stressing a biopsychosocial approach and cost-effective comprehensive care emphasizing prevention and health maintenance. Information management is provided through a network of personal computers that serve as a front end to the VHA Decentralized Hospital Computer Program (DHCP) mainframe. In addition to providing comprehensive and cost-effective care, the PACE program educates trainees in all health care disciplines, conducts research, and disseminates information about important procedures and outcomes. Undergraduate and graduate trainees from 11 health care disciplines rotate through the PACE program to learn an integrated approach to managed ambulatory care delivery. All trainees are involved in a problem-based approach to learning that emphasizes shared training experiences among health care disciplines. This paper describes the transitional phases of the PACE program (strategic planning, reorganization, and quality improvement) that are relevant for other institutions that are shifting to training programs emphasizing primary and ambulatory care.

Medical Education in Ambulatory Settings

The factors that have encouraged an increasing shift of medical education and training from inpatient hospital wards to the ambulatory setting are likely to intensify during the 1990s. Changes in the patterns of disease, with a greater prevalence of chronic conditions caused by multiple risk factors, cost-containment pressures to limit length of hospital stay, growth of managed care organizations, hospital sponsorship of expanded ambulatory services onsite and offsite, and improved ambulatory diagnostic and treatment modalities, will all encourage the expansion of ambulatory care and the contraction of inpatient services. Lesky and Borkan1 in this issue of the Archives present a useful set of recommendations to help faculty make better use of the learning opportunities presented by the expansion of ambulatory care in academic medical centers. The authors address the special challenges of restricted time for patient care and teaching in a busy ambulatory setting and the isolation and vulnerability of