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BackgroundElectronic consultation (eConsult) programs are crucial components of modern healthcare that facilitate communication between primary care providers (PCPs) and specialists. eConsults between PCPs and specialists. They also provide a unique opportunity to use real-world patient scenarios for reflective learning as part of professional development. However, tools that guide and document learning from eConsults are limited. The purpose of this study was to develop and pilot two eConsult reflective learning tools (RLTs), one for PCPs and one for specialists, for those participating in eConsults.MethodsWe performed a four-phase pragmatic mixed methods study recruiting PCPs and specialists from two public health systems located in two countries: eConsult BASE in Canada and San Francisco Health Network eConsult in the United States. In phase 1, subject matter experts developed preliminary RLTs for PCPs and specialists. During phase 2, a Delphi survey among 20 PCPs and 16 specialists led to consensus on items for each RLT. In phase 3, we conducted cognitive interviews with three PCPs and five specialists as they applied the RLTs on previously completed consults. In phase 4, we piloted the RLTs with eConsult users.ResultsThe RLTs were perceived to elicit critical reflection among participants regarding their knowledge and practice habits and could be used for quality improvement and continuing professional development.ConclusionPCPs and specialists alike perceived that eConsult systems provided opportunities for self-directed learning wherein they were motivated to investigate topics further through the course of eConsult exchanges. We recommend the RLTs be subject to further evaluation through implementation studies at other sites.

Background and aimUp to a third of patients with inflammatory bowel disease (IBD) have elevated liver enzymes (ELE). We evaluated the incidence, predictors, and outcomes associated with ELE in a diverse and vulnerable IBD cohort.MethodsWe retrospectively evaluated 336 IBD patients receiving care at the San Francisco safety net gastroenterology clinics between June 1996 and December 2019. Baseline characteristics were captured at first visit, then patients were followed until last clinic activity or death. Testing and etiology, pattern of ELE defined as transient (

In response to the COVID-19 pandemic, we developed and implemented a theory-informed process to adapt a comprehensive pre-clerkship medical school curriculum to run in the virtual learning environment utilizing sociocultural learning theory and cognitive load theory. Of 124 student respondents, 45% rated virtual learning as very or extremely effective, and 49% as moderately effective. Positive aspects of virtual learning included effectiveness of chat moderators, displaying pronouns on Zoom, active learning technology, and captioning and transcription. Negative aspects included access to technology and feeling isolated from community. Overall course ratings, examination performance, and work hours did not differ pre- and post-implementation.

Cognitive Load Theory has emerged as an important approach to improving instruction in the health professions workplace, including patient handovers. At the same time, there is growing recognition that emotion influences learning through numerous cognitive processes including motivation, attention, working memory, and long-term memory. This study explores how emotion influences the cognitive load experienced by trainees performing patient handovers. From January to March 2019, 693 (38.7%) of 1807 residents and fellows from a 24-hospital health system in New York city completed a survey after performing a handover. Participants rated their emotional state and cognitive load. The survey included questions about features of the learner, task, and instructional environment. The authors used factor analysis to identify the core dimensions of emotion. Regression analyses explored the relationship between the emotion factors and cognitive load types. Two emotion dimensions were identified representing invigoration and tranquility. In regression analyses, higher levels of invigoration, tranquility, and their interaction were independently associated with lower intrinsic load and extraneous load. The interaction of invigoration and tranquility predicted lower germane load. The addition of the emotion variables to multivariate models including other predictors of cognitive load types significantly increased the amount of variance explained. The study provides a model for measuring emotions in workplace learning. Because emotion appears to have a significant influence on cognitive load types, instructional designers should consider strategies that help trainees regulate emotion in order to reduce cognitive load and improve learning and performance.

IntroductionCognitive load theory (CLT) views working memory as the primary bottleneck for learning, as it is limited in both capacity and retention. CLT delineates three types of activities that impose on working memory: intrinsic load, germane load, and extraneous load. These three constructs have practical ramifications for direct teaching, learning environments, and curricular design. CLT could help educators across health professions improve quality of teaching, especially in demanding and unpredictable workplace environments. However, few educational resources exist to familiarize clinical workplace educators with CLT.MethodsWe developed a 2-hour workshop focused on CLT's core concepts and practical applications, targeted at health professions' workplace educators. It featured large-group, small-group, and individual reflective activities. An end-of-workshop survey was administered, and a follow-up survey was sent to participants 2 months after the workshop.ResultsA total of 134 educators attended the first two offerings of the workshop in two different states. Participants considered CLT as relevant to a variety of workplace teaching settings and activities. Participants' self-assessed familiarity with CLT on a 0-100 scale increased from a mean of 36 (SD = 26) before the workshop to 59 (SD = 17) after the workshop. At follow-up, participants scored an average of 85% on content knowledge questions. Approximately half of respondents to the follow-up survey stated they had made or planned to make specific changes to their workplace teaching leveraging tenets of CLT.DiscussionThe workshop conveyed CLT concepts and primed participants to independently craft CLT-based interventions for their own teaching practices.

