Warren P. Newton

Community Care of North Carolina: Improving Care Through Community Health Networks

The United States leads the world in health care costs but ranks far below many developed countries in health outcomes. Finding ways to narrow this gap remains elusive. This article describes the response of one state to establish community health networks to achieve quality, utilization, and cost objectives for the care of its Medicaid recipients. The program, known as Community Care of North Carolina, is an innovative effort organized and operated by practicing community physicians. In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost since their inception a decade ago. The program is now saving the State of North Carolina at least

Intimate Partner Violence Among Latinas in Eastern North Carolina

160 million annually. A description of this experience and the lessons learned from it can inform others seeking to implement effective systems of care for patients with chronic illness.

Competence and confidence with basic procedural skills: the experience and opinions of fourth-year medical students at a single institution.

This article explores the correlates of intimate partner violence (IPV) among rural, southern Latinas. A sample of 1,212 women in blue-collar work sites in rural North Carolina completed a questionnaire assessing IPV and other social, demographic, and health-related variables. Social and demographic correlates of IPV were examined. Adult lifetime prevalence of IPV in Latinas was 19.5%, similar to that of non-Latinas. As compared to Latinas who did not experience IPV and non-Latinas who experienced IPV, Latinas who experienced IPV were more likely to lack social support and to have children in the home. Agencies that provide services to victims of IPV in the rural South need to be prepared to meet the unique needs of Latina immigrants.

Family Physician Participation in Maintenance of Certification

Purpose Data indicate that students are unprepared to perform basic medical procedures on graduation. The authors’ aim was to characterize graduating students’ experience with and opinions about these skills. Method In 2011, an online survey queried 156 fourth-year medical students about their experience with, and actual and desired levels of competence for, nine procedural skills (Foley catheter insertion, nasogastric tube insertion, venipuncture, intravenous catheter insertion, arterial puncture, basic suturing, endotracheal intubation, lumbar puncture, and thoracentesis). Students self-reported competence on a four-point Likert scale (4 = independently performs skill; 1 = unable to perform skill). Data were analyzed by analysis of variance and Student t test. A five-point Likert scale was used to assess student confidence. Results One hundred thirty-four (86%) students responded. Two skills were performed more than two times by over 50% of students: Foley catheter insertion and suturing. Mean level of competence ranged from 3.13 ± 0.75 (Foley catheter insertion) to 1.7 ± 0.7 (thoracentesis). A gap in desired versus actual level of competence existed for all procedures (P < .0001). There was a correlation between the number of times a procedure had been performed and self-reported competence for all skills except arterial puncture and suturing. Conclusions Participants had performed most skills infrequently and rated themselves as being unable to perform them without assistance. Strategies to improve student experience and competence of procedural skills must evolve to improve the technical competency of graduating students because their current competency varies widely.

Infrastructure for large‐scale quality‐improvement projects: Early lessons from North Carolina improving performance in practice

PURPOSE The American Board of Family Medicine has completed the 7-year transition of all of its diplomates into Maintenance of Certification (MOC). Participation in this voluntary process must be broad-based and balanced for MOC to have any practical national impact on health care. This study explores family physicians’ geographic, demographic, and practice characteristics associated with the variations in MOC participation to examine whether MOC has potential as a viable mechanism for dissemination of information or for altering practice. METHODS To investigate characteristics associated with differential participation in MOC by family physicians, we performed a cross-sectional comparison of all active family physicians using descriptive and multinomial logistic regression analyses. RESULTS Eighty-five percent of active family physicians in this study (n = 70,323) have current board certification. Ninety-one percent of all active board-certified family physicians eligible for MOC are participating in MOC. Physicians who work in poorer neighborhoods (odds ratio [OR] = 1.105; 95% confidence interval [CI], 1.038–1.176), who are US-born or foreign-born international medical graduates (OR = 1.221; 95% CI, 1.124–1.326; OR = 1.444; 95% CI, 1.238–1.684, respectively), or who are solo practitioners (OR = 1.460; 95% CI, 1.345–1.585) are more likely to have missed initial MOC requirements than those from a large, undifferentiated reference group of certified family physicians. When age is held constant, female physicians are less likely to miss initial MOC requirements (OR = 0.849; 95% CI, 0.794–0.908). Physicians practicing in rural areas were found to be performing similarly in meeting initial MOC requirements to those in urban areas (OR = 0.966; 95% CI, 0.919–1.015, not significant). CONCLUSION Large numbers of family physicians are participating in MOC. The significant association between practicing in underserved areas and lapsed board certification, however, warrants more research examining causes of differential participation. The penetrance of MOC engagement shows that MOC has the potential to convey substantial practice-relevant medical information to physicians. Thus, it offers a potential channel through which to improve health care knowledge and medical practice.

