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Objectives: High rates of hospitalization and death disproportionately affected Black, Latino, and Asian residents of New York City at the beginning of the COVID-19 pandemic. To suppress COVID-19 transmission, New York City implemented a workforce of community engagement specialists (CESs) to conduct home-based contact tracing when telephone numbers were lacking or telephone-based efforts were unsuccessful and to disseminate COVID-19 information and sanitary supplies. Materials and Methods: We describe the recruitment, training, and deployment of a multilingual CES workforce with diverse sociodemographic backgrounds during July–December 2020 in New York City. We developed standard operating procedures for infection control and safety measures, procured supplies and means of transportation, and developed protocols and algorithms to efficiently distribute workload. Results: From July through December 2020, 519 CESs were trained to conduct in-person contact tracing and activities in community settings, including homes, schools, and businesses, where they disseminated educational materials, face masks, hand sanitizer, and home-based specimen collection kits. During the study period, 94 704 records of people with COVID-19 and 61 246 contacts not reached by telephone-based contact tracers were referred to CESs. CESs attempted home visits or telephone calls with 84 230 people with COVID-19 and 49 303 contacts, reaching approximately 55 592 (66%) and 35 005 (71%), respectively. Other CES activities included monitoring recently arrived travelers under quarantine, eliciting contacts at point-of-care testing sites, and advising schools on school-based COVID-19 mitigation strategies. Practice Implications: This diverse CES workforce allowed for safe, in-person implementation of contact tracing and other prevention services for individuals and communities impacted by COVID-19. This approach prioritized equitable delivery of community-based support services and resources.

COVID-19 vaccines have been available to all adults in the USA since April, 2021, but many adults remain unvaccinated. We aimed to assess the joint effect of a proof-of-vaccination requirement, incentive payments, and employer-based mandates on rates of adult vaccination in New York City (NYC).We constructed a synthetic control group for NYC composed of other counties in the core of large, metropolitan areas in the USA. The vaccination outcomes for NYC were compared against those of the synthetic control group from July 26, 2021, to Nov 1, 2021, to determine the differential effects of the policies. Analyses were conducted on county-level vaccination data reported by the Centers for Disease Control and Prevention. The synthetic control group was constructed by matching on county-level preintervention vaccination outcomes, partisanship, economic attributes, demographics, and metropolitan area population. Statistical inference was conducted using placebo tests for non-treated counties.The synthetic control group resembled NYC across attributes used in the matching process. The cumulative adult vaccination rate for NYC (in adults aged 18 years or older who received at least one dose of an authorised COVID-19 vaccine) increased from 72·5% to 89·4% (+16·9 percentage points [pp]) during the intervention period, compared with an increase from 72·5% to 83·2% (+10·7 pp) for the synthetic control group, a difference of 6·2 pp (95% CI 1·4-10·7), or 410 201 people (90 966-706 532). Daily vaccinations for NYC were consistently higher than those in the synthetic control group, a pattern that started shortly after the start of the intervention period.The combination of a proof-of-vaccination requirement, incentive payments, and vaccine mandates increased vaccination rates among adults in NYC compared with jurisdictions that did not use the same measures. Whether the impact of these measures occurred by inducing more people to get vaccinated, or by accelerating vaccinations that would have occurred later, the increase in vaccination rates likely averted illness and death.None.