We used the cognitive load inventory for handoffs (CLIH) to identify predictors of cognitive load types during patient handoffs in order to identify opportunities to improve instruction. In 2019, out of a total of 1,807 residents and fellows within a 24-hospital health system, 693 (38.4%) completed the CLIH after a patient handoff. Multivariable regression yielded predictors for each cognitive load type. Intrinsic load associated with features of the learner (fatigue positively associated) and task (higher complexity clinical setting, number of patients, and handoff length positively associated). Extraneous load associated with learner (fatigue positively associated, and number of times trained in the verbal protocol negatively associated) and task design (number of sources of written information positively associated). Germane load associated with learner (level of training negatively associated, and fatigue positively associated) and instructional environment (interruptions negatively associated and formal feedback positively associated). Implications for instructional design are explored.

Although autoimmune hepatitis (AIH) is more common in women and affects people of all races/ethnicities, there is currently limited information regarding the relationship between race/ethnicity and AIH, especially in the context of underserved populations. We aim to evaluate the relationship between race/ethnicity and AIH and better characterize its clinical features among different racial groups. We conducted a 15-year retrospective analysis, from January 2002 to June 2017, of patients seen at Zuckerberg San Francisco General Hospital (ZSFG). Sixty-three AIH patients and 2049 non-AIH controls were eligible for the study. The main predictor of interest was race/ethnicity, and the main outcome of interest was AIH diagnosis; other secondary measures recorded include clinical features such as ALT, bilirubin, and biopsy fibrosis at presentation. In a multivariable model adjusting for age and sex, we found that black (OR 9.6, 95% CI 1.8-178), Latino (OR 25.0, 95% CI 5.3-448), and Asian/Pacific Islander (API) (OR 10.8, 95% CI 2.2-196) race/ethnicity were associated with increased odds of an AIH diagnosis compared to the white reference group. Among people of colour with AIH, there were no significant differences in baseline ALT (p = .45), total bilirubin at presentation (p = .06), fibrosis at presentation (p = .74), and hospitalization (p = .27). Race/ethnicity is an independent risk factor for AIH. The clinical features of AIH did not differ significantly among black, Latino, and API patients.

BackgroundTo reduce unnecessary ambulatory gastroenterology (GI) visits and increase access to GI care, San Francisco Health Network gastroenterologists and primary care providers implemented guidelines in 2013 that discharged certain patients back to primary care after endoscopy with formal written recommendations. This study assesses the longer-term impact of this policy on GI clinic access, workflow, and provider satisfaction.MethodsAn email-based survey assessed gastroenterologist and primary care provider (PCP) opinions about the discharge process. Administrative data and chart review were used to assess clinic access, intervention fidelity, and re-referral rates.Results102/299 (34%) of PCPs and 5/7 (71%) of gastroenterologists responded to the survey. 74% of PCPs and 100% of gastroenterologists were satisfied or very satisfied with the discharge process. 80% of gastroenterologists believed the discharge process decreased their workload, while 53.5% of primary care providers believed it increased their workload. 6.7% of patients discharged to primary care in 2013 had re-referrals to GI. Wait time for the third-next-available new outpatient GI clinic appointment had previously decreased from 158 days (2012, pre-intervention) to 74 days (2013, post-intervention). In 2015, wait time was 19 days (p

