PhD, Tomer Levin MBBS, FAPM, Rozan Abdulrahman MPH, John ... · Anxiety: 67% Bipolar D/O: 3.8% Depression: 61% Alcohol D/O: 3.6% ... resource-rich NYP located in Manhattan focusing

Click to edit Master text stylesSecond level

Third level– Fourth level bulleted copy details

» Fifth level

Weill Cornell Medicine’s Psychiatry Collaborative Care Center: Primary Care Referral Patterns, Patient Characteristics and Treatment Outcomes

Results (Continued):Baseline:

Diagnosis Upon Initial Assessment:Anxiety: 67% Bipolar D/O: 3.8%Depression: 61% Alcohol D/O: 3.6%Adjustment D/O: 7.5% Insomnia: 3.3%

Others include ADHD, Tobacco Use Disorder, eating disorders, somatic symptom disorder, PTSD, and coping with medical conditions.

Conclusion: Referred patients are predominantly diagnosed with depressive and anxiety-related disorders; most have multiple medical comorbidities.

Limitations: This data reflects only patients who have presented for at least one appointment at the CCC.

Implications: 1) The CCC is a collaborative model designed to meet the psychiatric needs of primary care patients 2) Referred patients have a high medical and psychiatric symptom burden 3) Despite the complexity of the cases, significant improvement in psychiatric outcomes are noted 4) More data is needed to determine if changes in psychiatric symptoms are associated with changes in medical outcomes.

Objectives: To characterize patients seen at the CCC, describe treatment course and present preliminary outcomes.

Methods: Measures of psychiatric symptomatology are completed by each patient entering treatment via the Weill Cornell Connect account, and imported into the EMR. Record review was used to extract

Results:To date 1,174 patients have been seen at the CCC. Data here represent the first 720 patients:

Mean Age = 42.3 (Range 19-91)Gender: 62% Female, 38% MaleMean # Visits at the CCC = 5.23 (Range 1-58)Mean # of Comorbid Diagnoses in the 6 Months Prior to Assessment = 10.6

Outcomes:

Background: The Collaborative Care Center (CCC) was created to provide patients in Weill Cornell’s primary care practices with a

Judith Cukor PhD, Tomer Levin MBBS, FAPM, Rozan Abdulrahman MPH, John Barnhill MD, Justin Mohatt, MD,Adam Stracher MD, Michael Wolk MD, MACC, Geraldine McGinty MD, MBA, FACR, Philip Wilner MD, MBA

mean scores for measures, demographic information, and treatment outcomes.

comprehensive psychiatric assessment, formulation of a treatment plan in consultation with the PCP, an opportunity for brief treatments and referral to community-based programs.

About 10% of patients are defined as CCC “high utilizers”. They have higher baseline scores and poorer outcomes.



» Fifth level

Enhancing Internal Medicine Resident Training and Retention through a Novel “One-Two” Rural Residency Training Program

Primary Care Innovations SymposiumByron Demopoulos| September 12, 2017

Tables & Charts

ConclusionTompkins County, like much of rural America, lacks the workforce to care for its aging and disadvantaged population. CMC’s partnership with NYP to build an innovative “1-2” Internal Medicine residency will provide rural New York with physician leaders committed to the state’s healthcare disparities and social mission.

LimitationsAs a Sole Community Provider, CMC suffers financial limits on Indirect Medical Education (IME) reimbursements from the government. Furthermore, building a GME program at CMC will require a cultural transformation, targeted faculty development, new training models in population health, and curricular innovations to achieve its goals.

ImplicationsThe CMC and NYP partnership, if successful, may alter the paradigm for graduate medical education nationwide and drive the migration of rigorously trained primary care physicians into the geographic regions that need them most.

Funding Source: Grant provided through New York State Health Research Inc.

Conflicts of Interest: None

Acknowledgements: Michael Berlin, Lia Logio

Objective’s & HypothesisTo address the shortage of primary care physicians in its community, CMC has partnered with the New York Presbyterian (NYP) Internal Medicine Residency to develop a unique training program with the goal of training highly motivated primary care leaders in rural New York. We hypothesize that our unique training model will result in retention of primary care physicians in Tompkins.

Methods CMC is actively developing a new Internal Medicine residency seeking ACGME accreditation in the spring of 2018. This program will pursue a “1-2” training model more commonly employed by Family Medicine residency programs. The first year of training will be at the resource-rich NYP located in Manhattan focusing on inpatient and core specialty medicine while the final two years places the trainees in a rural community at several training sites less commonly encountered in urban settings.

ResultsThe program will track residents after completion of their training. A primary goal of the new residency will be high retention of graduates to practice in the community.

Background Cayuga Medical Center (CMC), located in Tompkins County, NY, is designated as a Health Professional Shortage Area (HPSA) for primary care by the Health Resources and Services Administration. Funding for residency training is heavily misaligned with the geography of underserved areas. Creating programs to train physicians where they are most desperately needed requires innovative programs that partner experienced academic medical educators with motivated rural hospitals who lack experience in residency education.

www.postersession.com

Increase screening rate of household food insecurity to 50% by June 2017 at the NYP-Queens Resident Clinic

Increase referral rate to Women Infant and Children (WIC) and Supplemental Nutrition Program (SNAP) for patients who screen positive to 90% by June 2017 at the NYP-Queens Resident Clinic

Methods

Improving Food Insecurity Screening and Referral at Theresa Lang Children’s Center- A Resident-led Quality Improvement Initiative

Angela Chan MD,1 Robyn Rosenblum MD,2 Erika Abramson MD MSc, Snezana Nena Osorio MD MS,3

Yishan Cheng MD, Melanie Dabakis MD, Eric Dybbro MD, Anshika Kaushik MD, Alexandra Satty MD, Megan Shea MD, Sonia Voleti MD

Background

Results

We established baseline food insecurity rate at the NYP-Queens Resident Clinic which was remarkably high, but similar to the national food insecurity rate of 21%

Using The Model for Improvement Resident QI team: Improved food insecurity screening process measure Achieved outcome measure of 100% referral rate to WIC and

SNAP

SMART Aims

In 2013, 16 million children (21%) in the US live in households without consistent access to adequate food

Food insecurity is associated with adverse health outcomes While food insecurity has demonstrated significant short and long term impacts on

pediatric growth and development, it is not routinely addressed in clinical settings AAP’s Policy Statement in October 2015 recommends using USDA’s 2 question

validated screening tool at health care maintenance visits, to promote food security for all children

Key Driver Diagram

Increase identification of household food insecurity to 50%by June 2017 at the NYP-Queens resident clinic and provide options to help meet needs of food insecure households

Use evidence-based criteria for identifyingfood insecurity

Increase resident education of why and how to screen families

Execute Medical Provider-Centered Handoff

Text macros generated on EMR

Informational Handouts

Posters in exam rooms explaining services available

3o Drivers2o Drivers1o DriverAim

Next Steps Increase the food insecurity screening rate to 90% Determine health impacts of food insecurity on growth and

development Assess improvement in outcomes such as BMI and weight, at

follow up visits, after referrals are made

Conclusions

Figures 1, 2. Food Insecurity Rate, and Food Insecurity Screening Rate at Resident Clinic

Figures 3. MCHAT screening rate as a balancing measureStudy Design: Observational time series study with multiple planned sequential interventions

Patient populations:Households with children 3 years of age and under

PlanDoStudyAct

Objective (Global Aim) To implement an evidence based screen for food insecurity at the NYP-Queens

Resident Clinic

Cycle 3: Group email reminders, in-time

feedbackP

DS

A

AP

DS

PDS A

Gain buy-in from residents, attendings, clinic staff and families

Implement 2 question electronic tool

UCL

LCL0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1/ 9

- 1/

13

1/16

- 1/

20

1/23

- 1/

27

2/27

- 3/

3

3/6

- 3/1

0

3/13

- 3/

17

3/20

- 3/

24

3/27

- 3/

31

4/3

- 4/7

5/8

- 5/1

2

MCHAT Screening rate P ChartPercent

CL = 84.62%

Screening Awareness

CL = 57.14%

Referral Rate 100%, data not shown

Observational study 64.2% of subjects who were already on WIC and SNAP also

reported food insecurity MCHAT not ideal balancing measure, majority of subjects age

<18 months

Limitations


Third level– Fourth

level bulleted copy details » Fifth

level

Using a Patient-Activated Learning System to to Improve Knowledge of and Confidence in

Completing Advance Directives and Managing Distress among Racial/Ethnic

Minority Patients

Primary Care Innovations SymposiumMegan Shen, PhD | September 12, 2017

Background/Relevance• An estimated 117 million Americans are living with at least one chronic disease, many of

whom suffer from cancer, and 70% of Americans will die from a chronic disease. • Despite the prevalence of chronic diseases within primary care populations, the majority

(approximately 73.7%) of Americans have not yet planned for the care they would want at the end of life by completing formal documentation called advance directives (living wills, health care proxies, do-not-resuscitate or DNR orders).

• Additionally, many of the patients living with chronic illness suffer from psychological distress but lack access to distress management techniques.

• Rates of completion of advance directives and of receiving care for distress are even lower among racial and ethnic minorities.