ImportanceContact tracing is a core strategy for preventing the spread of many infectious diseases of public health concern. Better understanding of the outcomes of contact tracing for COVID-19 as well as the operational opportunities and challenges in establishing a program for a jurisdiction as large as New York City (NYC) is important for the evaluation of this strategy.ObjectiveTo describe the establishment, scaling, and maintenance of Trace, NYC’s contact tracing program, and share data on outcomes during its first 17 months.Design, Setting, and ParticipantsThis cross-sectional study included people with laboratory test–confirmed and probable COVID-19 and their contacts in NYC between June 1, 2020, and October 31, 2021. Trace launched on June 1, 2020, and had a workforce of 4147 contact tracers, with the majority of the workforce performing their jobs completely remotely. Data were analyzed in March 2022.Main Outcomes and MeasuresNumber and proportion of persons with COVID-19 and contacts on whom investigations were attempted and completed; timeliness of interviews relative to symptom onset or exposure for symptomatic cases and contacts, respectively.ResultsCase investigations were attempted for 941 035 persons. Of those, 840 922 (89.4%) were reached and 711 353 (75.6%) completed an intake interview (women and girls, 358 775 [50.4%]; 60 178 [8.5%] Asian, 110 636 [15.6%] Black, 210 489 [28.3%] Hispanic or Latino, 157 349 [22.1%] White). Interviews were attempted for 1 218 650 contacts. Of those, 904 927 (74.3%) were reached, and 590 333 (48.4%) completed intake (women and girls, 219 261 [37.2%]; 47 403 [8.0%] Asian, 98 916 [16.8%] Black, 177 600 [30.1%] Hispanic or Latino, 116 559 [19.7%] White). Completion rates were consistent over time and resistant to changes related to vaccination as well as isolation and quarantine guidance. Among symptomatic cases, median time from symptom onset to intake completion was 4.7 days; a median 1.4 contacts were identified per case. Median time from contacts’ last date of exposure to intake completion was 2.3 days. Among contacts, 30.1% were tested within 14 days of notification. Among cases, 27.8% were known to Trace as contacts. The overall expense for Trace from May 6, 2020, through October 31, 2021, was approximately $600 million.Conclusions and RelevanceDespite the complexity of developing a contact tracing program in a diverse city with a population of over 8 million people, in this case study we were able to identify 1.4 contacts per case and offer resources to safely isolate and quarantine to over 1 million cases and contacts in this study period.

A large, well-trained public health workforce is needed to control coronavirus disease 2019 (COVID-19) in the United States in the short term and to address other disease burdens and health disparities in the long run. As the public health workforce declined following the 2008 financial crisis, many US jurisdictions struggled to hire a sufficient number of staff for roles initially including testing and contact tracing and more recently for vaccination. Ultimately, COVID-19 control will require a combination of vaccination and rapid investigation, contact tracing, and quarantine to stop chains of transmission. New federal resources for a public health workforce have been made available. With appropriate attention to addressing administrative barriers and ensuring equity, a 21st-century US public health workforce will hasten the control of COVID-19, provide economic relief to individuals and communities, and reduce the burden of other infectious diseases, noncommunicable diseases, and other disease burdens. A long-term commitment to a robust public health workforce is vital to ensuring health security and preparedness for future health threats.

Background: Integrating behavioral and primary care practices improves quality of care, but limited data exists regarding the extent or attributes of such integration. We conducted a baseline evaluation of the level and characteristics of integrated practices in Rhode Island. Methods: The Rhode Island Department of Health 2015 Statewide Health Inventory Behavioral Health Survey was sent to behavioral health clinics and outpatient psychiatry and psychology practices. Survey questions assessed indicators of integration, including colocation, shared electronic medical records (EMRs), and shared communication systems. Results: Only 19%, 9%, and 17% of behavioral health clinics, psychiatrists, and psychologists, respectively reported any integration with primary care practices. Compared to psychology (3.5%) and psychiatry (0.0%) practices, behavioral health clinics reported the highest level of practice colocation (10.4%, P

Rising physician burnout has adverse effects on healthcare. This study aimed to identify remediable stressors associated with burnout using the 10-item Mini-Z and the Maslach Burnout Inventory (MBI), and to compare performance of the Mini-Z's single-item burnout metric against the 22-item MBI. Surveys were emailed to 4,118 clinicians affiliated with an academic health system; 1,252 clicked the link, and 557 responded (completion rate 44%). Four hundred seventy-five practicing physicians were included: academic faculty (372), hospital employed (52), and private practitioners (81). Prevalence of burnout via the MBI was 56.6%. Predictors of burnout were poor control over workload [OR = 8.24, 95% CI 4.(81, 14.11)], inefficient teamwork [OR = 7.61, 95% (CI 3.28, 17.67)], insufficient documentation time [OR = 5.83, 95% (CI 3.35, 10.15)], hectic-chaotic work atmosphere [OR = 3.49, 95% (CI 2.12, 5.74)], lack of value-alignment with leadership [OR = 3.27, 95% (CI 2.12, 5.74)], and excessive electronic medical record time at home [OR = 1.99, 95% CI (1.21, 3.27)]. Academic faculty experienced more burnout than private practitioners (59.9% vs. 42.0%, p = 0.013). Odds of burnout associated with stressors were generally concordant via Mini-Z's burnout metric versus the MBI. The Mini-Z is a brief, valid method to identify stressors associated with burnout and guide interventions.