Background and study aims Limited international data have shown that non-physicians can safely perform upper endoscopy, but no such study has been performed in the United States. Our aim was to assess the quality of outpatient upper endoscopies performed by nurse practitioners (NPs).Patients and methods Retrospective chart review of upper endoscopies performed by 3 NPs between 2010 and 2013 was performed. Comparisons among all NPs performing upper endoscopy and assessment of individual NP performance over time with respect to quality indicators were performed.Results Three NPs performed 333 upper endoscopies (distribution of 166, 44, and 123, respectively). Of the cases, 98.2 %s were successfully completed to the second portion of the duodenum. In most cases, photo-documentation of required anatomical landmarks was performed: GE junction (84.2 %), GE junction in retroflexed view (84.2 %), antrum (82.1 %) and duodenum (80.9 %). Photo-documentation improved with increasing experience. NPs appropriately performed biopsies for specific medical conditions: 10/11 (90.9 %) gastric ulcers were biopsied and 63/66 (95.5) of patients with iron deficiency had duodenal biopsies performed for celiac disease. A physician endoscopist was required during the procedure 22.5 % of the time. Important parameters such as documenting informed consent (100 %) and documenting a discharge plan (99.4 %) in the procedure reports were overwhelming present. There was a single adverse event during the study period.Conclusion In the first US study of NPs performing upper endoscopy, they were able to perform high-quality and safe upper endoscopies. These findings support incorporation of non-physicians alongside physicians to help meet the growing demand for endoscopic services across the United States.

BackgroundInternet searches are an increasingly used tool in medical research. To date, no studies have examined Google search data in relation to common gastrointestinal symptoms.AimsThe aim of this study was to compare trends in Internet search volume with clinical datasets for common gastrointestinal symptoms.MethodsUsing Google Trends, we recorded relative changes in volume of searches related to dysphagia, vomiting, and diarrhea in the USA between January 2008 and January 2011. We queried the National Inpatient Sample (NIS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) during this time period and identified cases related to these symptoms. We assessed the correlation between Google Trends and these two clinical datasets, as well as examined seasonal variation trends.ResultsChanges to Google search volume for all three symptoms correlated significantly with changes to NIS output (dysphagia: r = 0.5, P = 0.002; diarrhea: r = 0.79, P

BackgroundAdvancing patient safety during handoffs remains a public health priority. The application of cognitive load theory offers promise, but is currently limited by the inability to measure cognitive load types.ObjectiveTo develop and collect validity evidence for a revised self-report inventory that measures cognitive load types during a handoff.MethodsBased on prior published work, input from experts in cognitive load theory and handoffs, and a think-aloud exercise with residents, a revised Cognitive Load Inventory for Handoffs was developed. The Cognitive Load Inventory for Handoffs has items for intrinsic, extraneous, and germane load. Students who were second- and sixth-year students recruited from a Dutch medical school participated in four simulated handoffs (two simple and two complex cases). At the end of each handoff, study participants completed the Cognitive Load Inventory for Handoffs, Paas' Cognitive Load Scale, and one global rating item for intrinsic load, extraneous load, and germane load, respectively. Factor and correlational analyses were performed to collect evidence for validity.ResultsConfirmatory factor analysis yielded a single factor that combined intrinsic and germane loads. The extraneous load items performed poorly and were removed from the model. The score from the combined intrinsic and germane load items associated, as predicted by cognitive load theory, with a commonly used measure of overall cognitive load (Pearson's r = 0.83, p

BackgroundEnteral access placement is performed among a variety of providers and specialties, yet there is a dearth of literature on trends and factors related to enteral access placement in the United States.ObjectiveTo examine trends in the incidence of enteral access procedures performed by gastroenterologists in the United States.DesignRetrospective review of upper endoscopic procedures that involved PEG tube placement between 2000 and 2010.SettingEndoscopy sites participating in the Clinical Outcomes Research Initiative (CORI).PatientsPatients undergoing upper endoscopy.InterventionsPEG tube placement.Main outcome measurementsNumber of PEG tubes placed.ResultsOverall PEG tube placement by a provider from 2000 to 2010 was 1.7% (number of PEG tubes performed/number of upper endoscopies performed), with the majority of them being performed by gastroenterologists. Very young and very old, non-white racial background (Hispanic: odds ratio [OR] 1.21; 95% CI, 1.13-1.28; black: OR 2.24; 95% CI, 2.12-2.36), and men (OR 1.44; 95% CI, 1.39-1.50) were patient characteristics associated with greater PEG tube placement. In terms of practice setting, PEG tube placement occurred more frequently in community and/or health maintenance organization environments and on the East Coast. With respect to provider characteristics, male providers were less likely than female providers to perform a PEG tube insertion (OR 0.67; 95% CI, 0.64-0.71), and there was a trend that as providers were further out of medical school they were less likely to perform a PEG tube procedure. Interestingly, surgeons (OR 6.69; 95% CI, 6.18-7.24) and other providers (non-pediatric/non-general practice) (OR 3.22; 95% CI, 2.63-3.94) were more likely to perform PEG tube procedures than were gastroenterologists.LimitationsParticipation in CORI is voluntary and may not capture data on non-gastroenterologist providers.ConclusionSignificant practice variation was noted in PEG tube placement in the United States with respect to patient and provider characteristics, geographic region, and endoscopy settings.