Overview• The proposed project will develop and pilot test patient education materials through a

web-based platform called the Patient Learning Activation System (PALS) to improve knowledge of and ability to utilize distress management techniques and complete advance directives.

Proposed Methods• The proposed project will develop and pilot test patient education materials through a

web-based platform called the Patient Learning Activation System (PALS) to improve knowledge of and ability to utilize distress management techniques and complete advance directives.

• PALS provides engaging and informative video, text, and images designed to improve patient knowledge specifically among underserved patient populations.

• Cancer patients will be targeted to develop materials, as they are one of the largest chronic patient populations and one for whom many patients eventually die from their disease

Phase I• In Phase I, this project will pilot test PALS content (videos and text) for six modules:

distress management techniques (guided imagery, muscle relaxation, and mindfulness) and advance directive documents (living will, health care proxy, and DNR order).

• A total of n=15 ethnically and racially diverse cancer patients will engage in think aloud exercises and qualitative interview feedback sessions in order to ensure that developed materials are engaging, easy to understand, and responsive to patient questions.

Phase II• In Phase II, a unique sample of n=30 cancer patients will engage in a pre-post pilot test

to examine the feasibility, acceptability, and impact of the modules on improving patients’ knowledge of and self-reported confidence in utilizing distress management techniques and completing advance directives.

Anticipated Impact • To develop a potentially low cost, low burden intervention to improve distress

management and completion of advance directives among racially and ethnically underserved patients.

• Results will be used to develop materials and obtain pilot data for an R01-level application to conduct a full-scale randomized control trial comparing PALS to a standard education control condition.

IMPROVING TOBACCO CESSATION SERVICES IN PRIMARY CARE: THE NURSE PRACTITIONER-PATIENT NAVIGATOR TEAM

Stasi Lubansky, DNP, CTTS, Maria V .Colon, BA, CTTS, and David Albert DDS,MPH

TABLES AND CHARTSEvery year: $96 Billion in medical costs

$97 Billion in lost productivity

DELIVERY SYSTEM REFORM INCENTIVE PAYMENT PROGRAM (DSRIP)

BACKGROUNDTobacco addiction is the leading preventable cause of morbidityand mortality in the United States. It is estimated that 70% ofsmokers want to quit and 70% of smokers see a healthcareprovider annually. 44% of smokers attempt to quit every year, but<10% are successful without assistance. In addition, smoking isdisproportionally concentrated in the lower socio economicclasses as well among those with mental illness and substanceabuse. Counseling and treatment by providers can increase thesuccess rate, to quit rates of >30%. It has been shown there aremany barriers to providers treatment and counseling of smokers.These barriers include time constraints of visits, lack ofknowledge of evidence based treatment options includingpharmacotherapy and lack of confidence in counseling skills. Aspart of a quality improvement effort, we set out to proactivelyidentify smokers in our hospital network, so that we could targetthem for smoking cessation interventions.

HYPOTHESISThis project will promote tobacco cessation, especially among lowSocial Economic Status (SES) populations and those with poormental health.

OBJECTIVES Use information technology to increase the use of the five A’s

(Ask, Advise, Asses, Assist, Arrange) Establish tobacco cessation clinics for intensive counseling Educate providers to deliver tobacco cessation treatment Identify vulnerable seniors and low income patients whom are

targeted by tobacco companies to provide tobacco cessationtreatment.

METHODSTo identify smokers, we generated a daily report from theElectronic Medical Record (EMR) of all patients with primarycare appointments who were identified as tobacco users. Referralswere similarly generated from specialty practices. We employeda patient navigator to reach out to theses patients either the day oftheir existing appointment or subsequently by telephone. Briefcounseling was provided by the patient navigator and documentedin the EMR. Patients whom were interested were then scheduledto see the nurse practitioner for one on one treatment, counseling,and optional group counseling. Follow ups were arranged asneeded . Certified Tobacco Treatment Specialist (CTTS) trainingwas held for providers, nurses, social workers, and communityhealth workers at our institution . Additionally, informationregarding this training was sent via email to health careprofessionals within our network as well as local communityhealth agencies.

4%8%

29%

28%

21%

10%

About 443,000 U.S. Deaths per Year Attributable to Cigarette Smoking

Stroke

Other Cancers

Lung Cancer

Ischemic Heart Disease

Chronic Obstructive Pulmonary DiseaseOther diagnosis

Source: CDC. Current Cigarette Smoking Among Adults ---U.S. 2005- 2015 Weekly/ November 11, 2016/ 65 (44); 1205-1211

0

10

20

30

40

50

60

70

February March April May June July August

Patient Visits for Tobacco Cessation 2016 vs 2017

20162017

RESULTSDuring the intervention period, the number of scheduled visits to ourpractice for tobacco cessation counseling increased by more than600%. For example, in March 2017, we saw 75 patients for tobaccocessation, compared to 12 visits during the same period in 2016.Additionally, 30 providers underwent CTTS training. Trainedparticipants included providers, nurses, social workers, andcommunity health workers.

CONCLUSIONIdentification of tobacco users from the EMR, combined with thepresence of a Nurse Practitioner-Patient Navigator team, increasedvisits for tobacco treatment and counseling. This effort also providededucation to health care professionals and community healthworkers. Our hope is that this will increase the provision of tobaccocessation service in a variety of clinical settings .

LIMITATIONSOur no show rate was 40% despite frequent reminders leading up tothe appointments. Tobacco users not appropriately flagged in theEMR were not included. Further research is needed to look into theetiology of high no show and broken appointment rates for thesevisits.

FUNDING SOURCENew York State Delivery System Reform Incentive PaymentProgram (DSRIP)

CONFLICT OF INTERESTNone

ACKNOWLEDGEMENTSAngela Ward, EDD,RDH,CHES,CTTS, Associate Research Scientist

Julie Chipman, Behavioral Health Integration Program Manager Evelyn Espana, Community Health Worker Program Manager



» Fifth level

Patient Reported Outcomes in Clinical Care: Best Domain, Best InterfaceAnna Cornelius-Schecter1, Bernadette Johnson2, Aprajita Jagpal2, Liana Fraenkel3 James Willig2, Monika Safford1,

Jeffrey Curtis2, Iris Navarro-Millán1,4

1Weill Cornell Medical College and New York-Presbyterian/Weill Cornell Medical Center, New York; 2University of Alabama at Birmingham, Birmingham, AL; 3Yale University, New Haven, CT; 4Division of Rheumatology, Hospital for Special Surgery New York, NY

September 12, 2017

Tables & Charts

Conclusion- The most important PRO domains that rheumatologists

were interested were medication compliance and patient function

- Synchronize PROs results into the electronic health record (EHR) was the most valuable interface for this group of rheumatologists

Limitations- There could be important topics not captured in the survey- Many RA patients may not readily adopt new technologies to

collect PROs not only at the point of care but also at home, but its use is growing

- Additional staffing requirements to assist with electronic PRO collection at point of care could be needed in the initial phases of using a tablet to collect PROs

- Preliminary results, definite conclusions cannot be achieved until have larger sample size

Implications - Rheumatologists prefer electronic platform that can be

integrated with EHR to collect PROs- Tailoring PRO collection tool to physician preferences

based on survey results should enhance uptake- PRO data collection platform is applicable to many

chronic diseases such as hypertension, diabetes, heart failure, and other forms of arthritis

Funding Source: Rheumatology Research Foundation/Pfizer


Acknowledgements: None

Objectives & Hypothesis- Determine which PRO domains

rheumatologists commonly use and how they would prefer to incorporate these assessments at the point of care

Methods- 4 nominal groups with 25

rheumatologists- Developed multiple choice questions

based on qualitative data from these nominal groups

- Rheumatologists with American College of Rheumatology membership were invited to participate

- Descriptive statistics and proportions were used to analyze the results

Results- Invited 600 rheumatologists, 56 responded to survey (ongoing)- Majority of respondents: 35-64 years of age, 65% male- A majority of respondents valued medication compliance,

physical functioning, and quality of life- NIH-funded Patient-Reported Outcomes Measurement

Information System (PROMIS) known to 16 respondents, only 1 rheumatologist was using it regularly in practice

- 42 respondents used other validated disease activity measurements during office visits

- Majority of respondents interested in having PROs collected electronically and synchronized with the EHR (86%)

BackgroundPatient reported outcomes (PROs)- Provide quantifiable information about

patients’ subjective symptoms- Facilitate longitudinal chronic disease

management- Potential to improve shared decision-

making- Electronic tools for this purpose are

efficient but not widespread

Figure 1: Items that rheumatologists considered “very important” to measure while assessing an established patient with rheumatoid arthritis

0% 20% 40% 60% 80% 100%

Willingness to change treatmentsDuration of morning stiffness

Length of flareAbility to walk, run, and get around

Work productivity (i.e. function at work)Patient’s perspective on their quality of life

Affordability of medicationChange in steroid use or dose

Patient perception of their response to treatmentSeverity of flare

Medication side effectsAbility to perform activities of daily living (ADLs)

Flares, and number of flares between visitsJoint swelling

Compliance with medications



» Fifth level

Building a Patient-Centered Cardiovascular Risk Reduction Program for Patients with Inflammatory Arthritis