Physicians “purchase” many health care services on behalf of patients yet remain largely unaware of the costs of these services. Electronic health record (EHR) cost displays may facilitate cost-conscious ordering of health services. To determine whether displaying hospital lab and imaging order costs is associated with changes in the number and costs of orders placed. Quasi-experimental study. All patients with inpatient or observation encounters across a multi-site health system from April 2013 to October 2015. Display of order costs, based on Medicare fee schedules, in the EHR for 1032 lab tests and 1329 imaging tests. Outcomes for both lab and imaging orders were (1) whether an order was placed during a hospital encounter, (2) whether an order was placed on a given patient-day, (3) number of orders placed per patient-day, and (4) cost of orders placed per patient-day. During the lab and imaging study periods, there were 248,214 and 258,267 encounters, respectively. Cost display implementation was associated with a decreased odds of any lab or imaging being ordered during the encounter (lab adjusted odds ratio [AOR] = 0.97, p = .01; imaging AOR = 0.97, p

Aim Cost awareness has been proposed as a strategy for curbing the continued rise of healthcare costs. However, most physicians are unaware of the cost of diagnostic tests, and interventions have had mixed results. We sought to assess resident physician cost awareness following sustained visual display of costs into electronic health record (EHR) order entry screens. Study Design We completed a preintervention and postintervention web-based survey. Participants were physicians in internal medicine, paediatrics, combined medicine and paediatrics, obstetrics and gynaecology, emergency medicine, and orthopaedic surgery at one tertiary co are academic medical centre. Costs were displayed in the EHR for 1032 unique laboratory orders. We measured attitudes towards costs and estimates of Medicare reimbursement rates for 11 common laboratory and imaging tests. Results We received 209 survey responses during the preintervention period (response rate 71.1%) and 194 responses during the postintervention period (response rate 66.0%). The proportion of residents that agreed/strongly agreed that they knew the costs of tests they ordered increased after the cost display (8.6% vs 38.2%; p Conclusions Resident cost awareness and ability to accurately estimate laboratory order costs improved significantly after implementation of a comprehensive EHR cost display for all laboratory orders. The improvement in cost estimation accuracy for imaging orders, which did not have costs displayed, suggested a possible spillover effect generated by providing a cost context for residents.

BACKGROUND It is desirable not to include planned readmissions in readmission measures because they represent deliberate, scheduled care. OBJECTIVES To develop an algorithm to identify planned readmissions, describe its performance characteristics, and identify improvements. DESIGN Consensus-driven algorithm development and chart review validation study at 7 acute-care hospitals in 2 health systems. PATIENTS For development, all discharges qualifying for the publicly reported hospital-wide readmission measure. For validation, all qualifying same-hospital readmissions that were characterized by the algorithm as planned, and a random sampling of same-hospital readmissions that were characterized as unplanned. MEASUREMENTS We calculated weighted sensitivity and specificity, and positive and negative predictive values of the algorithm (version 2.1), compared to gold standard chart review. RESULTS In consultation with 27 experts, we developed an algorithm that characterizes 7.8% of readmissions as planned. For validation we reviewed 634 readmissions. The weighted sensitivity of the algorithm was 45.1% overall, 50.9% in large teaching centers and 40.2% in smaller community hospitals. The weighted specificity was 95.9%, positive predictive value was 51.6%, and negative predictive value was 94.7%. We identified 4 minor changes to improve algorithm performance. The revised algorithm had a weighted sensitivity 49.8% (57.1% at large hospitals), weighted specificity 96.5%, positive predictive value 58.7%, and negative predictive value 94.5%. Positive predictive value was poor for the 2 most common potentially planned procedures: diagnostic cardiac catheterization (25%) and procedures involving cardiac devices (33%). CONCLUSIONS An administrative claims-based algorithm to identify planned readmissions is feasible and can facilitate public reporting of primarily unplanned readmissions. Journal of Hospital Medicine 2015;10:670–677. © 2015 Society of Hospital Medicine.

