Continuity of Care in Resident Outpatient Clinics: A Scoping Review of the Literature

Time Differences From Abnormal Cervical Cancer Screening to Colposcopy Between Insurance Statuses

OBJECTIVE

Screening and diagnostic follow-up to prevent cervical cancer are influenced by socioeconomic and systemic factors. This study sought to characterize intervals from abnormal cervical cancer screening to colposcopy between practices differing by insurance status at a large, urban academic center.

MATERIALS AND METHODS

This retrospective cohort study included patients aged 21-65 who presented for colposcopy between January 1, 2021, and January 1, 2022, at the resident and faculty gynecology practices of a single large urban academic medical center. Patient characteristics were compared using t tests or Wilcoxon rank sum tests for continuous measures and χ2 or Fisher exact tests for categorical measures. Intervals from abnormal cervical cancer screening to colposcopy were compared using the Wilcoxon rank sum test and linear regression analysis with multivariable models adjusted for age, cervical cytology result, human papillomavirus result, and HIV status.

RESULTS

Resident practice patients were publicly insured and more likely to be Black or Hispanic (p < .0001); rates of high-risk human papillomavirus and smoking were similar. Resident practice patients had longer intervals from abnormal cervical cancer screening to colposcopy compared with faculty practice patients (median 79.5 vs 34 d, p < .0001). On adjusted analysis, resident practice patients faced a 95% longer interval (p < .0001).

CONCLUSIONS

Publicly insured patients of a resident-based practice faced significantly longer intervals from abnormal cervical cancer screening to colposcopy than faculty practice patients at a single urban academic center. Effort to address these differences may be an area of focus in improving health disparities.

Language Disparities in Caregiver Satisfaction with Physician Communication at Well Visits from 0-2 Years

OBJECTIVE

This study aimed to describe caregiver satisfaction with physician communication over the first two years of life and examine differences by preferred language and the relationship to physician continuity.

METHODS

Longitudinal data were collected at well visits (2 months to 2 years) from participants in a randomized controlled trial to prevent childhood obesity. Satisfaction with communication was assessed using the validated Communication Assessment Tool (CAT) questionnaire. Changes in the odds of optimal scores were estimated in mixed-effects logistic regression models to evaluate the associations between satisfaction over time and language, interpreter use, and physician continuity.

RESULTS

Of 865 caregivers, 35% were Spanish-speaking. Spanish-speaking caregivers without interpreters had lower odds of an optimal satisfaction score compared with English speakers during the first 2 years, beginning at 2 months [OR 0.64 (95% CI: 0.43, 0.95)]. There was no significant difference in satisfaction between English-speaking caregivers and Spanish-speaking caregivers with an interpreter. The odds of optimal satisfaction scores increased over time for both language groups. For both language groups, odds of an optimal satisfaction score decreased each time a new physician was seen for a visit [OR 0.82 (95% CI: 0.69, 0.97)].

CONCLUSION

Caregiver satisfaction with physician communication improves over the first two years of well-child visits for both English- and Spanish-speakers. A loss of physician continuity over time was also associated with lower satisfaction. Future interventions to ameliorate communication disparities should ensure adequate interpreter use for primarily Spanish-speaking patients and address continuity issues to improve communication satisfaction.

Measuring continuity in primary care: how it is done and why it matters

Continuity of care (COC) is a foundational element of primary care and is associated with improved patient satisfaction and health outcomes and decreased total cost of care. The patient-physician relationship is highly valued by both parties and is often the reason providers choose to specialize in primary care. In some settings, such as outpatient residency clinics, however, patients may only see their primary care provider (PCP) 50% or less of the time. Considering the many benefits of COC for patients and providers, there is a clear need for us in primary care to understand how to compare different COC measures across studies and how to choose the best COC measure when conducting quality improvement efforts. However, at least 32 different measures have been used to evaluate COC. The manifold variations for measuring COC arise from data source restrictions, purpose (research or clinical use), perspective (patient or provider), and patient visit frequency/type. Key factors distinguishing common COC formulas are data source (e.g. claims data or electronic medical records), and whether a PCP is identifiable. There is no "right" formula, so understanding the nuances of COC measurement is essential for primary care research and clinical quality improvement. While the full complexity of COC cannot be captured by formulas and indices, they provide an important measure of how consistently patients are interacting with the same provider.

Continuity of Care: A Primer for Family Medicine Residencies

Continuity of care has been an identifying characteristic of family medicine since its inception and is an essential ingredient for high-functioning health care teams. Many benefits, including the quadruple aim of enhancing patient experience, improving population health, reducing costs, and improving care team well-being, are ascribed to continuity of care. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) added two new continuity requirements-annual patient-sided continuity and annual resident-sided continuity-in family medicine training programs. This article reviews continuity of care as it applies to family medicine training programs. We discuss the various types of continuity and issues surrounding the measurement of continuity. A generally agreed upon definition of patient-sided and resident-sided continuity is presented to allow programs to begin to collect the necessary data. Especially within resident training programs, intricacies associated with maintaining continuity of care, such as empanelment, resident turnover, and scheduling, are discussed. The importance of right-sizing resident panels is highlighted, and a mechanism for accomplishing this is presented. The recent ACGME requirements represent a cultural shift from measuring resident experience based on volume to measuring resident continuity. This cultural shift forces family medicine training programs to adapt their various systems, policies, and procedures to emphasize continuity. We hope this manuscript's review of several facets of contuinuity, some unique to training programs, helps programs ensure compliance with the ACGME requirements.