Iris Navarro-Millán1,2, Sarah R. Young3, Sally Shurbaji4, Chastity McDavid4, Anna Cornelius-Schecter1, Bernadette Johnson4, Andrea L. Cherrington4, Liana Fraenkel5, Jeffrey R. Curtis4, Monika M. Safford1

1Weill Cornell Medicine, New York, NY; 2Hospital for Special Surgery, New York, NY; 3Binghamton University, Binghamton, NY; 4University of Alabama at Birmingham, Birmingham, AL; 5Yale University, New Haven, CT

September 12, 2017

Results (Continued)− Patients were interested in information related to arthritis,

prognosis, and medications− Preference to understand arthritis before focusing on CVD− Receptive to CVD risk reduction program with emphasis

on lifestyle change− Interested in using peer support for exercise,

communication with physicians, and medication management

− Interested in improving communication with doctors to ensure understanding of symptoms and to better understand information and recommendations given to them

Tables & Charts

Conclusion‐ The results of this study suggest that patients with RA

interest is focused on learning about RA itself with an emphasis on non-medication approaches and coaching on optimizing communication with the physician

‐ CVD risk reduction strategies should be introduced once RA disease related topics are fulfilled

‐ Peer-to-peer support appears to be of interest to patients as tool for RA education and CVD risk reduction

Limitations‐ Participants in this study were a convenience sample from a

single academic referral center.

Implications‐ CVD risk reduction programs of patients with RA could

reduce this frequently overlooked comorbidity in arthritis

Funding Source: NIH/NIAMS K23 AR068449


Acknowledgements: None

Objectives & Hypothesis‐ Obtain stakeholder input on the

development of a patient-centered CVD risk reduction program for patients with arthritis using peer coaches

Methods‐ Qualitative study guided by Bandura’s

Social Cognitive Theory‐ Focus on relationship between

arthritis and CVD as well as barriers to receiving healthcare related to CVD risk such as screening and management for hyperlipidemia

‐ Participants had rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS)

‐ Data analyzed thematically

Background - Cardiovascular disease (CVD) is the

most common cause of death among patients with inflammatory arthritis

- CVD risk reduction programs for these patients are scarce

Theme Key pointsKnowledge about arthritis

- Interested in learning about expectations for living with arthritis and non-medical arthritis management

- Interest in learning about Arthritis medication side effects, risks and benefits, and possible interaction with other medications

Knowledge about CVD and arthritis

- Learn about how arthritis affects the heart and how to decrease CVD risk- Misconception that all laboratory drawn include a cholesterol test

CVD risk reduction program

- Interested in learning about exercise and diet to help with arthritis and CVD risk reduction

- Incorporate CVD risk reduction program into overall arthritis management- Preferred lifestyle changes over statins to control cholesterol

Preferred ways of learning

- Treating physician, seen as the most reliable source of information about arthritis

- The internet, despite concerns about reliability of the information available online

- Learning from another patient with arthritis. Interested in learning about the following topics:

- Strategies for arthritis management- Opinions, problems, benefits of arthritis medications- Experience with CVD events and strategies for managing CVD risk

reduction- Best exercise program (weights, cardio, pool exercises)- Engaging with another arthritis patient in a workout program (workout

partner)- Best ways to communicate with doctors

- These participants expressed concerns about working with another patient with arthritis in the following aspects:

- Confidentiality from these other patients with arthritis- Authenticity of the provided information

Communication with physicians

What kinds of questions to ask a rheumatologist about arthritis Frequency of communication and visits with rheumatologist Better ways to engage doctor in answering concerns about medications,

laboratory results and symptoms Better ways to communicate symptoms and personal situations to doctors

Table: Themes and key points that emerged from focus groups of patients with rheumatoid arthritis

Results‐ 17 participants in 3 focus groups

with mean age of 56 years (SD+7.7)

‐ 88% female, 18% on a statin, 6% had established CVD (history of myocardial infarction or stroke)

‐ Five themes emerged (Table)



» Fifth level

Barriers to Ambulatory Care EducationPeggy B.K. Leung, MD and Cathy Jalali, PhD | September 12, 2017

Department of Medicine, Weill Cornell Medical College, New York, NY

General internal medicine residents spend roughly one third of their residency training in ambulatory settings. We as educators are challenged with balancing 1) the educational needs of our residents and 2) delivering high-quality care to our complex patient population.

BACKGROUND

OBJECTIVES

METHODS

• Here we identify and describe barriers to ambulatory education as perceived by interns and residents at a tertiary care resident ambulatory clinic.

Residents (n=39) and interns (n=32) were given an eleven question survey (from July 2017 to August 2017) prompting them to:

• Describe how and how often they prepared for patient encounters.

• Reflect on the knowledge gained from their last 5 patient encounters.

The learners were given space to free write their thoughts.

RESULTSKnowledge gained from last 5 patients seen

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Residents (n=39)Interns (n=32)

What could have improved the patient encounter

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Resident (n=39)Interns (n=32)

Frequency of pre‐charting

0% 20% 40% 60% 80% 100%

Residents

Interns

Every timeMost of the timeHalf the timeFew timesNone

5.3%

CONCLUSIONSIn an era where learners in the ambulatory setting

perceive few educational opportunities, have less time to perform multiple tasks or lack skills to organize and prioritize tasks during visits, we need to find teaching models that integrates learning into the practice and process of caring for patients. These interventions need to target those perceived barriers and help learners to develop organizational strategies. The findings from our study are a platform to identify those barriers.

42.1% 42.1%

33% 30.8% 18%

7.7%

10.3%

Vulnerabilities to health disparities and hypertension control in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

Emily Anderson MS, MD Candidate, Joanna Bryan, MPH, Praful Schroff, MPH, Chris Gamboa, MPH, Monika M. Safford, MD

Table. Effect of number of vulnerabilities on BP control at follow-up among 7,656 hypertensive REGARDS participants

Vulnerability Count

NbCrude

Prevalence Ratio (95% CI)

Fully Adjusteda

Prevalence Ratio(95% CI)

0 599 1 1

1 1700 0.99 (0.95,1.03) 0.99 (0.95,1.03)

2 2368 0.97 (0.93,1.01) 0.98 (0.94,1.02)

3 1542 0.95 (0.91,1.00) 0.97 (0.93,1.01)

≥4 720 0.92 (0.88,0.97) 0.93 (0.89,0.99)

P for trend ‐‐ <0.001 0.003a. Full model adjusts for vulnerability count; enabling factors (usual source of care, living in a Health Professional Shortage Area); perceived need factors (medication adherence, awareness of hyperlipidemia); and evaluated need factors (obesity, current smoking, history of myocardial infarction, diabetes, and baseline SBP)b. Vulnerability count imputed for 727 participants in the sample.

•Disparities in hypertension control have been reported for blacks, the elderly, women, impoverished individuals, uninsured individuals, and residents of southeastern US or US rural regions.

•Little is known about the relationship between combinations of the factors listed above and hypertension control.

•We investigated the relationship between these vulnerabilities to health disparities and blood pressure control over a 10 year period.

Background

•REGARDS is a longitudinal cohort study of 30,239 US black and white adults age >45 years recruited between January 2003 and October 2007. Blacks and southeastern residents were oversampled.

•Baseline and 10-year follow-up data were investigated for 7,656 participants with hypertension at baseline.

•Individual vulnerabilities as well as the count of each participant’s vulnerabilities were regressed on both outcomes of interest, adjusting for enabling factors, perceived need factors, and evaluated need factors that influence health services utilization.

Methods

•The sample mean (SD) age was 64.5 (8.2) years, with 46.4% blacks and 57.3% women.

•8.0% had no vulnerabilities, 24.5% had one vulnerability, 33.8% had 2 vulnerabilities, 22.4% had 3, and 11.2% had 4 or more vulnerabilities.

•80.1% of the study sample had blood pressure control at 10-year follow up.

Outcome 1:•Residence in the stroke belt region of the southeast and age >74 years were significantly associated with BP control in the fully adjusted model when the influence of each vulnerability was examined.•Participants were more likely to be uncontrolled at 10 years as the number of vulnerabilities increased (see Table).

Outcome 2:•Individual vulnerability domains were not associated with a change in SBP among uncontrolled participants.•A greater number of vulnerabilities was associated with higher systolic blood pressure at 10 years (p for trend= 0.026).

Results•A greater number of vulnerabilities was associated with both lower likelihood of BP control and higher SBP for those uncontrolled at 10 years.

•The magnitude of this association was modest (7% less control for those with 4 or more vulnerabilities).

•This association was not explained by enabling factors, perceived need factors, and evaluated need factors, suggesting that other influences underlie the relationship. Societal biases may be at play.

•Hypertension is a modifiable risk factors for disease and mortality. By becoming aware of a patient’s number of vulnerabilities to health disparities, clinicians can target and treat individuals who are at the highest risk for not achieving BP control over 10 years.

•This information is also useful for population health management.

Conclusions and Implications

Limitations:•Some baseline covariates were self-reported.

•The sample who were uncontrolled at follow-up was modest in size, limiting the power of these analyses.