Background Concerns about duty hour and resident safety have fostered discussion about postshift fatigue and driving impairment. Objective We assessed how converting to a night float schedule for overnight coverage affected driving safety for trainees. Methods Brake reaction times were measured for internal medicine and orthopaedic surgery resident volunteers after a traditional 28-hour call shift and after a night float shift. We conducted matched paired t tests of preshift and postshift reaction time means. Participants also completed the Epworth Sleepiness Scale pre- and postshift. Results From June to July 2013, we enrolled 58 interns and residents (28 orthopaedic surgery, 30 internal medicine). We included 24 (41%) trainees on night float rotations and 34 (59%) trainees on traditional 28-hour call shifts. For all residents on night float rotations, there was no significant difference pre- and postshift. An increase in reaction times was noted among trainees on 28-hour call rotations. This included no effect on reaction times for internal medicine trainees pre- and postshift, and an increase in reaction times for orthopaedic trainees. For both night float and traditional call groups, there were significant increases in the Epworth Sleepiness Scale. Conclusions Trainees on traditional 28-hour call rotations had significantly worse postshift brake reaction times, whereas trainees on night float rotations had no difference. Orthopaedic trainees had significant differences in brake reaction times after a traditional call shift.

Although co-payments and deductibles are means of keeping health expenditures low, they have also been cited as barriers that inhibit patients from accessing necessary healthcare. We aimed to evaluate Rhode Island residents' experiences with cost-related access challenges within the state's healthcare system. We conducted a cross-sectional survey of resident experiences with healthcare in Rhode Island. Our survey instrument was composed of the RAND Corporation "Short-Form Patient Satisfaction Questionnaire (PSQ-18)", questions developed by the Rhode Island Office of the Health Insurance Commissioner, and ranking of health priorities based on prior community assessments conducted by the Rhode Island Department of Health. Data were collected at venues across the state as part of the Rhode Island Department of Health 2015 Statewide Health Inventory. From July to August 2015, 404 surveys were completed. We found that 40% of respondents had a co-pay of $20-$50, while 35.7% of respondents had a deductible of greater than $500. Further, one-third of respondents delayed receiving care due to financial barriers. This decision resulted in a worsening condition or hospital visit for nearly half of those respondents. Co-pays and deductibles pose challenges to Rhode Islanders accessing health care. Cost-related barriers to healthcare access should continue to be addressed, especially in the context of preventive care services, which are now being built into health insurance premiums through the Patient Protection and Affordable Care Act. [Full article available at http://rimed.org/rimedicaljournal-2016-11.asp].

Phenomenon: As an impending shortage of primary care physicians is expected, understanding career trajectories of medical students will be useful in supporting interest in primary care fields and careers. The authors sought to characterize recent trends in primary care interest and career trajectories among medical students at an academic medical institution that did not have a family medicine department.Match data for 2,477 graduates who matched into resident training programs between 1989 and 2014 were analyzed to determine the proportion entering primary care residency programs. An online search and confirmatory phone call methodology was used to determine primary care career trajectories for the 795 graduates who matched into primary care residency programs between 1989 to 2010. Subanalyses were performed to characterize primary care career entrance among graduates who matched into the three primary care residency programs: Family Medicine, Categorical and Primary Care Internal Medicine, and Categorical and Primary Care Pediatrics.Between 1989 and 2014, 911 (37%) of all matched graduates matched into primary care residency programs. Of the 795 graduates who matched into these programs between 1989 and 2010, less than half (245; 31%) entered primary care careers. Of the graduates who ultimately entered primary care careers, 82% matched into either internal medicine or pediatrics residency programs and 18% matched into family medicine programs. Although there have been fluctuations in primary care interest that seem to parallel health care trends over the 26-year period, the overall percentage of graduates entering primary care residency programs and careers has remained fairly stable. Between 2006 and 2010, entrance into both primary care residency programs and primary care careers steadily increased. Despite this, the overall percentage of matched graduates who entered primary care careers over the 22-year study period (12%) was less than the national average (16%-18%). Insights: In the 26-year period between 1989 and 2014, primary care career interest increased slightly among medical students at this academic medical institution, with fluctuations that seem to coincide with national health care trends. Year-to-year fluctuations appear to be driven by rising numbers of Categorical Pediatrics and Categorical Internal Medicine matchers pursuing careers in primary care. There may be a need for specialized curricula and strategies to promote and retain interest in primary care at academic medical institutions, especially at institutions without family medicine training programs.