Previous studies on loco-regional therapy (LRT) and alpha-fetoprotein (AFP) in predicting outcome after liver transplant (LT) for hepatocellular carcinoma (HCC) have shown inconsistent results. We analyzed the OPTN database in Region 5 from January 2004 to January 2009 and performed univariate and multivariate analysis of 11 pre-transplant recipient and donor variables in 1074 patients with HCC meeting Milan criteria to detect association with post-LT tumor recurrence or mortality. Mean waitlist time was 438 d. The 1- and 5-yr post-LT survival was 91.1% and 71.1%, respectively. In multivariate analysis, AFP before LT was the only predictor of HCC recurrence. The association between AFP and HCC recurrence was observed only in the subgroup receiving LRT but not in the subgroup without LRT. Predictors of mortality in multivariate analysis were HCC recurrence, Donor Risk Index, last AFP before LT, and MELD score. AFP before LT was the strongest predictor of post-transplant HCC recurrence or death in multivariate analysis. In conclusion, in Region 5 with prolonged waitlist time, high AFP was the only pre-transplant variable predicting post-transplant tumor recurrence and mortality for HCC meeting Milan criteria. Our results also supported the importance of the effects of LRT on AFP in predicting prognosis.

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IntroductionPreconsultation exchange is a method to promote expedited care among health care providers through communication between primary care providers and specialists before a clinic visit. We evaluated the efficacy of a preconsultation exchange in streamlining patient visits to the urology clinic with an emphasis on resource efficiency in a safety net hospital.MethodsBetween April 1, 2011 and March 31, 2012 there were 1,705 electronic referrals to our urology department. A random sample of 500 referrals was selected for evaluation, of whom 487 patients met study inclusion criteria. Scheduling outcome and preconsultation exchange were evaluated for each chief complaint.ResultsPatients with operative or procedural chief complaints, or potential oncologic diagnoses were most likely to be scheduled directly to the urology clinic. Of the 487 patients 36 (7.4%) were treated for benign urological conditions by primary care providers and did not need to be seen in the urology clinic. For 13.5% of patients recommended laboratory and radiological tests were obtained before the initial urology clinic visit as a result of preconsultation exchange.ConclusionsElectronic preconsultation exchange served as a method of quality improvement by promoting urology clinic efficiency. Unnecessary appointments were limited and the completeness of appropriate laboratory and imaging studies at the initial visit was increased. Health care was streamlined by increased access to urological care and by management of benign urological conditions without a formal clinic visit in appropriate cases.

BackgroundEffective communication between primary care providers and specialty providers is important to facilitate high-quality specialty care. Few studies have assessed the quality of communication from specialist to primary care providers or implemented interventions to improve quality. We developed a brief, low-cost intervention designed to improve the quality of ambulatory gastroenterology consultation notes written by fellows and nurse practitioners in our urban health care system.MethodsSix physicians (3 specialists and 3 primary care providers) scored pre- and postintervention notes using an objective quality assessment instrument that had excellent inter-rater reliability. They were blinded to note date, author, and pre/postintervention status. The primary outcome was improvement in Composite Quality Score, an objective, comprehensive assessment of quality. Secondary outcomes included improvements in 3 specific domains, and Global Quality Score (a subjective measure of quality).ResultsTwo hundred pre- and 200 postintervention notes written by 6 fellows and 2 nurse practitioners were included. Composite Quality Score improved from 3.74 (of 5) to 4.09 (P

BackgroundPreconsultation exchange is an emerging model of specialty care proposed by the American College of Physicians that seeks to answer a clinical question without a formal patient visit to the specialty clinic. This form of specialty care has been little studied. We sought to determine the appropriateness of preconsultation exchange for ambulatory hepatology consultations within our urban health care system.MethodsRetrospective study of referrals for ambulatory hepatology consultation in the safety net health care system of San Francisco, Calif from January 2007 through April 2010.ResultsOf the 500 referrals reviewed, 87 were excluded as repeat requests. The most common reasons for referral were hepatitis B (34.9%) and hepatitis C (32.0%). Fifty-six referrals (13.6%) were appropriate for preconsultation exchange, and 190 (46.0%) were inappropriate for preconsultation exchange. One hundred sixty-seven (40.4%) referrals did not include enough information to determine appropriateness for preconsultation exchange. Most of these (83.8%) were made for hepatitis B or hepatitis C, despite the presence of explicit referral guidelines. Midlevel providers were more likely than physicians to provide enough information to determine appropriateness for preconsultation exchange.ConclusionIn our urban health care system, preconsultation exchange appears to be an appropriate form of specialty care for some ambulatory hepatology consultations. Communication between primary care provider and specialist appears to be an important barrier to broader implementation of preconsultation exchange. Optimizing the preconsultation exchange is critical to improve the primary-specialty care interface, and to build a true Patient-Centered Medical Home Neighborhood.