Strengths:

•REGARDS cohort has a substantial sample size and national reach, enhancing generalizability.

•REGARDS oversampled blacks and residents of the southeastern US, allowing the evaluation of multiple vulnerabilities to health disparities.

Limitations/ Strengths

•Funded by a cooperative agreement U01 NS041588 from the National Institute of Neurological Disorders and Stroke and R01 HL080477 and K24 HL111154 from the National Heart, Lung and Blood Institute, NIH, Department of Health and Human Services.

•Authors report no potential conflict of interest.

Funding Sources and Conflicts of Interest

Stroke belt

Vulnerability Domains

Black &Female

No insurance

>25%

zip code

>25% poverty in zip code

Rural

Age >74

• Blood pressure (BP) control (BP < 140/90 mm Hg) at 10 years Outcome 1

• Change in systolic blood pressure (SBP) among 1,455 participants who were uncontrolled at follow‐up

Outcome 2



» Fifth level

Results (Continued)

Tables & Charts Conclusion Video discharge education provides a novel method to

significantly increase patient confidence to overcome common post-discharge medication barriers.

Nursing and patient feedback agree that the videos reduce confusion and prompt better discharge planning.

Video discharge education is feasible because it is a standardized tool which requires little extra time, can be incorporated into nursing workflow and is inexpensive while being scalable.

Implications: Our data suggests that the use of video discharge materials is

both clinically useful and feasible, however the next obstacle is obtaining devices and establishing a training regimen on tablet use for healthcare providers.

Funding Source: NYP Department of Internal Medicine

Conflicts of Interest: NoneAcknowledgements: John Dillon, BS, Alexi Archambault,

MPH, Savira Kochhar, MS

Objectives & Hypothesis To develop, test, and implement a standardized video

educational tool (VET) on discharge medication challenges to improve confidence and knowledge in dealing with these barriers.

To assess post-education knowledge retention. To measure the rate and cause of hospital revisits in patients

who completed video education. To achieve a 10% increase in patient self-efficacy in managing

medication discharge barriers after post-intervention.

Methods Single-arm intervention feasibility study in 40 patients recruited from

general medicine service (5C and 5N) planned for discharge home over 3 months.

Intervention: 5 videos, 60-90 seconds each, 1 knowledge question per video

Pre- and Post-confidence levels assessed on a 5-point Likert scale adapted from the Medication Understanding and Use Self-Efficacy Scale (MUSE) developed by Cameron, et al.

Self-efficacy evaluated as a composite score (range 5-25), which consists of the five confidence questions added together

Nonparametric Mann-Whitney U tests utilized to measure the statistical difference between pre-intervention and post-intervention scores

Results Patients who viewed the VET had a significant post-intervention increase in confidence (p=0.043**) in their ability to overcome common post-discharge medication barriers. Knowledge retention after video education was high

with 95% of patients getting 4 or 5 questions correct. 90% of patients found the intervention helpful 33% of patients stated that the video identified a new

or previously not considered challenge, demonstrating the benefit of the video as an additive measure.

Background The discharge process consists of providing patients with verbal

and written instructions, however many patients do not fully understand or recall the information provided at discharge leading to poor discharge planning.

Data from recent studies highlights that patients frequently feel unprepared for post-discharge challenges often leading to preventable readmissions.

One domain of unanticipated challenges is medication adherence barriers. As a response to the difficulty with written discharge instructions, and the advent of bedside tablets, some have used videos to offer instructions and education around discharge.

DemographicsTotal N 40

Age, mean 52

Gender, (%)

Female 63

Race/ Ethnicity, (%)

White 43

Asian/ South Asian 5

African American 23

Hispanic/ Latino 13

Other 13

Declined 5

77.50%

10.00%

12.50%

Health Literacy (%)

Adequate

Marginal

Inadequate

0.0% 0.0%5.0%

20.0%

75.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

0

5

10

15

20

25

30

35

1 Correct 2 Correct 3 Correct 4 Correct 5 Correct

Frequency of Knowledge Questions Correct

N Percentage

20.5

21

21.5

22

22.5

23

23.5

24

Pre-InterventionMedian

Post-InterventionMedian

Change in Median Composite Self-Efficacy Score from Pre- to Post-

Intervention

∆ = + 2.0 (~8%)*

Median = 21.5IQR = (19.0-

25.0)

Median = 23.5IQR = (21.0-25.0)

Limitations: Our study had several limitations: small sample size, restricted only

to patients who were being discharged home, restricted to patients who spoke English, patients without cognitive deficit, and a significant number of patients refused to participate. This was a pilot study intended to test the feasibility of a larger implementation of a VET. Next steps would include: a wider implementation with a more inclusive patient population.

What to Expect That You’re Not Expecting: Video Education to Improve Patient Confidence Around Discharge Medication Barriers

Primary Care Innovations SymposiumSanjai Sinha, MD | September 12th, 2017



» Fifth level

Rapid Primary Care Follow Up from the ED to Reduce Avoidable Hospital Admissions

Amanda S. Carmel, MD , Peter Steel, MA, MBBS, Robert Tanouye, MD, MBA, Aleksey Novikov, MD, Sunday Clark, ScD, Sanjai Sinha, MD, Judy Tung, MD

Tables & Charts

Conclusion Rapid access to primary care: • can avoid low acuity hospitalization for

select patients.• Did not increase ED revisits or subsequent

hospitalizations.• Engaged patients in primary care.

Limitations Retrospective study with subjective assessments by physicians not involved in the actual care of the study patients. Outcomes were limited to local data.Implications A program such as this has the

potential to reduce admissions, save on costs and engage patients in primary care. Funding Source: None


Objectives & Hypothesis• Evaluate the safety and impact of a rapid

primary care follow up protocol on admission avoidance

Methods• Created a Transitions Team (registrar, nurse

care manager) and Intranet-based schedule to facilitate ED PC within 2 days

• Performed a retrospective chart review of patients referred in the program’s 1st year (2014-2015)

• Referrals were classified as an avoided admission by Emergency Medicine (EM) and Internal Medicine (IM) physician reviewers

• Rapid appointment visit completion, ED revisits, hospitalizations and PC engagement rates were collected

Results Background• Multiple national efforts underway to

reduce avoidable hospital admissions• Protocol for ED Rapid Primary Care

developed at Cornell for low acuity patients who might otherwise be admitted



» Fifth level

Using “Pod-Cards” to Encourage Doctor-Patient Continuity in a Resident Primary Care Practice:

A Pilot Project using QI MethodologyLaura Gingras M.D. Lauren Acinapura M.D., Masha Jones M.D., Brett Ehrmann M.D., Jaime Fineman M.D., Jamuna Krishnan M.D.,

Perola Lamba M.D., Peggy Leung M.D., Derek Mazique M.D., Mariella Ntamatungiro M.D., Jennifer Lee M.D.

ResultsSurvey data was collected from a total of 44 residents. 64-88% responded positively to questions assessing the usability of the cards. Numerous concrete suggestions were collected to improve the cards and the process for future iterations.

Process Map

ConclusionThe use of Pod-Cards as a tool to promote patient-provider continuity is a feasible intervention that was found to be useful by residents and staff.

LimitationsThis initial phase of the project focused on understanding the process, and testing the feasibility of a possible intervention. Concrete data on continuity outcomes was not collected in this phase.

ImplicationsIn the next phase of the project we will implement a new version of the cards based on user feedback, and we will collect concrete data on patient-provider continuity rates.

Funding Source: The next phase of this project is being funded by the Weill Cornell Dept of Medicine Quality University program.


ObjectivesDuring this initial pilot phase, the goals were: 1) to understand the current process by which patients are either scheduled with their PCP or not scheduled with their PCP2) to design a possible intervention to promote continuity3) to gather feedback on feasibility and ways to improve the intervention and the process

MethodsWe are using a QI framework, utilizing an iterative PDSA-cycle approach to continuous improvement. The pilot project described here was the first phase in an ongoing improvement effort.

This first phase involved:▪ interviews with front-line staff▪ detailed process mapping of current workflows▪ design and implementation of a pilot intervention▪ collection of feedback from front-line users.

Data was gathered through informal discussions with stakeholders and through written surveys of residents, and oral surveys of front-desk staff.

The pilot intervention involved “Pod-Cards” – colorful printed cards containing photos of the patient’s primary care provider and the primary care team, or “pod.” These cards are used in each visit as a tool to:

▪ Prompt a discussion between resident and patient about continuity.▪ Allow the resident to easily identify when/with whom the patient should follow-up.▪ Provide a clear means of communication between resident and

registrar (front desk scheduling staff).

BackgroundStudies have shown that provider-patient continuity in outpatient primary care is associated with: decreased hospitalizations, increased completion of recommended preventative care, improved patient, provider, and staff satisfaction, decreased cost, and even decreased mortality. Continuity of care is also essential to resident education in Internal Medicine.

It is very challenging, however, in a resident practice to preserve provider-patient continuity, given the logistical complexity of resident schedules and competing inpatient demands.

Office Encounter btwn Pt and Resident

New Patient is seen by a

resident. This resident

becomes the PCP.

Patient is seen by their PCP.