Hemoptysis, a common sign of diffuse alveolar hemorrhage, can be caused by multiple factors, both infectious and noninfectious. A 45-year-old male with hypertension, obstructive sleep apnea, and stage IV pulmonary sarcoidosis with cardiac involvement, presented with a two-month history of cough and acute nonmassive hemoptysis with hypoxia. A chest CT showed ground glass consolidation and interlobular septal thickening, concerning for diffuse alveolar hemorrhage. Flexible bronchoscopy confirmed diffuse alveolar hemorrhage; microbiological analyses of bronchoalveolar washings did not reveal a causative organism. Mycoplasma pneumoniae-specific IgM in serum studies was consistent with mycoplasma pneumonia as the most likely etiology of this patient's diffuse alveolar hemorrhage and resultant hemoptysis. This report points to the need to consider atypical mycoplasma pneumonia as a possible etiology of hemoptysis in patients with underlying sarcoidosis.

Cost awareness, to ensure physician stewardship of limited resources, is increasingly recognized as an important skill for physicians. The Accreditation Council for Graduate Medical Education has made cost awareness part of systems-based practice, a core competency of resident education. However, little is known about resident cost awareness.Background We sought to assess senior resident self-perceived cost awareness and cost knowledge.Objective In March 2014, we conducted a cross-sectional survey of all emergency medicine, internal medicine, obstetrics and gynecology, orthopaedic surgery pediatrics, and medicine-pediatrics residents in their final year at Yale–New Haven Hospital. The survey examined attitudes toward health care costs and residents' estimates of order prices. We considered resident price estimates to be accurate if they were between 50% and 200% of the Connecticut-specific Medicare price.Methods We sent the survey to 84 residents and received 47 completed surveys (56% response rate). Although more than 95% (45 of 47) felt that containing costs is the responsibility of every clinician, and 49% (23 of 47) agreed that cost influenced their decision when ordering, only 4% (2 of 47) agreed that they knew the cost of tests being ordered. No residents accurately estimated the price of a complete blood count with differential, and only 2.1% (1 of 47) were accurate for a basic metabolic panel. The overall accuracy of all resident responses was 25%.Results In our study, many trainees exit residency with self-identified deficiencies in knowledge about costs. The findings show the need for educational approaches to improve cost awareness among trainees.Conclusions

Background: We created a tool to improve communication among health professional trainees in the ambulatory setting. The tool was devised to both inform practice partner teams about high-risk patients and assign patient follow-up issues to team members. Team members were internal medicine residents and nurse practitioner fellows in the VA Connecticut Healthcare System Center of Excellence in Primary Care Education (CoEPCE), an interprofessional training model in primary care. Methods: We used a combination of Likert scale response questions and open ended questions to evaluate trainee attitudes before and after the implementation of the tool, as well as solicited feedback to improve the tool. Results: After using the primary care sign out tool, trainees expressed greater confidence that they could identify high-risk patients that had been cared for by other trainees and that important patient care issues would be followed up by others when they were not in clinic. In terms of areas for improvement, respondents wanted to have the sign out tool posted online. Discussion: Our sign out tool offers a strategy that others can use to improve communication and knowledge of shared patients within teams comprised of interprofessional trainees.

Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. This was a qualitative study based on semi-structured, in-person interviews. Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27–39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents’ decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care.

Identifying and understanding the root causes of preventable hospitalization (PH) is important for improving health outcomes and reducing unnecessary healthcare costs. Thus far, however, the desire to address this issue has been impeded by a general lack of research on factors associated with PH. To begin to address this gap, we propose an evidence-based logic model of individual, environmental, and systemic factors related to PH. We aim to use this logic model to design public health interventions to reduce PH in the State of Rhode Island and to stimulate an industry-wide discussion of the problem and its possible solutions.