Enhanced Scheduling to Improve Resident Continuity in a Family Medicine Teaching Clinic

BACKGROUND AND OBJECTIVES

Continuity of care is a core concept at the heart of primary care practices. Increased patient-provider continuity of care is associated with better satisfaction scores, better clinical outcomes, decreased hospitalizations and emergency department utilization, improved completion of preventive health services, adherence to medical treatment plans, and improved show rates. Compared to traditional outpatient practices, resident teaching clinics traditionally have lower rates of continuity and face unique challenges in improving continuity given the curricular demands, complex scheduling, and high turnover of providers. The objective of our study was to assess the impact of front office training and new electronic medical record (EMR) scheduling protocols on resident continuity in a family medicine teaching clinic.

METHODS

From July 2021 through May 2022, optimized scheduling through a provider search function in the EMR was implemented in a family medicine teaching clinic. We compared the monthly continuity rates between corresponding months in the prior year and the intervention year.

RESULTS

Over an 11-month implementation process, continuity for resident physicians increased from 36.4% to 64.6% (χ2=675.41, P<.001) using EMR tools and scheduling search functions to improve and sustain continuity over the study period.

CONCLUSIONS

This intervention to enhance continuity in a family medicine residency clinic led to rapid and sustained improvement in provider continuity. This result demonstrates that optimization of EMR scheduling with tools and protocols can improve overall continuity. This scheduling process can likely be applied to clinical sites for residency programs across disciplines.

Impact of Set-Day Clinic on Physician Continuity in a Family Medicine Residency Clinic

BACKGROUND AND OBJECTIVES

Continuity of care between patients and their primary care providers is associated with improved patient outcomes and experience, decreased health care costs, and improved provider well-being. Strategies to enhance continuity of care in residency programs involve electronic health record, scheduling, and panel management methods. Our study compared physician-patient continuity rates (pre and post) for one family medicine residency's implementation of a set-day clinic (SDC) scheduling model.

METHODS

In July 2019, Bethesda Clinic switched from a rotation-driven scheduling (RDS) model to SDC. Physicians were divided into two scheduling groups: Monday, Thursday, or Friday; or Tuesday, Wednesday, or Friday. We used visit data from two 6-month periods, October 2018 to March 2019 (RDS) and October 2021 to March 2022 (SDC), to calculate continuity using the continuity for physician formula. We used t tests to compare mean continuity rates between the RDS and SDC periods. In June 2022, faculty and residents were emailed a nine-question survey about SDC.

RESULTS

Adherence to the SDC model ranged from 65% to 76%. Postgraduate year (PGY) 3 residents' continuity increased significantly (P<.001) from 44% (RDS) to 56% (SDC), while PGY2 residents' continuity increased, nonsignificantly, from 38% to 43%. Among those that completed the survey, 94% of residents and 78% of faculty were in favor of SDC.

CONCLUSIONS

We demonstrated that SDC is feasible and well received by residents and faculty alike. Continuity was highest for PGY2 and PGY3 residents during the SDC period. Predictable clinic schedules have the potential to improve continuity in family medicine residency clinics and may improve physician well-being.

Longitudinality Matters: Qualitative Perspectives on a Longitudinal Clinical Experience in a Psychiatry Residency Training Program

OBJECTIVE

Longitudinal models of clinical care and education can positively impact the patient and provider experience in terms of health outcomes, satisfaction, and motivation. While residency programs have seen an increase in primary care longitudinal clinical experiences (LCEs), defined as outpatient clinics in which patients are seen by residents over the course of their entire training, less is known about such opportunities in psychiatry residency programs. This qualitative study explores the impact of a longitudinal training model on psychiatric resident skill development, relationships in the clinical learning environment, and professional identity formation.

METHODS

The authors conducted 24 semi-structured interviews of residents, graduates, and faculty in three well-established LCE clinics in a single, multi-site, academic psychiatry residency program. Transcripts were analyzed using inductive thematic analysis techniques.

RESULTS

Themes were categorized into benefits and challenges. For benefits, themes included longitudinal relationships, improved feedback, near-peer teaching, early outpatient exposure, graduated independence, skill development, patient population expertise, and solidification of professional identity. For challenges, themes included system logistics, offsite panel management, and intermittent presence of junior trainees.

CONCLUSION

Results suggest that overall, residents and faculty find the LCE a positive learning opportunity that has contributed to their professional development. LCEs do appear to have distinct challenges, largely logistical in nature, which can interfere with the favorability of residents' experiences. Developing strategies up front to minimize these logistical challenges will support the success of a longitudinal program.

Personal Continuity and Appropriate Prescribing in Primary Care

PURPOSE

Personal continuity between patient and physician is a core value of primary care. Although previous studies suggest that personal continuity is associated with fewer potentially inappropriate prescriptions, evidence on continuity and prescribing in primary care is scarce. We aimed to determine the association between personal continuity and potentially inappropriate prescriptions, which encompasses potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), by family physicians among older patients.

