William G. Weppner

Randomized trial of a video-based patient decision aid for bariatric surgery.

The decision to have bariatric surgery should be based on accurate information on possible risks and benefits of all treatment options. The goal of this study was to determine whether a video‐based bariatric decision aid intervention results in superior decision quality compared to an educational booklet. We conducted a prospective, randomized controlled trial among adult patients in a single health plan who met standard criteria for bariatric surgery. Patients were randomly assigned to review either a video‐based decision aid (intervention) or an educational booklet on bariatric surgery (control). Changes in patient decision quality were assessed using bariatric‐specific measures of knowledge, values, and treatment preference after 3 months. Of 152 eligible participants, 75 were randomly assigned to the intervention and 77 to the control. The 3‐month follow‐up rate was 95%. Among all participants, significant improvements were observed in knowledge (P < 0.001), values concordance (P = 0.009), decisional conflict (P < 0.001), decisional self‐efficacy (P < 0.001), and in the proportion who were “unsure” of their treatment choice (P < 0.001). The intervention group had larger improvements in knowledge (P = 0.03), decisional conflict (P = 0.03), and outcome expectancies (P = 0.001). The proportion of participants choosing bariatric surgery did not differ significantly between groups, although there was a trend toward decreased surgical choice in the intervention group (59% booklet vs. 42% video at 3 months; P = 0.16). The use of bariatric surgery decision aids was followed by improved decision quality and reduced uncertainty about treatment at 3 months. The video‐based decision aid appeared to have a greater impact than the educational booklet on patient knowledge, decisional conflict, and outcome expectancies.

Instituting systems-based practice and practice-based learning and improvement: a curriculum of inquiry

Background The Accreditation Council for Graduate Medical Education (ACGME) requires that training programs integrate system-based practice (SBP) and practice-based learning and improvement (PBLI) into internal medicine residency curricula. Context and setting We instituted a seminar series and year-long-mentored curriculum designed to engage internal medicine residents in these competencies. Methods Residents participate in a seminar series that includes assigned reading and structured discussion with faculty who assist in the development of quality improvement or research projects. Residents pursue projects over the remainder of the year. Monthly works in progress meetings, protected time for inquiry, and continued faculty mentorship guide the residents in their project development. Trainees present their work at hospital-wide grand rounds at the end of the academic year. We performed a survey of residents to assess their self-reported knowledge, attitudes and skills in SBP and PBLI. In addition, blinded faculty scored projects for appropriateness, impact, and feasibility. Outcomes We measured resident self-reported knowledge, attitudes, and skills at the end of the academic year. We found evidence that participants improved their understanding of the context in which they were practicing, and that their ability to engage in quality improvement projects increased. Blinded faculty reviewers favorably ranked the projects’ feasibility, impact, and appropriateness. The ‘Curriculum of Inquiry’ generated 11 quality improvement and research projects during the study period. Barriers to the ongoing work include a limited supply of mentors and delays due to Institutional Review Board approval. Hospital leadership recognizes the importance of the curriculum, and our accreditation manager now cites our ongoing work. Conclusions A structured residency-based curriculum facilitates resident demonstration of SBP and practice-based learning and improvement. Residents gain knowledge and skills though this enterprise and hospitals gain access to trainees who help to solve ongoing problems and meet accreditation requirements.

Changes in Idaho primary care physician clinical work hours, 1996-2009.

increase in related costs, calling attention to the increasingly important role these hospitals play in the US health care system. Drs Votto and Hotes and Dr Muldoon correctly state that our study cannot be used to infer whether care in a longterm acute care hospital is beneficial or harmful compared with an alternative site of care. As we stated in our discussion, there are plausible reasons why long-term acute care hospitals might either improve or worsen outcomes after critical illness. The studies quoted by Votto and Hotes, as well as others, provide important preliminary evidence but do not offer definitive conclusions. Rigorous comparative effectiveness research is needed to determine not only which patients may benefit from the services long-term acute care hospitals provide, but also the optimal site of care for these services. We disagree with the letter writers that MedPAR files lack sufficient “clinical nuances” or are “necessarily dated” and thus are unable to contribute to the policy debate. Despite their well-known limitations, for decades administrative data such as MedPAR have been an essential resource for important questions concerning US health policy. By suggesting an implausible evidentiary standard, the writers create a world in which the structures and processes that comprise the health care system cannot be critically evaluated. Such a scenario is neither practical nor tenable. For matters so consequential to patient welfare and public finances as the care of critically ill individuals, real-world effectiveness research using the best available data are urgently needed.