BackgroundRace and socioeconomic status (SES) significantly affect the content and delivery of healthcare for multiple chronic disease states. Inflammatory bowel disease (IBD) is a set of complex, chronic diseases with the potential for significant morbidity if the content or delivery of healthcare is suboptimal. However, the literature related to race, SES, and IBD remains fragmented.MethodsUsing guidelines published by the Centre for Reviews and Dissemination, we performed a systematic review of the world's literature to identify studies related to: 1) IBD, 2) race/ethnicity, 3) SES, 4) healthcare delivery, and 5) healthcare effectiveness.ResultsWe identified 40 studies that met inclusion criteria. Twenty-four studies (60%) assessed the role of SES and 21 (53%) evaluated race. Topics addressed by these studies included: 1) Utilization of Medical and Surgical Therapy; 2) Adherence to Medical Therapy; 3) Clinical Outcomes; 4) Healthcare Access and Utilization; 5) Disease Perception and Knowledge; and 6) Employment/Insurance. We identified race- and SES-based disparities in the content of medical and surgical healthcare, utilization of inpatient and ambulatory medical care, adherence to medical therapy, and disease perceptions and knowledge. Several studies also identified race- and SES-based disparities in outcomes for IBD, including in-hospital mortality rates and health-related quality of life.ConclusionsRace- and SES-based disparities in the delivery and effectiveness of healthcare for patients with IBD exist in numerous domains, yet studies remain limited in their scope and breadth. Concerted, prospective, multicenter efforts are needed to address underlying causes for disparities and to identify methods of reducing and eliminating disparities.

AbstractBackgroundStudies document increasing rates of hospitalization among patients with inflammatory bowel disease, but temporal trends for in-hospital mortality among patients with inflammatory bowel disease are not characterized. We sought to determine whether in-hospital mortality changed over a 13-year period among nationwide hospitalizations associated with inflammatory bowel disease. We additionally sought to identify factors correlated with mortality.MethodsWe used the National Hospital Discharge Survey, a large nationally representative database, for the years 1994 through 2006. Age- and mortality-adjusted rates of in-hospital mortality and standardized mortality ratios were calculated for four time periods. Logistic regression analysis was used to assess associations between advancing time and mortality in adjusted analyses.Results150 (0.9%) of 17,393 hospitalizations for patients with inflammatory bowel disease ended in death. Age-adjusted in-hospital mortality decreased from 3.6 deaths per 1,000 hospital days in 1994–96 to 2.4 per 1,000 in 2003–06; standardized mortality ratio decreased from 0.33 to 0.27. Similar trends were seen for patients with ulcerative colitis, but mortality did not change over time among patients with Crohn’s disease. Multivariable logistic regression analysis confirmed the significance of these changes in mortality, with 17% decreased odds of in-hospital death per three-year period (P = 0.012). Subject age (OR 1.06 per year, P

Inflammatory bowel disease (IBD) is increasingly common among non-Caucasian populations, but interracial differences in disease characteristics and management are not well-characterized.We tested the hypothesis that disease characteristics and management vary by race among IBD patients in an ethnically diverse healthcare system.A retrospective study of the safety net healthcare system of San Francisco, CA, from 1996 to 2009 was undertaken. Patient records with International Classification of Diseases, 9th Revision (ICD9) codes 555.xx, 556.xx, and 558.xx were reviewed. Adult patients with confirmed IBD diagnoses were included. Interracial variations in disease characteristics and management were assessed broadly; focused between-race comparisons identified specific differences.The 228 subjects included 77 (33.4%) with Crohn’s disease (CD), 150 (65.8%) with ulcerative colitis, and 1 (0.4%) with IBD, type unclassified. The race distribution included 105 (46.1%) white, 34 (14.9%) black, 35 (15.4%) Hispanic, and 51 (22.4%) Asian subjects. Asians and Hispanics were diagnosed at older ages (41.0 and 37.1 years, respectively) and had shorter disease durations (5.4 and 5.2 years, respectively) than whites (30.5 years at diagnosis and 8.6 years duration, P