Patient is seen by a resident who is NOT their PCP or

Pod.

Patient is seen by their PCP’s Pod.

Next visit scheduled by Registrar

Patient is seen by their PCP.

Patient is seen by a resident who is NOT their PCP or

Pod.

Patient is seen by their PCP’s Pod for short‐interval follow‐up or acute concern.

Patient goes to front desk

Next Office Encounter btwn Pt

and Resident

Patient calls to schedule routine follow‐up

appt

Patient d/c’dfrom Inpt or ED. TC or PN arranges f/u.

Patient No‐

shows.

Patient cancels

Access Team

involved

Patient calls with

new acute

concern

Next visit scheduled by Alt Route

Patient shows up for visit

Patient leaves w/o

checkout.

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Nopatient

Fewpatients

Somepatients

Mostpatients

Everypatient

How often do you use Pod Cards?

n = 44

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

StronglyDisagree

Disagree Neutral Agree StronglyAgree

Pod Cards are useful to improve continuity

n = 44

Acknowledgements:The authors thank the leadership of Weill Cornell Internal Medicine Associates, Dr. Fred Pelzman, Dr. Judy Tung, Stephen Toppin, and Diego Rivera, for their encouragement, guidance and support for this project.

Pilot Intervention

(Front desk staff)



» Fifth level

Direct Observation of Residents: An evolving financial incentive program to facilitate meaningful evaluation of EPAs

Lauren Acinapura, MD, MPH, Anthony Pho, MSN, MPH, ANP-C, Johanna Martinez, MD, MS

Results (Continued)The program has evolved to acknowledge some of its barriers while maintaining its intended benefits: • Baseline expectation for minimal number of observation

pro-rated based on the number of weekly preceptingsessions

• Shifted to an individual incentive system that acknowledges the faculty who observe above their expected baseline.

• Two 8-week direct observation focused blocks created to help faculty remember to prioritize DO

2016-2017 academic year : 244 DO completed & documented, (112 Physical Exam, 132 Communication skills) demonstrating some sustainability of this program over 5 years.

Conclusion:• A direct observation program that includes a central

collection system allows for the capture of meaningful performance data to inform semi-annual resident evaluation and provide more consistent feedback throughout the year.

• Periodic faculty development, regular reports, a financial incentive and focused direct observation blocks help keep faculty engaged in the program.

Limitations• Program implemented at only 1 Internal Medicine Residency. • Administrative support is required to monitor and report

participation data.

Implications• A financial-incentive linked direct observation program is a

promising approach to successfully evaluating residents. • Directly observing EPAs and using cumulative DO ratings

and comments allows educational leadership to more readily identify residents’ strengths and weaknesses.

Funding Source: n/a | Conflicts of Interest: n/aAcknowledgements: Judy Tung, MD and Fred Pelzman, MD at Weill Cornell Medicine for their support of the ambulatory Direct Observation program at Weill Cornell Internal Medicine Associates

Objective’s & HypothesisResidents Increase frequency of being directly observed and

subsequent formative feedback Improve ambulatory physical exam and communication

skillsFaculty Increase frequency of resident direct observations Derive enhanced knowledge of resident ’s skills in EPAs Hypothesis: 1. Would linking a direct observation program to an incentive

program help promote faculty involvement in DO over competing patient care and teaching demands?

2. A financial incentive program could be funded through visit reimbursement and increasing the number of appropriately billed higher level 4/5GC visits

MethodsAn incentive-based Direct Observation (DO) program implemented in 2012 by a working group of members who had completed the ABIM DO training The program was adapted & adjusted over time to meet our needs: • developed a series of faculty development workshops around

direct observation,• created a streamlined DO feedback form• Web-based database to track observations & faculty participation

Results Preliminary data showed this program was feasible and acceptable to residents and faculty.Within the first three months: 357 direct observations were completed 129 residents directly observed for at least one communication

& one physical exam skill 84% of faculty had participated

• Faculty agreed that DO was important for resident evaluation but noted conflicting priorities & time constraints as barriers.

• Group financial incentive cited as a key motivator during programs’ initial adoption.

• A significant increase in the number of higher level visits, 159% for 9924GC and 119% for 9925GC visits was noted in the program’s initial 6 months compared to the same time period the prior year.

Background • ACGME requires faculty to evaluate resident performance on

measurable and frequently observable entrustableprofessional activities (EPAs)

• Frequent direct observations of residents in the ambulatory resident practice can be challenging

• An evolving program was created to promote consistent observation and feedback of resident performance by linking direct observation to a financial incentive

Methods (cont)• Program linked to a group financial incentive to promote faculty

involvement • Each DO documented with a rating (outstanding to requires redo)

& qualitative feedback. (see ex below)• Faculty reports were distributed quarterly detailing faculty and

residents’ participation, and biannually summarizing the quantitative and qualitative data that helped inform residents’ semi-annual evaluations

“J did not expose the patient's knee to perform the exam. We gowned her and did a thorough knee exam together, reviewing

landmarks & special maneuvers. We appreciated a small effusion that could not have been evaluated through jeans. I think he now appreciates the importance of exposing the joint

when performing a musculoskeletal exam.”

ex “Dr I did a good job explaining the plan for DM management, explaining possible connection of

diarrhea to metformin along with goal A1c in this 85 yo. Lay language & teachback was focused on in

feedback session.”



» Fifth level

The Quality of the Evidence Behind Recommendations for Creating Patient Education Materials: A Systematic ReviewMasha G. Jones, MD, Amanda S. Carmel, MD, Monika M. Safford, MDWeill Cornell Medicine, NY, NY

Table 2. Summary of evidence supporting each of the 13 identifierecommendations

ConclusionsThe recommendations to use visual aids and pictographs orbar graphs are based on high quality evidence.The majority of recommendations are based on low quality evidence.

Implications Additional research is needed to optimize patient educationespecially among populations with low health literacy.

LimitationsMeta-analysis not possible due to study heterogeneity.

Funding Source: Weill Cornell Medicine Division of General Internal Medicine Conflicts of Interest: None

ObjectiveTo systematically review the strength of the evidence for current recommendations for creating effective patient education materials.

MethodsLibrarian search of databases2-person review of articles-Identify RCTs-Assess quality of each RCT using

CEBM framework-Assess overall quality of evidence

of each recommendation using GRADE framework

ResultsSearch results yielded 228 articles.87 selected for additional review.13 recommendations identified –one presented in detail here (Table 1).

Results Table 1. Recommendation 1: Use visual aidsBackgroundPatient education is a foundational first step toward shared decision-making.Several recommendations for creating patient education materials have been promulgated, but the quality of the evidence behind these recommendations is not well described.

References1. Austin PE, Matlack R, Dunn KA, Kesler C, Brown CK. Discharge instructions: do illustrations help our patients understand them? Annals of emergency medicine. 1995;25:317-320.2. Delp C, Jones J. Communicating information to patients: the use of cartoon illustrations to improve comprehension of instructions. Academic Emergency Medicine. 1996;3:264-270.3. Michielutte R, Bahnson J, Dignan MB, Schroeder EM. The use of illustrations and narrative text style to improve readability of a health education brochure. Journal of Cancer Education. 1992;7:251-260.4. Kools M, van de Wiel MW, Ruiter RA, Kok G. Pictures and text in instructions for medical devices: effects on recall and actual performance. Patient education and counseling. 2006;64:104-111.5. Leiner M, Handal G, Williams D. Patient communication: a multidisciplinary approach using animated cartoons. Health education research. 2004;19:591-595.

6. Edwards A, Thomas R, Williams R, Ellner AL, Brown P, Elwyn G. Presenting risk information to people with diabetes: evaluating effects and preferences for different formats by a web-based randomised controlled trial. Patient education and counseling. 2006;63:336-349.7. Brotherstone H, Miles A, Robb KA, Atkin W, Wardle J. The impact of illustrations on public understanding of the aim of cancer screening. Patient education and counseling. 2006;63:328-335.8. Muscatello DJ, Searles A, Macdonald R, Jorm L. Communicating population health statistics through graphs: a randomised controlled trial of graph design interventions. BMC medicine. 2006;4:33.9. Knapp P, Raynor DK, Jebar AH, Price SJ. Interpretation of medication pictograms by adults in the UK. Annals of Pharmacotherapy.2005;39:1227-1233.

