Sally Dodds

IMPACT - Integrative Medicine PrimAry Care Trial: protocol for a comparative effectiveness study of the clinical and cost outcomes of an integrative primary care clinic model

BackgroundIntegrative medicine (IM) is a patient-centered, healing-oriented clinical paradigm that explicitly includes all appropriate therapeutic approaches whether they originate in conventional or complementary medicine (CM). While there is some evidence for the clinical and cost-effectiveness of IM practice models, the existing evidence base for IM depends largely on studies of individual CM therapies. This may in part be due to the methodological challenges inherent in evaluating a complex intervention (i.e., many interacting components applied flexibly and with tailoring) such as IM.Methods/DesignThis study will use a combination of observational quantitative and qualitative methods to rigorously measure the health and healthcare utilization outcomes of the University of Arizona Integrative Health Center (UAIHC), an IM adult primary care clinic in Phoenix, Arizona. There are four groups of study participants. The primary group consists of clinic patients for whom clinical and cost outcomes will be tracked indicating the impact of the UAIHC clinic (n = 500). In addition to comparing outcomes pre/post clinic enrollment, where possible, these outcomes will be compared to those of two matched control groups, and for some self-report measures, to regional and national data. The second and third study groups consist of clinic patients (n = 180) and clinic personnel (n = 15-20) from whom fidelity data (i.e., data indicating the extent to which the IM practice model was implemented as planned) will be collected. These data will be analyzed to determine the exact nature of the intervention as implemented and to provide covariates to the outcomes analyses as the clinic evolves. The fourth group is made up of patients (n = 8) whose path through the clinic will be studied in detail using qualitative (periodic semi-structured interviews) methods. These data will be used to develop hypotheses regarding how the clinic works.DiscussionThe US health care system needs new models of care that are more patient-centered and empower patients to make positive lifestyle changes. These models have the potential to reduce the burden of chronic disease, lower the cost of healthcare, and offer a sustainable financial paradigm for our nation. This protocol has been designed to test whether the UAIHC can achieve this potential.Trial registrationClinical Trials.gov NCT01785485.

Pediatric Integrative Medicine in Residency (PIMR): Description of a New Online Educational Curriculum

Use of integrative medicine (IM) is prevalent in children, yet availability of training opportunities is limited. The Pediatric Integrative Medicine in Residency (PIMR) program was designed to address this training gap. The PIMR program is a 100-hour online educational curriculum, modeled on the successful Integrative Medicine in Residency program in family medicine. Preliminary data on site characteristics, resident experience with and interest in IM, and residents’ self-assessments of perceived knowledge and skills in IM are presented. The embedded multimodal evaluation is described. Less than one-third of residents had IM coursework in medical school or personal experience with IM. Yet most (66%) were interested in learning IM, and 71% were interested in applying IM after graduation. Less than half of the residents endorsed pre-existing IM knowledge/skills. Average score on IM medical knowledge exam was 51%. Sites endorsed 1–8 of 11 site characteristics, with most (80%) indicating they had an IM practitioner onsite and IM trained faculty. Preliminary results indicate that the PIMR online curriculum targets identified knowledge gaps. Residents had minimal prior IM exposure, yet expressed strong interest in IM education. PIMR training site surveys identified both strengths and areas needing further development to support successful PIMR program implementation.

When a Whole Practice Model Is the Intervention: Developing Fidelity Evaluation Components Using Program Theory-Driven Science for an Integrative Medicine Primary Care Clinic

Integrative medicine (IM) is a clinical paradigm of whole person healthcare that combines appropriate conventional and complementary medicine (CM) treatments. Studies of integrative healthcare systems and theory-driven evaluations of IM practice models need to be undertaken. Two health services research methods can strengthen the validity of IM healthcare studies, practice theory, and fidelity evaluation. The University of Arizona Integrative Health Center (UAIHC) is a membership-supported integrative primary care clinic in Phoenix, AZ. A comparative effectiveness evaluation is being conducted to assess its clinical and cost outcomes. A process evaluation of the clinics practice theory components assesses model fidelity for four purposes: (1) as a measure of intervention integrity to determine whether the practice model was delivered as intended; (2) to describe an integrative primary care clinic model as it is being developed and refined; (3) as potential covariates in the outcomes analyses, to assist in interpretation of findings, and for external validity and replication; and (4) to provide feedback for needed corrections and improvements of clinic operations over time. This paper provides a rationale for the use of practice theory and fidelity evaluation in studies of integrative practices and describes the approach and protocol used in fidelity evaluation of the UAIHC.