METHODS

We conducted an observational cohort study using routine care data from patients enlisted in 48 Dutch family practices from 2013 to 2018. All 25,854 patients aged 65 years and older having at least 5 contacts with their practice in 6 years were included. We calculated personal continuity using 3 established measures: the usual provider of care measure, the Bice-Boxerman Index, and the Herfindahl Index. We used the Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) specific to the Netherlands version 2 criteria to calculate the prevalence of potentially inappropriate prescriptions. To assess associations, we conducted multilevel negative binomial regression analyses, with and without adjustment for number of chronic conditions, age, and sex.

RESULTS

The patients' mean (SD) values for the usual provider of care measure, the Bice-Boxerman Continuity of Care Index, and the Herfindahl Index were 0.70 (0.19), 0.55 (0.24), and 0.59 (0.22), respectively. In our population, 72.2% and 74.3% of patients had at least 1 PIM and PPO, respectively; 30.9% and 34.2% had at least 3 PIMs and PPOs, respectively. All 3 measures of personal continuity were positively and significantly associated with fewer potentially inappropriate prescriptions.

CONCLUSIONS

A higher level of personal continuity is associated with more appropriate prescribing. Increasing personal continuity may improve the quality of prescriptions and reduce harmful consequences.

Resident Versus Attending Prenatal Care Models: an Analysis of the Effects of Race and Insurance on Appointment Attendance

OBJECTIVE

To describe patient differences by prenatal care (PNC) model and identify factors that interact with race to predict more attended prenatal appointments, a key component of PNC adherence.

METHODS

This retrospective cohort study used administrative data targeting prenatal patient utilization from two OB clinics with different care models (resident vs. attending OB) from within one large midwestern healthcare system. All appointment data among patients receiving prenatal care at either clinic between September 2, 2020, and December 31, 2021, were extracted. Multivariable linear regression was performed to identify predictors of attended appointments within the resident clinic, as moderated by race (Black vs. White).

RESULTS

A total of 1034 prenatal patients were included: 653 (63%) served by the resident clinic (appointments = 7822) and 381 (38%) by the attending clinic (appointments = 4627). Patients were significantly different across insurance, race/ethnicity, partner status, and age between clinics (p < 0.0001). Despite prenatal patients at both clinics being scheduled for approximately the same number of appointments, resident clinic patients attended 1.13 (0.51, 1.74) fewer appointments (p = 0.0004). The number of attended appointments was predicted by insurance in crude analysis (β = 2.14, p < 0.0001), with effect modification by race (Black vs. White) in final fitted analysis. Black patients with public insurance attended 2.04 fewer appointments than White patients with public insurance (7.60 vs. 9.64) and Black non-Hispanic patients with private insurance attended 1.65 more appointments than White non-Hispanic or Latino patients with private insurance (7.21 vs. 5.56).

CONCLUSION

Our study highlights the potential reality that the resident care model, with more care delivery challenges, may be underserving patients who are inherently more vulnerable to PNC non-adherence at care onset. Our findings show that patients attend more appointments at the resident clinic if publicly insured, but less so if they are Black than White.

Perceived Access and Appropriateness: Comparison of Teaching and Resident Family Physicians' Patients

BACKGROUND AND PURPOSE

Teaching clinics aim to provide patients with care that is comprehensive, high quality, and timely. Since resident presence at the clinic is irregular, timely access to care and continuity remain challenging. The two main objectives of our study were to compare the experience of timely access by patients of family residents vs staff and to determine if there was a difference between resident and staff patients in reported appropriateness and patient-centeredness of the visit.

METHODS

This cross-sectional survey study was carried out in nine family medicine teaching clinics part of University of Montreal and McGill University Family Medicine Networks. Patients self-administered two anonymous questionnaires, before and after their consultation.

RESULTS

We collected 1,979 preconsultation questionnaires. Teaching physician (staff) patients rated the usual wait time for an appointment as very good or excellent more frequently than resident patients (46% vs 35 %; P=.001). One out of five reported consulting another clinic in the last 12 months. Resident patients consulted elsewhere more often. In postconsultation questionnaires staff patients rated their visit experience better than resident physician patients and patients of second-year residents better than first-year residents.

CONCLUSION

Although patients generally have a positive perception of access to care and adequacy of the consultations meet their needs, staff also face the challenge of providing better access to their patients. Finally, we found the patients' perceived visit-based patient centeredness was higher for visits of second-year than first-year resident physicians, supporting the impact of training efforts toward patient-centered best practices.

Resident Visit Productivity and Attitudes About Continuity According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Study

BACKGROUND AND OBJECTIVES

Training models in the Length of Training Pilot (LOTP) vary. How innovations in training length affect patient visits and resident perceptions of continuity is unknown.

METHODS

We analyzed resident in-person patient encounters (2013-2014 through 2018-2019) for each postgraduate year (PGY) and total visits at graduation derived from the Accreditation Council for Graduate Medical Education reports for each LOTP program. We collected data on residents' perceptions of continuity from annual surveys (2015-2019). We analyzed continuous variables using independent samples t tests with unequal variance and categorical variables using χ2 tests in comparing 3-year (3YR) versus 4-year (4YR) programs.

RESULTS

PGY-1 and PGY-2 residents in 4YR programs saw statistically more patients than their counterparts in 3YR programs. In PGY3, 3YR program residents had statistically higher visit volume compared to 4YR program residents. Visits conducted in PGY4 ranged from 832 to 884. The additional year of training resulted in approximately 1,000 more total patient visits. Most residents in 3YR and 4YR programs rated their continuity clinic experience as somewhat or very adequate (range 86.3% to 93.7%), which did not statistically differ according to length of training.