-CEBM: Center for Evidence-Based Medicine-GRADE: Grading of Recommendations Assessment, Development and Evaluation

Recommendation Number of RCTs

Total Sample Size of All Trials

Average Sample Size

Overall Quality Rating

Use visual aids 9 1846 205 High

Use pictographs or bar graphs 9 7239 804 High

Avoid sole use of verbal risk descriptors 7 2225 318 Moderate

Present information clearly 5 3615 723 Low

Consider the impact of negative versus positive risk framing 5 899 179 Low

Describe incremental rather than total risk 4 4393 1098 Low

Avoid presenting information as number needed to treat 3 1999 666 Low

Present risk as natural frequencies 3 16716 5572 Low

Use plain language 2 405 202 Low

Use patient testimonials. 2 430 215 Low

Present absolute rather than relative risks 1 203 203 Low

Use a tailored, interactive approach 0 -- -- Low

Use particular layouts & formats 0 -- -- Low

Trial Participants Intervention Comparison Outcome Treatment Effect and Significance

Austin 19951

Convenience sample of 101 patients discharged from ED with diagnosis of laceration

Discharge instructions with illustrationsN=54

Discharge instructions without illustrationsN=47

Comprehension of discharge instructions

Likelihood of intervention group choosing 5+ correct responses vs control group:65% vs 43%, P=.033

Delp 19962

234 consecutive ED patients with lacerations, discharged home, or parents of patients <14 years of age; mean age 20.6 years

Wound care instructions with cartoon illustrationsN=103

Wound care instructions without cartoon illustrationsN=102

Recall Understanding Compliance with wound care instructions

Intervention vs comparison group:-Very satisfied with instructions: 97% vs 66%, P<.001-More likely to answer all wound care questions correctly: 46% vs 6%, P<.001

Michielutte 19923

217 women age >18 (majority <35 years of age) not seriously ill from 1 private and 3 public health primary care clinics (family planning, STD clinic, ob/gyn clinic)

Cervical cancer brochure with more difficult text formatted in narrative style (reading level grade 8.4) with drawings to complement textN=112

Cervical cancer brochure with text as simple bulleted sentences (reading level grade 7.7)N=105

Comprehension Perceived ease of understanding Overall rating of brochure based on responses to 8 questions

-65.2% in illustration group vs 53.3% in no-illustration group answered 7-8 of 8 comprehension questions correctly, P=.076. -Overall rating of brochure as “excellent” was higher among illustration group, 52.7% v 35.2%, P=.01

Kools 20064

General public recruited via posters/flyers in local supermarkets. N=50 in inhaler chamber trial, N=49 in peak flow meter trialAges 33-40 years

Saw 7 line drawings visualizing the actions of using inhaler chamber or peak flow meter.N=24, inhaler chamberN=25, peak flow meter

Saw 2 existing text-only instructions on asthma devices (inhaler chamber and peak flow meter).N=26, inhaler chamberN=24, peak flow meter

Recall of instructionsPerformance of instruction observed from videos

-No difference between groups in number of mistakes made in recalled propositions. -Text-picture group had more correctly recalled propositions (6.04 vs 4.81, 95% CI 2.31, -0.15) and more recall of steps (5.96 v 4.69, 95% CI -2.06, -0.48) with inhaler chamber instructions.

Leiner 20045

192 caretakers of pediatric clinic patients getting polio vaccines

Viewed video of animated cartoons in waiting roomN=96

Received vaccine information sheet (4 pages, Q/A format, 7.7 grade level in English or Spanish), read by participants in quiet roomN=96

Knowledge of polio vaccine based on pre and post intervention test questionnaires

-Post-test scores higher among intervention group: 6.24 vs 5.03 correct responses, P<.001. -30.3% in video group vs 0% in text group answered all questions correctly.

Edwards 20066

508 participants from Diabetes UK patient organization. Recruited via website, printed newsletters, and annual conference. Included patients with diabetes or their caregivers.

4 intervention groups got additional information on diabetes control: 1) detailed numerical info, N=81; 2) anchoring to familiar risks or descriptions, N=90; 3) graphical, N=85; 4) combination of 1-3, N=79.

Received information on risks/benefits of tight diabetes control based on BMJ “Best Treatments.”N=173

Decision conflict scale (DCS—measure of uncertainty) scores Satisfaction with information Free text responses via online survey.

-Mean DSC scores ranged from 2.12 to 2.24 for the groups. -No statistically significant difference in DCS or satisfaction with information among groups.

Brother-stone 20067

318 participants from general practices in London eligible for colorectal cancer screeningAges 60-64

Written leaflet with illustrations showing development of cancer from polyps and polyp removal during flexible sigmoidoscopyN=167 (total)N=30 (interviewed)

Written leaflet aloneN=151 (total)N=35 (interviewed)

Telephone interviews with randomly selected subset of participants assessing knowledge and understanding

Good understanding of test aims in 84% of intervention group vs 57% of control group (OR=3.75, CI: 1.1, 12.09, P=.027).

Muscatello 20068

363 employees of public health system in Australia. Participants randomly selected from phone directories of health system employees.Wide age range

Booklet with same statistical information as control booklet, with changes to improve comprehension of statistical informationN=176

Booklet of 12 graphs from population health publication covering range of graph styles and numerical measuresN=187

Comprehension of graphical designs based on self-completed 39-item mailed survey

Interventions giving greatest improvement in comprehension: changing pie chart to bar graph (prevalence ratio 3.6, 95% CI 2.8, 4.6), changing y-axis of graph so theupward direction represented an increase (2.9, 95% CI 2.1, 9.9), footnote to explain acronym (2.5, 95% CI 1.6, 3.8).

Knapp 20059

67 adults from 2 day centers in LeedsMean age 79.3yo

Full-size pictograms reviewed, 1 week later, viewed same pictograms and gave their interpretation.N=33

Small (1/3 size) pictograms. N=34

Comprehension, based on interpretation of each pictogram, rated as correct or incorrect by investigator

Participants more likely to correctly interpret larger pictograms immediately (P=.037) and at second presentation (P<.001).



» Fifth level

Results• Students preferred having community-based speakers over Weill Cornell physicians teach the sessions (17/44 preferring community speakers, 0/44 preferring Weill Cornell speakers)• Students wanted more structure for both the presentation and debrief• Respondents were split between whether the a clinical skills series should be required during the area of concentration research block, with 15/44 responses in favor, 12/44 preferring optional sessions, and the remainder unsure

ConclusionTeaching clinical skills can continue during research-dedicated blocks to supplement research experiences. Teaching through didactic sessions and debriefs was successful, but future work can investigate ways in which students can apply learned skills in an educational environment. We propose focusing on one skillset, such as motivational interviewing and counseling, and applying it across different topics to allow for concrete skill development.

LimitationsData collected includes responses from first year and third year students. A limited number of people who attended each session filled out the survey, perhaps biasing our results. Similarly, students who attended multiple sessions were able to fill out multiple surveys. Despite being called a clinical skills series, students were not given an opportunity to actually practice skillsets discussed, and thus data on changes in skills and techniques could not be observed or recorded.

ImplicationsInterest exists among third year students during research-dedicated blocks to continue advancing clinical skills. Having community-based organizations teach clinical skills allows for development of skillsets tailored to working with patients from diverse backgrounds.

Funding Source: WCMC Medical School Executive Council Conflicts of Interest: NoneAcknowledgements: Many thanks for advising and support from Dr. Linnie Golightly and Dr. Oli Fein, and session coordination help from Rana Khan, Andrea Liu, Daniel Wang, and Sophie White

Methods• First and third year student organizers selected topics for discussion, prioritizing topics disproportionately impacting underserved communities• Topics selected were substance use and abuse, sexual assault, integrating alternative medicine, and post-incarceration health• Community-based physicians in areas of interest were identified, briefed on the series format and goals, and invited to participate • Four sessions were planned for consecutive Wednesday evenings after required third year lectures during area of concentration (AOC) time• Sessions were divided into 2 components: a speaker presentation (in an informal interview format) and a student-only debrief discussion (Figure 2)• Target audience of third year medical students, first years also allowed• Students evaluated each speaker and debrief session

BackgroundMedical education traditionally teaches clinical skills and physical diagnosis during preclinical years, with supplemental teaching and enhancement during clinical curricula (Figure 1). With more medical schools creating dedicated research time during the third and fourth year, new opportunities and challenges exist in the teaching of clinical skills (defined as verbal and nonverbal communication skills required during the doctor-patient interaction). This pilot project investigated if and how clinical skills can best be incorporated in dedicated research time to allow for further enhancement without interfering with other student commitments. Speaker Session

• Who are you, and what do you/your organization do? How does the topic being discussed today fit into your organization’s mission?

• How do you identify if the given topic is relevant for an individual patient?• Once the problem is identified, how do you tailor your clinical encounter?

What best practices can you share for performing a history, physical exam, patient outreach and follow up?

Student-Only Debrief• How does the scope of the problem compare to your perception of the

problem? • How do the techniques for identifying and addressing the problem

compare to your clinical experiences to date?• How will you modify your practice? Biggest barriers to these changes,

and how can you overcome them?

Pre-Session Readings: • What is the problem, how is it defined, and what medical literature on the

topic exists? • What has the community published on the topic? What recommendations

exist regarding cultural humility for this topic?