Proportion of Family Physicians Providing Maternity Care Continues to Decline

Introduction: Little is known regarding how to accomplish large‐scale health care improvement. Our goal is to improve the quality of chronic disease care in all primary care practices throughout North Carolina. Methods: Methods for improvement include (1) common quality measures and shared data system; (2) rapid cycle improvement principles; (3) quality‐improvement consultants (QICs), or practice facilitators; (4) learning networks; and (5) alignment of incentives. We emphasized a community‐based strategy and developing a statewide infrastructure. Results are reported from the first 2 years of the North Carolina Improving Performance in Practice (IPIP) project. Results: A coalition was formed to include professional societies, North Carolina AHEC, Community Care of North Carolina, insurers, and other organizations. Wave One started with 18 practices in 2 of 9 regions of the state. Quality‐improvement consultants recruited practices. Over 80 percent of practices attended all quarterly regional meetings. In 9 months, almost all diabetes measures improved, and a bundled asthma measure improved from 33 to 58 percent. Overall, the magnitude of improvement was clinically and statistically significant (P = .001). Quality improvements were maintained on review 1 year later. Wave Two has spread to 103 practices in all 9 regions of the state, with 42 additional practices beginning the enrollment process. Discussion: Large‐scale health care quality improvement is feasible, when broadly supported by statewide leadership and community infrastructure. Practice‐collected data and lack of a control group are limitations of the study design. Future priorities include maintaining improved sustainability for practices and communities. Our long‐term goal is to transform all 2000 primary‐care practices in our state.

Shaping the Future of Academic Health Centers: The Potential Contributions of Departments of Family Medicine

Family physicians traditionally have played an integral role in delivering babies as a component of the comprehensive care they provide for women. The proportion of family physicians who report providing any maternity care continues to decrease. This trend is particularly concerning because family physicians are the most widely distributed specialty and are essential to health care access in rural areas.

Natural History of Practice Transformation: Development and Initial Testing of an Outcomes-Based Model

Academic health centers (AHCs) must change dramatically to meet the changing needs of patients and society, but how to do this remains unclear. The purpose of this supplement is to describe ways in which departments of family medicine can play leadership roles in helping AHCs evolve. This overview provides background for case studies and commentaries about the contribution of departments of family medicine in 5 areas: (1) ambulatory and primary care, (2) indigent care, (3) education in community and international settings, (4) workforce policy and practice, and (5) translational research. The common theme is a revitalization of the relationship between AHCs and the communities they serve across all missions. Family medicine leadership can provide dramatic organizational improvement in primary and ambulatory care networks and foster opportunities for leadership by AHCs in improving the health of the population. Departments of family medicine can also play a leading role in developing new partnerships with community-based organizations, managing the care of the indigent, and developing new curricula in community and international settings. Finally, family medicine departments and their faculty have a central role in helping AHCs respond to workforce needs and in developing translational research that emphasizes the health of the population and effectiveness of care. AHCs are a public good that must now evolve substantially to meet the needs of patients and society. By pushing for substantial change, by helping to reinvigorate the relationship between AHCs and the communities they serve, and by emphasizing fundamental innovation in clinical care, teaching, and research, family medicine can help lead the renewal of the AHC.

Research Published in 2003 by U.S. Family Medicine Authors

PURPOSE Practice transformation is the cornerstone of the future of family medicine and health care reform, but little is known about how the process occurs. We sought to develop and test a model of the natural history of practice transformation. METHODS We developed an outcomes-based model of how a practice moves through practice transformation in 2 phases: (1) initial model created through meetings with collaborative experts and practice facilitators, and (2) clinical and practice systems change reports examined from the first group of participating North Carolina Improving Performance In Practice practices to test and further refine the model. RESULTS The resultant model described motivators and supports to transformation. Three emerging practice patterns were identified with the model: transformed practices experiencing robust improvement, activated practices with moderate change, and engaged practices with minimal change in measured quality over a 2-year period. Transformed practices showed broad-based improvement; some reached a threshold and others continued to improve. These practices had highly engaged leadership and used data to drive decisions. Activated practices had a slower improvement trajectory, usually encountering a barrier that took time to overcome (eg, extracting population data, spreading practice changes). Engaged practices did not improve or were unable to sustain change; despite good intentions, multiple competing distractions interfered with practice transformation. CONCLUSIONS Practice transformation is a continuous and long-term process. Internal and external practice motivations and specific practice supports provided by a community-based quality improvement program appear to have an impact on engagement, rate of quality improvement, and long-term sustainability. Early successes play a key role as practices learn how to change their performance.

Medication documentation in a primary care network serving North Carolina medicaid patients: results of a cross-sectional chart review

Objectives: The discipline of family medicine seeks to build its research enterprise. To assess the state of family medicine research in the United States, this study identifies and describes research articles published by family medicine researchers from the United States in 2003 and assesses the growth in articles, authors, and publishing journals since 2000. Methods: We searched for all research articles published in 2003 in scholarly, English-language journals authored by individuals in US family medicine organizations and by family physicians from the United States. Search approaches included a hard copy review of 22 journals and Medline searches of articles by family medicine authors and organizations. Similar search approaches, previously reported, were used to identify articles published in 2000. Results: For 2003 we found 790 research articles dispersed across 285 journals from 801 family medicine researcher-authors. Twenty-nine journals published 6 or more family medicine research articles; 159 journals published just 1 research article from the discipline. Family medicine journals published 18% of the disciplines research articles. People in academic departments authored the vast majority (89%) of the disciplines research. Between 2000 and 2003 family medicines research articles increased by an estimated 58%, its authors increased by 41%, and journals used increased by 82%. Conclusions: Family medicines research enterprise in the United States is larger and more productive than generally recognized, and it is growing. Nevertheless, family medicine likely publishes fewer research articles than some other clinical disciplines.