CONCLUSIONS

Resident visits were significantly different at each PGY level when comparing 3YR and 4YR programs in the LOTP and the additional year of training resulted in about 1,000 more total visits. Resident perspectives on the adequacy of their continuity clinic experience appeared to not be affected by length of training. Future research should explore how the volume of patient visits performed in residency affects scope of practice and clinical preparedness.

Continuity of Care in Primary Care for Young Children With Chronic Conditions

OBJECTIVES

1) To assess continuity of care (CoC) within primary-care practices for children with asthma and autism spectrum disorder (ASD) compared to children without chronic conditions, and 2) to determine patient and clinical-care factors associated with CoC.

METHODS

Retrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0-1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits.

RESULTS

Of 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean = 0.58, SD 0.21) and ASD (M = 0.57, SD = 0.20) than Controls (M = 0.66, SD = 0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR = 0.90, 95% CI, 0.85-0.94). Lower overall and well-care CoC were associated with public insurance (aOR = 0.77, CI, 0.74-0.81; aOR = 0.64, CI, 0.59-0.69).

CONCLUSION

After accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary-care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC.

Understanding Perceived Barriers to Colposcopy Follow-Up Among Underserved Women at an Urban Teaching Hospital: A Qualitative Study

OBJECTIVE

Loss to follow-up after abnormal cervical cancer screening disproportionately impacts underserved populations. Our objective was to identify perceived barriers to follow-up after abnormal Pap smear among underserved women.

METHODS

Women with abnormal Pap smear presenting for colposcopy at an urban teaching hospital were asked to participate in qualitative interviews. A topic guide was developed to assess knowledge about cervical cancer screening and perceived barriers to follow-up. A demographic survey was completed and interviews were recorded and transcribed. Responses were coded and placed into a framework: intrapersonal, interpersonal, and community barriers. Major themes and subthemes were identified. Demographic data were reported descriptively.

RESULTS

Of 24 women enrolled, 18 (75%) completed full interviews. Median age was 38 years (range = 21-64). Participants were racially diverse: 10 (56%) Hispanic, 7 (39%) non-Hispanic White, 1 (5.5%) non-Hispanic Black, and 1 (5.5%) Asian, and all had public insurance. Seven (39%) presented for their 1st colposcopy visit and 11 (61%) had previous visits. Seventeen (94%) had a positive human papillomavirus test and 7 (39%) had atypical squamous cells of undetermined significance. The most common themes identified were related to knowledge gaps, including lack of understanding of Pap smears/human papillomavirus and cervical cancer risk factors. Most participants were satisfied with provider communication but dissatisfied with communication with the office, like scheduling appointments.

CONCLUSIONS

Despite positive patient perception of physician communication, knowledge was most commonly identified as a barrier to colposcopy follow-up. Implementing a web-based intervention addressing knowledge gaps may improve abnormal cervical cancer screening follow-up among this population.

Introduction of Otolaryngology Outpatient Examination Training Program for junior residents as part of rural regional medical support in Japan

Background

Nagasaki Prefecture is located in the most western part of Japan, and there are a considerable number of clinics in its many remote islands and rural areas. Thus, the Regional Medical Support Center in Nagasaki Prefecture dispatches doctors to rural hospitals to provide medical support. We introduced an outpatient training program at these rural hospitals for all residents to improve their clinical training in the field of otorhinolaryngology, whereby one otolaryngologist trains one resident.

Methods

This otolaryngology outpatient training program is randomly assigned, and conducted for 4–5 days a year, transported by a helicopter in Nagasaki Prefecture, which is a 30‐minute one‐way trip. We used a case checklist that included the 35 items that should be experienced and are defined as frequent by the Ministry of Health, Labor and Welfare. We also conducted a survey using an anonymous questionnaire.

Results

The survey response rate was 100%. Comparing the experience rate of symptoms between the pre‐introduction resident and the post‐introduction resident who underwent the otolaryngology outpatient training program, the experience rates of common diseases, including vertigo and otolaryngologic symptoms such as nasal bleeding and hoarseness, significantly increased after the program was introduced (p ≤ .001). Notably, the experience rate of headache, cough/sputum, and vertigo was 100%.

Conclusion

Our training program provides a suitable medical environment for the resident and secures a doctor who can provide secondary medical service support. Furthermore, the program will improve the level of primary care provided by the residents in remote island and rural area hospitals.

The Reliability of Graduate Medical Education Quality of Care Clinical Performance Measures

BACKGROUND

Graduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied.

OBJECTIVE

To examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care.

METHODS

From 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated.

RESULTS

The highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable.

CONCLUSIONS

GME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.

Continuity and Health Outcomes in Resident Clinics: A Scoping Review of the Literature

Continuity of care is an essential component of primary care, resulting in improved satisfaction, management of chronic conditions, and adherence to screening recommendations. The impact of continuity of care in teaching practices remains unclear.

We performed a scoping review of the literature to understand the impact of continuity on patients and trainees in teaching practices. A systematic search was performed through PubMed to identify articles published prior to January 2020 addressing continuity of care and health outcomes in resident primary care clinic settings. A total of 543 abstracts were evaluated by paired independent reviewers.