Post-Session Involvement: • Session evaluation

Community Perspectives in Medicine: Clinical Skills Series Pilot Project

Eric Kutscher | September 12, 2017

Presentation Content

Excellent Above Average Average or Below

87%

13%

0%

Presentation Topics

61%

30%

9%

Presentation Content

80%

20%

0%

Overall Satisfaction

Figure 3. Select Student Survey Results (n = 46)

Figure 2. Guiding Questions By Session Component

Health, Illness, and Disease 2 Clerkship Didactics

Clerkship Didactics AOC and Translational Sciences

Sub‐I and Electives Electives

Preceptorship & Lectures

Physicianship & LEAP


Physicianship & LEAP


Physicianship

Patient Care

Clinical Duties

Patient Care

Clinical Duties Advanced Clinical Ethics

Patient Care

Clinical Duties

Patient Care

Clinical Duties

Clinical Skills Series

MS1

MS2

MS3

MS4

Fall Spring

Essential Principles of Medicine Health, Illness, and Disease 1

Components of Medical Training: Science, Patient Care, Professionalism

Figure 1. WCM’s Medical Curriculum Framework

Select Participant Quotes“Awesome interview skill building. Loved the low key/informal nature of

it... Great content for future medical interviews.”“So glad this is an option for interested students. Love being able to

drop in.”“Excellent overview from wonderful speaker. Highly informative.”“Very, very important topic with a very knowledgeable speaker.”

“Appreciated his comfort discussing social/economic/legal/medical interface”

“Very informal setting, with moderator: loved it!”“It was an opportunity to learn about something that has not yet been, or may not be, explicitly covered in the medical school curriculum. I think hearing from doctors from community-based organizations is useful

because we usually hear from physicians who work at a huge academic medical center.”

“So useful! I can’t believe these sessions aren’t required for everyone.”




level

A Pilot Study to Improve the Bedside Teaching of Clinical Ethics: A Novel

Collaboration Between Hospital MedicineAnd Medical Ethics

Matthew W. McCarthy, Ezra Gabbay, Diego Real de Asua, Joseph J. Fins

Background/Relevance

Hospitalists now provide the bulk of primary care for hospitalized patients, where they confront a bevy of ethical quandaries in daily practice. Although the majority of these situations do not cross the threshold to prompt a formal Clinical Ethics consultation (CEC), they still cause significant moral distress. Despite abundant knowledge about the ethical issues for which CEC services are consulted, relatively little is known about the sources of ethical conflict encountered by hospitalists at the bedside, especially regarding these more quotidian cases, which nonetheless have meaningful ethical dimensions. We hypothesize that the ethical problems that hospitalists confront differ, in type and degree, from those that reach CEC services. Thus, we aim to characterize the epidemiology of clinical ethics issues that arise on the General Internal Medicine (GIM) hospitalist service and compare them to those seen by the CEC service of the Hospital Ethics Committee.

Proposed Methods

We will perform a cross-sectional study of all ethical problems consecutively identified during daily rounds on every teaching GIM hospitalist service. The projected observation time will lead to include an estimated sample of 260-312 patients. We will collect data on the frequency of ethical and contextual issues pertinent to clinical decision-making using a standardized instrument by two independent observers. This same instrument will be used to retrospectively review and catalog all consultations received during 2016 at the Division of Medical Ethics. We will then compare the baseline frequency of ethical and contextual problems between each group (i.e., Hospitalist vs. Medical Ethics).

Anticipated Impact

In an initial pilot study on the house-staff GIM service, observer-ethicists identified a variety of ethical and contextual issues (TABLE 1). The global estimated frequency of ethical issues during the observation period was 54%. These involved conflicts with consultant physicians on diagnostic or treatment procedures, issues pertaining to interpreter services, de-prescription of usual treatment in an end-of-life setting, inpatient treatment non-adherence, and physician’s responsibility after a patient left against medical advice. These issues are routinely addressed without the assistance of formal clinical ethics consultation. A better characterization of the most common ethical issues that arise in the practice of Hospital Medicine may aid in the development of targeted ethical didactic sessions for students and practitioners, which could improve the quality of care delivered to patients.



» Fifth level

• 203 biopsies in 186 patients were analyzed.

• Culture yield was 28% (Table 3).

• WBC count was the only factor associated with positivecultures (Table 1).

• Histological yield was 29%.

• Culture & histology were both positive in 7% of cases.

• Empiric therapy was changed in 60% of culture-positivecases and 43% of culture-negative cases (Table 3).

• Empiric therapy was discontinued in only 8/98 culture-negative cases (Table 3).

• Empiric antibiotics were “inadequate” in only 3 cases.

• Final antibiotics were “targeted” in 11 cases.

• Bone biopsy yield was 28% in this study.

• Elevated WBC count was the only factor predictive of apositive microbiologic yield.

• There was poor diagnostic concordance betweenmicrobiology and histology results.

• Physicians rarely discontinued antibiotics for negativecultures.

• Bone organisms were adequately treated by empirictherapy in most patients.

• In patients with non-vertebral OM, bone biopsy culturesrarely yielded results that necessitated changes inantibiotic management. Further work is needed to identifypatients whose management may be impacted by thisprocedure.

1. Fincke BG, Miller DR, Turpin R: A classification of diabetic foot infections using ICD-9-CM codes: application to a large computerized medical database. BMC Health Serv Res 10:192, 2010.

2. Lipsky BA, Aragon-Sanchez J, Diggle M, et al: IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 32 Suppl 1:45-74, 2016.

3. Wu JS, Gorbachova T, Morrison WB, et al: Imaging-guided bone biopsy for osteomyelitis: are there factors associated with positive or negative cultures? AJR Am J Roentgenol 188:1529-34, 2007.

4. Senneville E, Lombart A, Beltrand E, et al: Outcome of diabetic foot osteomyelitis treated nonsurgically: a retrospective cohort study. Diabetes Care 31:637-42, 2008.

• Contiguous osteomyelitis (COM) is seen in 1/3 of patientswith diabetic foot ulcers or full-thickness pressure ulcers.1

• Clinicians have yet to agree on the best approach todiagnosing and treating COM.

• Bone biopsy is the “gold standard” as it can providediagnostic and microbiologic data.2

• One major drawback of bone biopsies is the expectedmicrobiological yield of only 30%.3

• Little evidence suggests that bone culture-basedantibiotics improve outcomes in patients with COM.2,4

• No study has evaluated how biopsy results impactphysicians’ antibiotic choices for these patients.

• Primary analysis

Assess changes to empiric antibiotic therapy after finalbone biopsy results are reported.

• Secondary analysis

Determine the microbiological and histological yield ofdiagnostic bone biopsies.

Identify predictors of positive or negative microbiologicalcultures.

• Retrospective analysis of non-vertebral OM in patientswho had image-guided biopsies between 2009 and 2016

• Inclusion criteria: (1) age 18+ (2) image-confirmed OM (3)had image-guided biopsy

• Collected and analyzed various patient characteristics todetermine impact on culture yield (Table 1)

• Performed case-by-case review of antibiotic changes fromempiric to final therapy (Figure 1)

• Changes were classified as initiated, discontinued,broadened, narrowed, or no change (Table 3)

• Broadened/narrowed were defined as +/- coverage forMRSA, Pseudomonas, anaerobes, VRE, or other GP/GN.

Introduction

Materials and Methods

Results

Discussion

References

Objectives

Conclusion

Figure 2a

Tables & Figures

Utility of Diagnostic Bone Biopsies in the Management of Osteomyelitis: How Golden is this Gold Standard?Cole B. Hirschfeld | September 12, 2017

Figure 1: Timeline of antibiotic administration

Table 2. Distribution of microbiology results

Table 1. Effect of patient characteristics on the risk of a positive culture

Table 3: Changes in antibiotic spectrum from empiric to final therapy

Culture- Culture-positive negative

No change 23 (40%) 83 (57%) Never given abx 4 (7%) 31 (21%) Cont'd empiric abx 19 (33%) 52 (36%)Narrowed 15 (26%) 29 (20%)Initiated 13 (23%) 17 (12%)Broadened 6 (11%) 9 (6%)Discontinued 0 (0%) 8 (5%)Total 57 146

Antibiotic changes

Characteristic Adjusted RR (95% CI) P Biopsy needle gauge 1.05 (0.97 - 1.13) 0.23 Number of samples cultured 1.07 (0.84 - 1.36) 0.60 Highest WBC within 7 days of biopsy 1.05 (1.01 - 1.10) 0.02 Overlying cellulitis 1.06 (0.64 - 1.76) 0.82 Ulcers 0.99 (0.55 - 1.79) 0.97 Antibiotics prior to biopsy 1.03 (0.96 - 1.10) 0.44 Prior antibiotics 1.16 (0.43 - 3.13) 0.77 Diabetes 0.63 (0.37 - 1.07) 0.09 ESRD 1.46 (0.69 - 3.08) 0.32 Paraplegia 1.18 (0.58 - 2.43) 0.64 Significant other neuropathy 0.73 (0.36 - 1.46) 0.37 Amputations 0.81 (0.37 - 1.81) 0.61 PVD 1.28 (0.58 - 2.43) 0.64

Organism N N/57Staphylococcus aureus 17 30%

MSSA 10MRSA 7

Coagulase negative staph 13 25%Streptococcus spp 14 21%Enterococcus spp. 2 4%Coryneiform bacteria 2 4%Enterobacteriaciae 11 19%Non-enteric GNR 2 4%Anaerobes 6 11%Cryptococcus neoformans 1 2%

67Total



» Fifth level

The Sweetest Pea: The Effect of a Focused Primary Care Visit on Glycemic Control

Michael Chen, MD; Janine Harewood, MD; Blanca Sckell, MD, MPH, FACP; Cindy Sadikot, MDSeptember 12, 2017

Results 57 patients were included in the final study. 53% were female and the average age was 62. The average initial HbA1c was 10.5%. Patients had average of 2 visits (1-10). The average maximum change in HbA1c was -2.7%. The average overall change in HbA1c was -1.9%. Of the patients analyzed, 56.1% achieved HbA1c <8% and 38.6% achieved HbA1c <7%

ConclusionWe were able to demonstrate that at least one visit to our primary care based SP clinic was able to successfully decrease HbA1c an average of 2.7%.