“You don't know when the patient last ate?” Exasperated by another sloppy consult, my chief resident reminded me that, “they call because they need help. Remember, the patient really needs us.” Who said this? A chief on internal medicine? Or surgery? Can you tell? In truth, we have all felt this same sense of frustration with a late-night, seemingly incompetent consult. As residents, the intensity of training—and the pressure to complete ever-accumulating work—causes us to dread the shrill page portending another consult. Can't they figure out this question? Did they even look at the patient before calling? The frustration from poor consults, and the need for consult courtesy, has been well documented.1 As communication and teamwork break down, we take on tribal identities: the belief that they are different from us. And by different, we mean inferior. Other services don't work as hard or understand the patient the way we do. This lack of partnership and respect can lead to delays in providing care, an inefficient system, and more concerning, suboptimal patient care.2 Academic medicine is in the thick of a national dialogue on team-based approaches, with a focus on “interprofessionalism,” which examines the interactions between medicine, nursing, pharmacy, and other health professions.3 We suggest that something is missing in medical education—that it also must foster intra-professionalism. This concept is not new. More than 2 decades ago, surgeons began to discuss the need for modification of their own “ethic of rugged individualism,” realizing that the evolving health care system required “that we play as a team.”4 Residents should be learning not only to know when and how to consult other physicians and medical teams, but also to trust, depend on, and work in concert with other specialties. Currently, there is no formal graduate medical curriculum related to intra-professional teamwork. As residents from different specialties, we have common backgrounds in our dedication to quality and access to care, and 1 of us (M.D.S.) is a program director who enthusiastically supports intra-professional training. Despite that alignment, the pressures of residency training encourage us to silo ourselves into specialty-specific subcultures. Through our graduate medical training, we learn not only the intricacies of the human body, but also the culture of our new “in-crowd.” Through this, we have allowed ourselves to see specialties we interact with as the “other.” Whether or not the rationale is valid, all too often consulting specialties are not on the same page. Here, a crucial opportunity emerges: We must train intra-professional teams to examine, design, and deliver the medical care we all envision. Our inability as a house of medicine to optimally work alongside one another poses considerable risk—for our profession and for our patients. Teamwork training as a strategy for improving quality has been associated with substantially improved outcomes.5,6 For example, when the Veterans Health Administration implemented a formalized medical team training program for personnel in the surgical operating room, the result was an impressive 18% reduction in annual mortality among patients who were treated by teams that had undergone this training.7 Where team-based care and coordination among different services have been encouraged, there have been great strides in improving patient outcomes, and even evidence of sustained collaboration between different specialties.8–10 The promise of these findings is seen in emerging intra-professional models (t a b l e). An example is the University of California, San Fransisco's hospital-neurosurgery team-based approach. This combined service has led to decreased costs and increased physician perception of quality.11 For residents, there has been another benefit: learning from other services. As Dr Robert Wachter highlights in his online blog,8 the hospitalist who runs this service won a departmental teaching award last year from the Department of Neurosurgery. The lesson is clear: embracing intra-professional teams helps hospitals, patients, residents, and learning. TABLE Examples of Intra-Professional Teams Teams aren't just made; they require skills that can be taught. Team-based science teaches us that experienced teams are able to develop psychologically safe environments where team members can make better use of each other's knowledge, skills, and abilities.12 Residency programs should embrace this, and begin to teach with this approach. These team science lessons include the cultivation of psychological safety, enabling the development of transactive memory—a group-level memory system, and the recognition that the leader's behavior matters.12 Structured programming engaging intra-professional teams in health care and health care delivery improvement should happen through purposeful reorganization of teams into shared intern rotations, or collective research opportunities. Having met beyond the wards through a mutual interest in health policy, the authors have repeatedly found that high-quality care emerges from cross-specialty efforts around a common goal. To that end, the collective impact amassed will not be additive—it will be exponential. In an era where the medical education community, including the Accreditation Council for Graduate Medical Education, strives to meaningfully engage trainees to lead change in quality and safety,13 substantive intra-professional training may provide a compelling solution. As our health care delivery system shifts toward new collaborative payment models, such as bundled payment models and Accountable Care Organizations, specialties will no longer be stand-alone silos. We will need to work together to enhance and support high-quality care, and to continue to innovate in medicine. By being part of these types of teams during training, residents will be less likely to hide in the shelter of their own tribal identity. They will be better prepared to work together through mutual respect and understanding, which will lead to improved patient outcomes and efficiency of the health care system as a whole.

Background High rates of attrition from general surgery residency may threaten the surgical workforce. We sought to gain further insight regarding resident motivations for leaving general surgery residency. Methods We conducted in-depth interviews to generate rich narrative data that explored individual experiences. An interdisciplinary team used the constant comparative method to analyze the data. Results Four themes characterized experiences of our 19 interviewees who left their residency program. Participants (1) felt an informal contract was breached when clinical duties were prioritized over education, (2) characterized a culture in which there was no safe space to share personal and programmatic concerns, (3) expressed a scarcity of role models who demonstrated better work–life balance, and (4) reported negative interactions with authority resulting in a profound loss of commitment. Conclusions As general surgery graduate education continues to evolve, our findings may inform interventions and policies regarding programmatic changes to boost retention in surgical residency.