In total, 24 articles met the inclusion criteria and were abstracted by four authors. These articles included a total of 6,973 residents (median = 96, range = 9-5,000) and over 1,000,000 patients (median = 428, range = 70-1,000,000). Most publications demonstrated that higher continuity was associated with better diabetic care (71%, n = five of seven), receipt of preventive care per guidelines (60%, n = three of five), and lower costs or administrative burden of care (100%, n = three of three). A smaller proportion of publications reported a positive association between continuity and hypertension control (28%, n = two of seven). The majority of publications evaluating patient/resident satisfaction demonstrated that better continuity was associated with higher patient (67%, n = four of six) and resident (67%, n = six of nine) satisfaction.

A review of the existing literature revealed that higher continuity of care in resident primary care clinics was associated with better patient health outcomes and patient/resident satisfaction. Interventions to improve continuity in training settings are needed.

Perspectives of internal medicine residency clinics: A national survey of US medical directors

BACKGROUND

Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited.

METHODS

We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US.

RESULTS

Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%-20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1-3). For new patient appointments, 34.9% of programs reported a 1-7 day wait and 25.8% reported an 8-14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%-50% for new patients and 11%-25% for established patients. Most programs reported that interns see 3-4 patients per ½-day and senior residents see 5-6 patients per ½-day. Most interns and residents maintain a panel size of 51-120 patients.

DISCUSSION

Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work.

Longitudinal training models for entrusting students with independent patient care?: A systematic review

OBJECTIVE

The participation of students from both undergraduate medical education (UGME) and postgraduate medical education (PGME) in independent patient care contributes to the development of knowledge, skills and the professional identity of students. A continuing collaboration between students and their preceptor might contribute to opportunities for students to independently provide patient care. In this systematic review, we aim to evaluate whether longitudinal training models facilitate the independent practice of students and what characteristics of longitudinal training models contribute to this process.

METHOD

This systematic review was performed according to the PRISMA guidelines. In May 2020, we performed a search in three databases. Articles evaluating the impact of longitudinal training models on the independent practice of students from both UGME and PGME programmes were eligible for the study. A total of 68 articles were included in the study. Quality of the included studies was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD).

RESULTS

Both UGME and PGME students in longitudinal training models are more frequently allowed to provide patient care independently when compared with their block model peers, and they also feel better prepared for independent practice at the end of their training programme. Several factors related to longitudinal training models stimulate opportunities for students to work independently. The most important factors in this process are the longitudinal relationships with preceptors and with the health care team.

CONCLUSION

Due to the ongoing collaboration between students and their preceptor, they develop an intensive and supportive mutual relationship, allowing for the development of a safe learning environment. As a result, the professional development of students is fostered, and students gradually become part of the health care team, allowing them the opportunity to engage in independent patient care.

"First Five" Quality Improvement Program Increases Adherence and Continuity with Well-child Care

The American Academy of Pediatrics Bright Futures recommends routine well-child care as optimal care for children. This quality improvement project aimed to increase adherence to the "First Five" visits after newborn follow-up at 2, 4, 6, 9, and 12 months-by 25% (50% or higher) and continuity with providers by 20% (64% or higher) between 2013 and 2016.

METHODS

Retrospective data collection identified a quality gap, in which only 25% had the required well-child visits by the first year. We interviewed parents/caregivers of 12- to 15-month-old children for their perspectives on access to care, scheduling, and the medical home concept. Plan-Do-Study-Act cycles targeted modification of electronic medical record templates, scheduling, staff and parental education, standardization of work processes, and birth to 1-year age-specific incentives. We then piloted interventions in one of our clinic's pod/subgroup. Process and outcome measures were analyzed using descriptive statistics, a run chart, and a 2-sample % Defective Test.

RESULTS

Parent/caregiver interviews revealed that only 6% knew what a medical home was, and only 40% "almost always saw the same provider for care." At baseline in 2012, we documented completion of all 5 visits in only 25% of the children; <10% of those children had consecutive visits with the same provider. After multiple Plan-Do-Study-Act cycles and pilot, our "First Five" well-child care adherence rose to 78%, and continuity increased to 74% in 2018 (P < 0.001 for adherence, P < 0.001 for continuity).

CONCLUSION

A multifaceted, evidence-based approach improved both well-child care adherence and provider continuity.

Defragmenting the Day: The Effect of Full-Day Continuity Clinics on Continuity of Care and Perceptions of Clinic

PROBLEM

Traditional half-day continuity clinics within primary care residency programs require residents to split time between their assigned clinical rotation and continuity clinic, which can have detrimental effects on resident experiences and patient care within continuity clinics. Most previous efforts to separate inpatient and outpatient obligations have employed block scheduling models, which entail significant rearrangements to clinical rotations, team structures, and didactic education and have yielded mixed effects on continuity of care. A full-day continuity clinic schedule within a traditional, non-block rotation framework holds potential to de-conflict resident schedules without the logistical rearrangements required to adopt block scheduling models, but no literature has described the effect of such full-day continuity clinics on continuity of care or resident experiences within continuity clinic.