Increasing Resident Recruitment into Family Medicine: Effect of a Unique Curriculum in Integrative Medicine

INTRODUCTION Healthcare reform is highlighting the need for more family practice and other primary care physicians. The Integrative Medicine in Residency (IMR) curriculum project helped family medicine residencies pilot a new, online curriculum promoting prevention, patient-centered care competencies, use of complementary and alternative medicine along with conventional medicine for management of chronic illness. A major potential benefit of the IMR program is enhanced recruitment into participating residencies, which is reported here. METHODS Using an online questionnaire, accepted applicants to the eight IMR pilot programs (n = 152) and four control programs (n = 50) were asked about their interests in learning integrative medicine (IM) and in the pilot sites how the presence of the IMR curriculum affected their ranking decisions. RESULTS Of residents at the IMR sites, 46.7% reported that the presence of the IMR was very important or important in their ranking decision. The IMR also ranked fourth overall in importance of ranking after geography, quality of faculty, and academic reputation of the residency. The majority of IMR residents (87.5%) had high to moderate interest in learning IM during their residency; control residents also had a high interest in learning IM (61.2%). CONCLUSIONS The presence of the IMR curriculum was seen as a strong positive by applicants in ranking residencies. Increasing the adoption of innovative IM curricula, such as the IMR, by residency programs may be helpful in increasing applications of competitive medical students into primary care residencies as well as in responding to the expressed interest in learning the IM approach to patient care.

OA05.02. Relationships among well-being and wellness behaviors over time in residents in eight family medicine residencies

Methods Residents in the 2011 graduating class of the IMR (n=56) were assessed at the beginning of PGY2 and PGY3 and at graduation. Measures were self-administered online and included established measures of wellbeing: perceived stress, burnout (emotional exhaustion, depersonalization), depression, and satisfaction with life. Wellness behaviors assessed included restful sleep, nutrition, physical activity, mind-body activities, being in nurturing relationships, being outdoors in nature, and alcohol use. Stepwise regression analysis examined relationships between wellness behaviors and each wellbeing measure at each timepoint.

P03.01. Characteristics of residents and training sites influence successful completion of the Integrative Medicine in Residency program

Methods Resident and residency site characteristics were examined to determine factors influencing completion of the Integrative Medicine in Residency (IMR) curriculum for the 2011 graduating class. Completion criteria included finishing ≥80% of the online courses plus a final score on the medical knowledge test of ≥70%. Resident characteristics used as predictors included demographics; medical school type [US MD, DO, foreign medical graduates (FMG)]; and, responses to a post-match survey administered before the residency began in 2008 on previous participation in CAM courses or experiences, importance of the IMR in choosing residency, and interests in learning IM and applying IM after graduation. Site characteristics included: extent of IM in the residency culture (e.g., faculty practicing IM consultations; IM consultation on site; an IM 4th year fellowship at the site); faculty characteristics (i.e., faculty leader IM fellowship trained; faculty leader with designated IM teaching time); and curriculum delivery (i.e., using the IMR plus other IM teaching/rotation/electives; monthly IM case conferences; resident IM clinical application).

Environmental Health: Evaluating an online educational curriculum for healthcare workers

Objective: A healthy environment is integral to health, yet clinicians receive minimal environmental health training, missing repeated opportunities for preventive counseling. To address educational gaps and examine the usefulness of online education in environmental health, a 6-hour online course, Environmental Health: An Integrative Approach was developed for healthcare practitioners. The objective of this study was to evaluate the feasibility and effectiveness of the course. Methods: This was a within subjects longitudinal study examining change in medical knowledge, beliefs and attitudes toward environmental health topics, attitude toward the importance of conducting an environmental health history, barriers to conducting an environmental health history and confidence in environmental health history assessment skills.. Participants included physicians, nurses, nurse practitioners and other healthcare providers. Measures were completed prior to the course, upon completion, and at a 30-day follow-up. A course evaluation survey assessing educational quality, personal benefit/improved patient care, meeting course expectations, faculty expertise, and course completion time was completed. Data were collected 2012-2013 and analyzed in 2013-2014. Results: Evaluation results indicate the online format and content were well-received, easily implemented, met learners’ expectations, and completed in a manageable timeframe (N=436). Participants evidenced positive pre-post changes in attitudes toward environmental health issues, taking an environmental health history, and confidence in conducting an environmental health history (N=478; P < .007). Positive changes were maintained at follow-up for attitudes and confidence (N=344; P < .001); however reductions in some history taking barriers were not maintained. Conclusion: An online curriculum is a promising method for delivering a foundational environmental health education course to diverse healthcare professionals. Further study is needed to assess best methods for translation of the curriculum into effective clinical practice and improved patient outcomes.

P05.34. Well-being and wellness behaviors among family medicine residents: an exploratory descriptive study

Methods FM residents in the 2011 graduating class (n=56) were assessed at four time points, the beginning of each of the three years of residency and at graduation. Measures were self-administered online and included established measures of well-being: perceived stress, burnout (emotional exhaustion and depersonalization), emotional intelligence (empathy and perspective taking), depression, positive and negative affect, satisfaction with life, mindfulness, gratitude, and a measure of wellness behaviors (sleep, nutrition, physical activity, mind-body activities, being in nurturing relationships, being outdoors in nature, and alcohol use).