Traditional and Block Scheduling Challenges and Solutions for Internal Medicine Residents

This chapter reviews the most common scheduling models used in internal medicine residency programs. The true impact of different scheduling models on outcomes such as patient continuity, access to care, resident satisfaction, and clinical outcomes has been evaluated in a handful of studies. This chapter will review the current evidence surrounding scheduling models. Each scheduling model has potential benefits and barriers that should be considered when a residency is considering converting to a new model.

Maximizing Continuity in Continuity Clinic

The inpatient and outpatient rotations during residency impact resident clinic continuity. Even with block systems separating inpatient and outpatient duties, keeping continuity between resident providers and their clinic patients is challenging. This chapter reviews the evidence for continuity, different metrics of measuring continuity, as well as strategies to maximize continuity between residents and patients. It also examines how continuity measures may fail for account for meaningful forms of contact and continuity between patients and providers.

Nontraditional Methods of Care

Innovative models of care delivery are being developed and implemented with the goals of meeting patient needs with better efficiency and cost-savings. Patient portals, OpenNotes, secure messaging, team-based care, and telemedicine are moving from innovations into usual care. Current residents will likely see changing care models and new technologies develop over the course of their careers. This chapter discusses each of these digital care tools, evidence supporting them, and how they may be incorporated into teaching clinics.”

Primary care collaborative practice in quality improvement: Description of an interprofessional curriculum

Purpose. An innovative quality improvement (QI)–focused interprofessional training curriculum for pharmacy residents and other healthcare trainees is described. Summary. Effective interprofessional collaboration and the ability to carry out QI initiatives are important skills for all healthcare trainees to develop when they are in training. To cultivate those skills, in 2011 a Veterans Affairs medical center in Idaho implemented a unique yearlong interprofessional curriculum for healthcare trainees, including postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) pharmacy residents, physician trainees in internal medicine, nurses, and psychologists. The curriculum has both didactic and experiential components. After attending a series of 1‐hour workshops early in the academic year, trainees are assigned to interprofessional teams and work for the remainder of the year to complete QI projects. Over 100 trainees have participated in the interprofessional QI curriculum, with the majority of trainee projects based in the primary care setting. Pharmacy residents were involved in 62% of the projects completed in the 6 academic years ending with the 2016–17 year. Conclusion. Establishing an interprofessional QI curriculum allowed pharmacy residents in PGY1 and PGY2 programs to collaborate with other members of the healthcare team. Benefits include QI skills development, a greater understanding of QI initiatives at the institution, stronger relationships with other healthcare trainees and mentors, and improvements to patient care and safety and facility performance.

Implications for Evaluation

When you are trying something completely new, like an interprofessional medical home training clinic, how do you know if it works? This question has different answers depending on whether the report is for the funder, considering return on investment; the institution, considering whether to continue the program after the grant expires; the trainees, wanting to judge participation by whether it “works”; or the faculty, wanting to know “how” and “why” it works. Each local CoE site faced these tensions in trainee assessment and local program evaluations, and the CoE as a whole faced them for enterprise-wide evaluation. Our site has learned much along the way about differences between program evaluation and trainee assessment and also expectations for simple, complicated, and complex adaptive system evaluations. In this chapter, we hope to share some lessons learned that can guide your assessment and evaluation plans.

The Argument for the Patient-Centered Medical Home: Replicating Good Primary Care

The patient-centered medical home (PCMH) represents, quite simply, good primary care that has been systematized to be shared among highly functional teams. This seems at odds with classic views of primary care, in which one provider shouldered the responsibilities for a panel of patients, with specific tasks delegated to ancillary staff. PCMH allows the development of a team, featuring dynamic distributed leadership by different team members, with common goals in providing and improving clinical care. It also requires networks of providers and systems of care designed to maximize patient-centered, proactive, and appropriately responsive care. As anyone who has embarked upon the PCMH journey knows, this transformation can be very difficult. We suggest this challenge is due to the complex adaptive system in which it must be implemented and evaluated. In this chapter, we discuss the case for implementing a PCMH transformation. This lays the groundwork for the argument that such a transformation is one of the most important goals for those interested in improving healthcare. We argue that the preponderance of evidence supports that highly functioning primary care delivery is the foundation for a solid healthcare system and that the PCMH model offers much to maximize efficiency, quality patient care, and staff satisfaction. In this chapter, we will review a brief history of primary care, why we need to maintain the “primacy of primary care” in our system, and how the PCMH model can help to bridge the gap between desired and delivered practice in the USA.

SHED: Four Important Sub-theories That Help Us to “Bracket”

The concepts of simple, complicated, and complex adaptive systems helped us to understand some difficulties that our team was experiencing. However, for some problems, this perspective seemed too broad, and a more fine-grained approach was desirable.