INTERVENTION

A pediatric residency program implemented full-day continuity clinics within a traditional rotation framework. We examined the change in continuity for physician (PHY) measure in the six months prior to versus the six months following the switch, as well as changes in how often residents saw clinic patients in follow-up and personally followed up clinic laboratory and radiology results, which we term episodic follow-up. Resident and attending perceptions of full-day continuity clinics were measured using a survey administered 5-7 months after the switch.

CONTEXT

The switch to full-day continuity clinics occurred in January 2018 within the Wright State University/Wright-Patterson Medical Center Pediatric Residency Program. The program has 46 residents who are assigned to one of two continuity clinic sites, each of which implemented the full-day continuity clinics simultaneously.

OUTCOME

The PHY for residents at one clinic decreased slightly from 18.0% to 13.6% (p<.001) with full-day continuity clinics but was unchanged at another clinic [60.6% vs 59.5%, p=.86]. Measures of episodic follow-up were unchanged. Residents (32/46 = 77% responding) and attendings (6/8 = 75% responding) indicated full-day continuity clinics improved residents' balance of inpatient and outpatient obligations, preparation for clinic, continuity relationships with patients, and clinic satisfaction.

LESSONS LEARNED

Full-day continuity clinics within a traditional rotation framework had mixed effects on continuity of care but improved residents' experiences within clinic. This model offers a viable alternative to block scheduling models for primary care residency programs wishing to defragment resident schedules.

Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1879652.

Scoping reviews in medical education: A scoping review

OBJECTIVES

Over the last two decades, the number of scoping reviews in core medical education journals has increased by 4200%. Despite this growth, research on scoping reviews provides limited information about their nature, including how they are conducted or why medical educators undertake this knowledge synthesis type. This gap makes it difficult to know where the field stands and may hamper attempts to improve the conduct, reporting and utility of scoping reviews. Thus, this review characterises the nature of medical education scoping reviews to identify areas for improvement and highlight future research opportunities.

METHOD

The authors searched PubMed for scoping reviews published between 1/1999 and 4/2020 in 14 medical education journals. The authors extracted and summarised key bibliometric data, the rationales given for conducting a scoping review, the research questions and key reporting elements as described in the PRISMA-ScR. Rationales and research questions were mapped to Arksey and O'Malley's reasons for conducting a scoping review.

RESULTS

One hundred and one scoping reviews were included. On average, 10.1 scoping reviews (SD = 13.1, median = 4) were published annually with the most reviews published in 2019 (n = 42). Authors described multiple reasons for undertaking scoping reviews; the most prevalent being to summarise and disseminate research findings (n = 77). In 11 reviews, the rationales for the scoping review and the research questions aligned. No review addressed all elements of the PRISMA-ScR, with few authors publishing a protocol (n = 2) or including stakeholders (n = 20). Authors identified shortcomings of scoping reviews, including lack of critical appraisal.

CONCLUSIONS

Scoping reviews are increasingly conducted in medical education and published by most core journals. Scoping reviews aim to map the depth and breadth of emerging topics; as such, they have the potential to play a critical role in the practice, policy and research of medical education. However, these results suggest improvements are needed for this role to be fully realised.

Perinatal care experiences among racially and ethnically diverse mothers whose infants required a NICU stay

OBJECTIVE

To learn how diverse mothers whose babies required a neonatal intensive care unit (NICU) stay evaluate their obstetric and neonatal care.

STUDY DESIGN

We conducted three focus groups stratified by race/ethnicity (Black, Latina, White, and Asian women, n = 20) who delivered infants at <32 weeks gestation or <1500 g with a NICU stay. We asked women to assess perinatal care and applied classic qualitative analysis techniques to identify themes and make comparisons across groups.

RESULTS

Predominant themes were similar across groups, including thoroughness and consistency of clinician communication, provider attentiveness, and barriers to closeness with infants. Care experiences were largely positive, but some suggested poorer communication and responsiveness toward Black and Latina mothers.

CONCLUSION

Feeling consulted and included in infant care is critical for mothers of high-risk neonates. Further in-depth research is needed to remediate differences in hospital culture and quality that contribute to disparities in neonatal care and outcomes.

Delivering Complex Care: Designing for Patients and Physicians

The management of high-utilizing patients is an area of active research with broad implications for the healthcare system. There are significant operational challenges to designing primary care models for these medically complex, high-needs patients. Although it is crucial to provide a high degree of continuity of care for this population, managing a cohort of these patients can lead to provider over-work and attrition. This may be magnified by the lack of training dedicated to addressing the unique care needs of these patients. While academic medical centers would seem well suited to care for individuals with multimorbidity needing intensive and specialized treatment, primary care providers in this setting need additional support to be clinically available for patients while pursuing scholarship and teaching. Formally recognizing intensive outpatient care as a specialty within internal medicine would help overcome some of these challenges. This would require a committed effort to high-level systems changes including a new focus on graduate medical education, the creation of division-level infrastructure within academic departments of medicine, and realistic levels of financial support to make this a viable career path.

Reducing the Pain Behind Opioid Prescribing in Primary Care

OBJECTIVE

To describe the efficacy of a comprehensive approach aimed at reducing opioid prescribing in an internal medicine resident clinic.

DESIGN

Retrospective observational study.

SETTING

Internal medicine primary care resident clinic at a large urban academic medical center.

SUBJECTS

All patients receiving opioid prescriptions from the primary care clinic.