OBJECTIVE In the emergency department, hyperglycemic patients are screened for diabetic ketoacidosis (DKA) via a urine dipstick. In this prospective study, we compared the test characteristics of point-of-care β-hydroxybutyrate (β-OHB) analysis with the urine dipstick. RESEARCH DESIGN AND METHODS Emergency-department patients with blood glucose ≥250 mg/dL had urine dipstick, chemistry panel, venous blood gas, and capillary β-OHB measurements. DKA was diagnosed according to American Diabetes Association criteria. RESULTS Of 516 hyperglycemic subjects, 54 had DKA. The urine dipstick had a sensitivity of 98.1% (95% CI 90.1–100), a specificity of 35.1% (30.7–39.6), a positive predictive value of 15% (11.5–19.2), and a negative predictive value of 99.4% (96.6–100) for DKA. Using the manufacturer-suggested cutoff of >1.5 mmol/L, β-OHB had a sensitivity of 98.1% (90.1–100), a specificity of 78.6% (74.5–82.2), a positive predictive value of 34.9% (27.3–43), and a negative predictive value of 99.7% (98.5–100) for DKA. CONCLUSIONS Point-of-care β-OHB and the urine dipstick are equally sensitive for detecting DKA (98.1%). However, β-OHB is more specific (78.6 vs. 35.1%), offering the potential to significantly reduce unnecessary DKA work-ups among hyperglycemic patients in the emergency department.

House staff physicians (medical residents and fellows) represent a significant proportion of the physician workforce in the U.S. and are a potentially important force in health care transformation, but little is known about house staff health policy attitudes or priorities.We conducted a cross-sectional survey of all house staff at Yale-New Haven Hospital (YNHH) and the University of Connecticut Health Center (UCHC). We calculated means of Likert-scale attitude response scores and rankings of health policy priorities. We then performed linear regression of postgraduate year (PGY) and surgical specialty on health policy priorities.We received back 308 surveys (response rate of 19%). One hundred thirty-five responses (44%) were from UCHC and 173 responses were from YNHH (56%). Eighty-nine percent agreed that health policy was important to them, but only 21% felt confident in their knowledge of health policy. Thirty-two percent felt they had a good understanding of the Affordable Care Act. In terms of health policy priorities, malpractice reform and future salary were ranked the highest. There was a statistically significant positive association between PGY and malpractice reform as well as a negative association with Medicaid expansion and PGY after adjusting for surgical specialty.House staff physicians feel that health policy is important to them, but they are not confident in their knowledge of health policy. Malpractice reform and future salary are policy priorities for house staff, and malpractice reform is increasingly important to house staff as they advance through their postgraduate training.

In the USA, the politics around healthcare reform have created polarised views of the Affordable Care Act (ACA), but underlying these views is a disquieting lack of knowledge that could have harmful consequences for patients. Recently, television host Jimmy Kimmel interviewed a series of citizens on the street, all of whom vehemently stated their objections to Obamacare but were supportive of the ACA, suggesting misperceptions and lack of knowledge about the legislation among the public. But this is not just a case of late-night comedy. A recent Commonwealth Fund Health Insurance Marketplace Survey found that only two out of five adults in the USA were aware of health insurance exchanges or that there might be financial assistance to purchase plans.1 Even among childhood cancer survivors with substantial long-term healthcare needs, almost all participants surveyed did not have knowledge about health-insurance related laws.2 Physicians, who are experts in practicing medicine, are often assumed by patients to be experts in the legal changes affecting healthcare delivery. However, the reality is that most physicians are not experts in health policy,3 and it is not only the public that lacks knowledge about the ACA. In a recent survey of 2958 physicians in the USA, 45% did not know what an accountable care organisation was, but 65% felt that healthcare will deteriorate over the next 5 years after passage of the ACA, while only 27% believed the ACA will have a positive effect on patients.4 Furthermore, despite the ACA increasing Medicare and Medicaid reimbursement to …

Whether in the USA or UK, the resounding question in the health sphere is: How do we achieve better value in healthcare? The answer to date has been simple: get bigger, merge administrative departments, get more managerialised, and so cut costs. But none of this represents real change: just some tinkering of the current hospital-centric system. In order to find a sustainable and effective solution, we must consider value and not cost while focusing on what contributes to better health. This means becoming serious about caring for people beyond a hospital's walls. Population health, which links health outcomes for a population to the context of medical system and social determinants of health,1 offers the promise of dramatic improvement in value and personalisation for patients. This is not to diminish or downgrade the importance of continuing to improve healthcare for the individual, but rather to link that with an active approach to improving health. Doctors and other healthcare professionals will need to refocus their roles and renegotiate their relationships across the healthcare sector. Health systems across the globe are pressured to derive greater value in healthcare, which in the context of the continuing groundbreaking developments in medical technology must now centre on becoming serious about population health. The Institute for Healthcare Improvement's triple aim sets out the laudable ambition for all health systems: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of healthcare to ensure benefits can be applied across communities. It is the first of these, improving the health of the population, that is the most difficult and which seems out of the scope of healthcare. Delivering on this promise will not happen without clear leadership. Primary care—which assumes nearly 60% of all US patient visits and 90% of …