LimitationsThe study population cohort was small with a short follow up period. Long term patient compliance and glycemic control will need to be studied in the future.

ImplicationsAt least one diabetes directed clinical visit and patient education can help achieve significant HbA1c reduction in resident based clinics.

Funding Source: noneConflicts of Interest: noneAcknowledgements: Jyoti Gupta MD, Cindy Sadikot MD, Blanca Sckell MD, MPH, FACP, Internal Medicine Residents and staff of NYPQ Ambulatory Care Clinic

Objectives & HypothesisThe purpose of the study is to assess the effect of a primary care based resident run diabetes clinic on glycemic control for patients with Type 2 Diabetes Mellitus. We predicted at least one visit to the Sweet Pea clinic would result in HbA1c reduction to <8% in at least 50% of the patients.

MethodsPatients with Type 2 Diabetes Mellitus with HbA1c >8% were referred from residents’ primary care clinic between March 2015 to March 2016. During Sweet Pea (SP) visits, patients met with a resident to address barriers to diabetic care, receive focused education and counseling of the disease process, lifestyle modifications from residents and nurses, and medication adjustments. Revisits occurred every 1-4 weeks at the discretion of the provider, until HbA1c is <8%. Data was collected up to March 2017.

BackgroundOne in three adults are projected to have diabetes by 2050. Fewer patients seen in residency clinics achieve appropriate diabetes quality measures compared to practicing general internists. In residency clinics, barriers to diabetes care include lack of continuity of care with providers, high percentage of Medicaid patients, and medical complexity of clinic patients. One possible solution is the use of a chronic care clinic for diabetes within primary care, which has been shown to be successful in faculty practices at improving clinical outcomes of glycemic control and in the completion of recommended diabetes care processes.



» Fifth level

Psychiatric Consultation for the Medically-ill Older Adult: An Embedded Psychiatry Pilot Program

Alanna Chait, Joseph Mermelstein, Liliya Gershengoren, Eugenia L. Siegler, Janna S. Gordon-Elliott

September 12, 2017

Tables & Charts

Conclusions• An embedded psychiatrist can improve

quality of care in a geriatric population.• An embedded psychiatry senior resident

rotation is valid and feasible.

Implications• Integrated psychiatric and medical care can

enhance delivery of mental health services to patient populations in need.

• May improve in medical outcomes and provider collaboration.

• Help prepare and encourage trainees to work in multidisciplinary settings.

No funding sources, conflicts of interest, or acknowledgements.

Objectives & Hypothesis• Assess the impact of an embedded

psychiatrist on patient care for a geriatric medicine service.

• Evaluate the feasibility and experience of an embedded psychiatry rotation as a senior resident elective.

Methods• From July 2016 to February 2017, a PGY4

psychiatry resident was embedded on a geriatric medicine service.

• The resident performed all consultations, attended rounds, and was available to the team throughout the week.

• Data were compared to an equivalent period one year earlier when consultations were performed by the general C-L service.

Results• Greater than 50% increase in number of

consultations.• 65% of consultations seen within 2 days of

admission compared with 48.7%. • More frequent discontinuation of constant

observation status.• More medication adjustments.• Fewer consultations for decision-making

capacity.• All cases managed within the confines of a

part-time elective.

Background• Embedded psychiatrists in medical settings

can improve and facilitate patient care.• Depression and anxiety in the older adult

can negatively affect disease progression, treatment adherence, functional status, and mortality.

Embedded Psychiatrist(2016-2017)

General C-L Service (2015-2016)

Number of consults 60 39Average age (range) 85.75 (66-101) 83.33 (68-98)Gender

Female 43 25Male 17 14

Prior psychiatric history 29 (48%) 10 (49%)New psychiatric medication started during admission

39 (65%) 22 (56.4%)

Psychiatric medication stopped during admission

20 (33.3%) 8 (20.5%)

Constant Observation Continued

2 (15.3%) 4 (40%)

Constant Observation Discontinued

11 (84.6%) 6 (60%)

0%

10%

20%

30%

40%

50%

60%

70%

0‐2 3‐5 6‐8 10‐12 13‐15 >15

Percen

tage of p

atients

Time to consult (days)

Time to Consult

2015‐2016 2016‐2017

Chart 2: Time to Psychiatric Consultation

Table 1: Patients Referred for Psychiatric Consultation

Limitations• No assessment of length of stay, patient

satisfaction or health outcomes.• Funding and training for collaborative model.




level

Quality of Care and Characteristics of Middle-Aged Hispanics Disabled with Arthritis

2017 Primary Care Innovations SymposiumIris Navarro-Millán, MD MSPH | September 12, 2017

Background/Relevance Disability of any kind, including disabling arthritis, is associated with social stigma and resultant stress, which in Hispanics may be compounded by stress from acculturation. Furthermore, arthritis patients have on average of 3.8 chronic conditions while similarly aged patients without arthritis have a total of 1.8 total chronic conditions. This greater illness burden is potentially augmented in Hispanics, who are at greater risk for chronic conditions like diabetes. The greater number of medical conditions increases the importance of high quality healthcare to optimize long-term outcomes, but little is known about the quality of care received by disabled Hispanics with arthritis. Indeed, Hispanics have been shown to have lower quality of healthcare than non-Hispanics, but little is known about the quality of healthcare among younger disabled Hispanics with arthritis, who face the greatest risks of long-term health compromise. Hispanics are expected to be 20% of the US workforce by 2020, the majority in manual labor, which has been associated with increased risk for disability. For that reason, research specifically focused on quality of care among younger disabled Hispanics with arthritis (a common cause for disability) should be a priority.The main goals of this study are to investigate the characteristics of Hispanics with arthritis who are disabled before the age of 65, and to investigate the patterns and quality of healthcare in this population. Proposed Methods Study design: Multi-year cross-sectional study using national Medicare disability dataPopulation: Medicare Beneficiaries from 2006-2015 Main exposure variable: race/ethnicityOutcome Variables: Patterns of health services utilization (patients with arthritis) Quality of care measures will be defined using NCQA (National Committee for Quality Assurance) Health Effectiveness Data Information System (HEDIS) measures and American Diabetes Association guideline recommendations (Patients with arthritis and diabetes since there is no measure of quality of care specific for arthritis). Analysis: We will construct separate multivariable Poisson regression models with robust variance estimates for each outcome to examine whether age, sex, the number of comorbidities, and poverty account for observed differences among race/ethnic groups. We will use multivariable Poisson regression models with robust variance estimates to examine associations between race/ethnicity and quality of care metrics, examined in separate models, one for each quality metric. We will calculate counts and rates of each of these measures.Anticipated ImpactThis study will determine if there are differences in patterns and quality of care in a population that is frequently overlooked: disabled Hispanics with arthritis who are younger than 65 years of age. Among the relevant reasons to study this population are: 1) young individuals that become disabled increase the cost of healthcare by greater health services utilization and decreased productivity from not being part of the workforce; 2) Hispanics in particular are important members of society that will compose 20% of the U.S. workforce by 2020; therefore, understanding the patterns and quality of their healthcare should be a priority; 3) this study is the first step towards developing a large Medicare claims dataset resource in the GIM Division at WCM by building on a long-term relationship with the University of Alabama at Birmingham (UAB) for future proposals using large datasets; 4) the results of this study will inform where to target interventions to diminish health disparities among Hispanics.



» Fifth level

Results/Curriculum Development:

The curriculum is multi-medium and delivered on the ITunes University and iBook. It consists of:• Four unique videos capturing

conversations between a provider and a transgender patient highlighting how to perform a transgender-sensitive history and physical, tips for creating an accepting office environment, gender-affirming hormone therapy, surgical interventions.

• Links to content resources including guidelines for screening, PrEP, and hormone therapy.

• Schematics illustrating gender affirmation surgeries.

• Links to web-based resources \in transgender health.

• Local resources for referring transgendered patient to hormonal or surgical therapy.

Background• Transgender patients face health

disparities due to discrimination and misunderstanding by medical professionals

• Discrimination against transgender persons has been associated with psychiatric disorders, substance abuse, and depression

• Primary Care Internists can be a valuable resource for transgender individuals

Comprehensive Medical Care for Transgender PatientsJohnston CD, Shearer LS, Logio LS

Prior Transgender Care Education

No55%

Yes45%

0

10

20

30

40

1 2 3 4 5

Resident TG Care Confidence (N=67)

Low Confidence High

Documents

PhD, Tomer Levin MBBS, FAPM, Rozan Abdulrahman MPH, John ... · Anxiety: 67% Bipolar D/O: 3.8% Depression: 61% Alcohol D/O: 3.6% ... resource-rich NYP located in Manhattan focusing