METHODS

We reviewed pharmacy dispensing data for two hospital-affiliated pharmacies for resident primary care patients filling opioid prescriptions between July 2016 and July 2018. We instituted a comprehensive set of interventions that included resident education, limiting supervision of encounters for long-term opioid therapy (LTOT) to a fixed set of faculty champions, and providing alternate modalities for pain control. We calculated the change in number of opioid prescriptions dispensed, number of patients receiving opioid prescriptions, morphine milligram equivalents (MMEs) dispensed, and average per-patient daily MMEs dispensed.

RESULTS

We observed an average monthly reduction of 2.44% (P < 0.001) in the number of prescriptions dispensed and a 1.83% (P < 0.001) monthly reduction in the number of patients receiving prescriptions. Over the two-year period, there was a 74.3% reduction in total MMEs prescribed and a 66.5% reduction in the average MMEs prescribed per patient.

CONCLUSIONS

Our findings demonstrate a significant reduction in opioid prescribing after implementation of a comprehensive initiative. Although our study was observational in nature, we witnessed a nearly threefold decrease in opioid prescribing compared with national trends. Our results offer important insights for other primary care resident clinics hoping to engender safe prescribing practices and curb high-dose opioid prescribing.

Five ways to get a grip on evaluating and improving educational continuity in health professions education programs

Presence of educational continuity is essential for progressive development of competence. Educational continuity appears to be a simple concept, but in practice, it is challenging to implement and evaluate because of its multifaceted nature. In this Black Ice article, we present some practical tips to help avoid misunderstandings and irregularities in implementation for those involved in evaluating and improving educational continuity in health professions education programs.

Caregiver and Adolescent Patient Perspectives on Comprehensive Care for Inflammatory Bowel Diseases: Building a Family-Centered Care Delivery Model

BACKGROUND

Children with inflammatory bowel diseases (IBDs) require primary and gastrointestinal (GI) care, but little is known about patient and family preferences for care receipt. We aimed to understand caregiver perceptions of current healthcare quality, describe barriers to receiving healthcare, and elicit caregiver and adolescent preferences for how comprehensive care ideally would be delivered.

METHODS

This was an anonymous survey of caregivers of 2- to 17-year olds with IBD and adolescents with IBD aged 13-17 years at a large, free-standing children's hospital. Surveys assessed patient medical history, family demographics, perceptions of health care quality and delivery, barriers to primary and GI care, and preferences for optimal care delivery.

RESULTS

Two hundred and seventeen caregivers and 140 adolescents were recruited, 214 caregivers and 133 adolescents consented/assented, and 160 caregivers and 84 adolescents completed the survey (75% and 60% response rate, respectively). Mean patient age was 14 years (SD = 3); 51% male; 79% Crohn's disease, 16% ulcerative colitis, and 4% indeterminate colitis. Caregivers were primarily female (86%), Caucasian (94%), and living in a 2-caregiver household (79%). Most caregivers reported that their child's primary care physician (PCP) and GI doctor oversaw their primary care (71%) and their IBD care (94%), respectively. Caregivers were satisfied with communication with their PCP and GI providers (>90%) but did not know how well they communicated with one another (54%). Barriers to primary and GI care varied, and few caregivers (6%) reported unmet healthcare needs. Caregivers and adolescents saw PCPs and GI doctors having important roles in comprehensive care, though specific preferences for care delivery differed.

CONCLUSION

Caregivers and adolescent perspectives are essential to developing family-centered care models for children with IBD.

Patients' missed appointments in academic family practices in Quebec

OBJECTIVE

To determine the prevalence of no-show patients in 4 family medicine teaching units (FMTUs) and to investigate the reasons given by patients for past missed appointments in order to identify factors that could be acted on to improve access to care.

DESIGN

Retrospective data collection through electronic medical records and a self-administered survey.

SETTING

Four FMTUs at the University of Montreal in Quebec.

PARTICIPANTS

Patients older than 18 years of age (or younger patients' guardians) who were able to read French and had visited the clinic at least once.

MAIN OUTCOMES MEASURES

No-show prevalence among patients scheduled to see different types of health care professionals, and patients' reasons for past missed appointments and for not notifying the clinic before missing an appointment.

RESULTS

The overall prevalence of no-show patients was 7.8% (2700 missed appointments of 34 619 scheduled appointments), ranging from 6.3% to 9.0% among the 4 FMTUs. The survey participation rate was 91.0% (1757 completed surveys of 1930 distributed surveys). A total of 19.1% of respondents acknowledged previous no-show behaviour. Resolved issues (22.9%) and work obligations (19.4%) were the most frequent personal reasons for missing an appointment, whereas inconvenient timing of the appointment (17.0%), delay before the appointment (14.6%), and lack of confirmation (13.7%) were the most frequent organizational reasons. The most frequent reason for not notifying the clinic of the absence was forgetting to call (55.2%).

CONCLUSION

The no-show phenomenon, although not very prevalent in our clinics, is present and can potentially affect access to care. Reasons for missing an appointment without notifying the clinic are varied and point toward different potential solutions to reduce no-shows. Educating patients about the importance of informing the clinic when they cannot come, offering a wider range of appointment dates and times, systematically confirming appointments, improving telephone service, and offering different methods to communicate with the clinic could all be solutions to improve access to care.

Enhanced Scheduling Support to Improve Continuity of Care in a Resident Training Clinic

BACKGROUND

Clinical continuity is recognized as a driver of satisfaction for patients and physicians. Greater continuity may positively affect trainee decisions to enter primary care. Maintaining clinical continuity remains a challenge in residency clinics.

OBJECTIVE

We determined whether enhanced scheduling support was associated with improvement in internal medicine resident continuity with patients.

METHODS

This study was conducted from June 2017 to December 2018. In the intervention clinic, a single scheduling staff member (ratio of 10 residents to 1 scheduler) was colocated within the clinical space, allowing the scheduler to participate in clinical discussions and direct communication with physicians regarding future appointments. In the comparison clinic, scheduling staff (19:1 ratio) were located at a remote front desk area and relied on patient reports or electronic health record orders to identify appointment needs and arrange follow-up appointments. The main outcome of the intervention was resident continuity, calculated using the continuity for physician formula.

RESULTS

During the study period, mean resident continuity was 23% (range 13%-37%) in the comparison clinic (57 residents) and 54% (range 38%-66%) in the intervention clinic (10 residents). Resident continuity was significantly higher in the intervention clinic compared with the traditional control clinic for every quarter measured (P < .001 for all comparisons).

CONCLUSIONS

Enhancing scheduling support through colocation and a lower resident to scheduler ratios was associated with significantly higher rates of resident continuity compared with a traditional front desk model, with results sustained over 18 months.

X + Y Scheduling in Pediatric Residency: Continuity, Handoffs, and Trainee Experience

BACKGROUND

Many internal medicine residency programs have transitioned to an X + Y clinic schedule, in which weekly continuity clinics are removed and clinic experience is instead condensed into 2-week blocks interspersed throughout the year, but few pediatric training programs have adopted this approach. We initiated X + Y scheduling in the 2015 academic year, with the hypothesis that outpatient continuity could be maintained or improved while inpatient handoffs would be reduced. We also hypothesized that learner experience with X + Y scheduling would be positive.

METHODS

Continuity and handoffs were compared over a 7-month period in 2013 to 2014 and 2015 to 2016. Outpatient continuity was calculated as the proportion of visits in which the patient was seen by the designated primary care provider (PCP). Handoffs were calculated through analysis of the online resident schedule with comparison of weekly totals for all inpatient teams. Resident perceptions were obtained in an online survey of residents who experienced both systems.

RESULTS

With X + Y scheduling, overall outpatient continuity improved from 2914 of 9882 (29.5%) of visits seen by a patient's PCP to 3066 of 9769 (31.4%) (P = .004), but preventive visit continuity decreased from 2170 of 4687 (46.2%) to 2025 of 4709 (43%) (P = .001). Inpatient handoffs decreased with X + Y scheduling from 30 to 20 weekly handoffs (P < .001). In total, 85% of residents reported a positive experience with X + Y scheduling.

CONCLUSIONS

An X + Y scheduling approach in pediatrics is a viable alternative to weekly clinics, resulting in improved learner experience, reductions in inpatient handoffs, and small mixed effects on outpatient continuity.

Empanelment in a Resident Teaching Practice: A Cornerstone to Improving Resident Outpatient Education and Patient Care

BACKGROUND

Improving continuity is challenging in residency training practices. Studies have shown that empanelment enables high-performing primary care and is foundational to improve accountability and continuity.

OBJECTIVE

An empanelment process was created in a large, urban, residency training practice as an effective approach to enhancing continuity among residents and their patients.

METHODS

In 2016, we formed an empanelment committee that included stakeholders from the department of medicine, the internal medicine residency program, and hospital and IT leadership. This committee set goal panel sizes, selected an empanelment algorithm, determined which patients needed re-empanelment, and facilitated medical record integration. Empanelment was followed and reassessed quarterly for 2 years. We measured anticipated visit demand using visits in the prior year and continuity using the continuity for physician formula.

RESULTS

Of 18 495 active patients in July 2016, 8411 (45%) were assigned a new PCP in the empanelment process. At baseline, panel sizes and expected visit demand were highly variable among residents (from 40 to 107 and 120 to 480, respectively). Empanelment led to more equivalent panel sizes and expected visit demand across same year residents (eg, PGY-3: 80-100 and 320-440, respectively). Continuity for all PCPs in the practice improved from 63% before empanelment to over 80% after empanelment, and improved from 55% to 72% for individual residents.

CONCLUSIONS

In a large and complex practice environment, we were able to empanel resident clinic patients to improve continuity and maintain it over 2 years.

Resident Experience and Education in Academic and Community Pediatric Primary Care Sites: Lessons for a Changing Healthcare Landscape

INTRODUCTION

Efforts to improve pediatric primary care training in residency are important both for the residents and for the patients cared for in residency clinics. Pediatric residents typically get their primary care training at primary care centers affiliated with an academic center or at community-based locations. We aimed to compare residents' experience of continuity clinic in academic centers and community settings, and to identify relative strengths and weaknesses of each.

METHODS

Survey data was evaluated for residents at one large pediatric residency program.

RESULTS

Community sites had relative strengths in patient flow, population management, and perception of overall quality of care. Academic sites had relative strengths in continuity of care and ease of follow-up of results.

CONCLUSIONS

Community and academic pediatric primary care training sites have varied strengths that could inform efforts to improve residency training to better meet the needs of residents and patients.