Background One major goal of the Patient-Centered Medical Home (PCMH) is to improve continuity of care between patients and providers and reduce the utilization of non-primary care services like the emergency department (ED). Objective To characterize continuity under the Veterans Health Administration’s PCMH model – the Patient Aligned Care Team (PACT), at one large Veterans Affair’s (VA’s) primary care clinic, determine the characteristics associated with high levels of continuity, and assess the association between continuity and ED visits. Design Retrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012. Patients The 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011. Main Measures Our exposure variable was continuity of care –a patient seeing their assigned primary care provider (PCP) at each clinic visit. The outcome of interest was having an ED visit. Results The patients encompassed 42,969 total clinic visits, and 3185 (24%) of them had 15,458 ED visits. In a multivariable logistic regression analysis, patients with continuity of care – at least one visit with their assigned PCP – had lower ED utilization compared to individuals without continuity (adjusted odds ratio [AOR] 0.54; 95% CI: 0.41, 0.71), controlling for frequency of primary care visits, comorbidities, insurance, distance from the ED, and having a trainee PCP assigned. Likewise, the adjusted rate of ED visits was 544/1000 person-year (PY) for patients with continuity vs. 784/1000 PY for patients without continuity (p = 0.001). Compared to patients with low continuity (50%) continuity were less likely to utilize the ED. Conclusions Strong continuity of care is associated with decreased ED utilization in a PCMH model and improving continuity may help reduce the utilization of non-primary care services.

Background and Aim. While aortic valve replacement for aortic stenosis can be performed safely in elderly patients, there is a need for hemodynamic and quality of life evaluation to determine the value of aortic valve replacement in older patients who may have age-related activity limitation.Materials and Methods. We conducted a prospective evaluation of patients who underwent aortic valve replacement for aortic stenosis with the Hancock II porcine bioprosthesis. All patients underwent transthoracic echocardiography (TTE) and completed the RAND 36-Item Health Survey (SF-36) preoperatively and six months postoperatively.Results. From 2004 to 2007, 33 patients were enrolled with an average age of 75.3 ± 5.3 years (24 men and 9 women). Preoperatively, 27/33 (82%) were New York Heart Association (NYHA) Functional Classification 3, and postoperatively 27/33 (82%) were NYHA Functional Classification 1. Patients had a mean predicted maximumVO2(mL/kg/min) of 19.5 ± 4.3 and an actual maxVO2of 15.5 ± 3.9, which was 80% of the predictedVO2. Patients were found to have significant improvements (P≤0.01) in six of the nine SF-36 health parameters.Conclusions. In our sample of elderly patients with aortic stenosis, replacing the aortic valve with a Hancock II bioprosthesis resulted in improved hemodynamics and quality of life.

Background Education in health policy and advocacy is recognized as an important component of health professional training. To date, curricula have only been assessed at the medical school level. Objective We sought to address the gap in these curricula for residents and other health professionals in primary care. Innovation We created a health policy and advocacy curriculum for the VA Connecticut Healthcare System, Center of Excellence in Primary Care Education, an interprofessional, ambulatory-based, training program that includes internal medicine residents, nurse practitioner fellows, health psychology fellows, and pharmacy residents. The policy module focuses on health care finance and delivery, and the advocacy module emphasizes negotiation skills and opinion-based writing. Trainee attitudes were surveyed before and after the course, and using the Wilcoxon signed rank test, relative change was determined. Knowledge acquisition was evaluated with precourse and postcourse examinations using a paired sample t test. Results From July 2011 through June 2013, 16 trainees completed the course. In the postcourse survey, trainees demonstrated improved comfort with understanding health law and the American health care system (Likert mean increased from 2.1 to 3.0, P = .01), as well as with associated advocacy skills (Likert mean increased from 2.0 to 2.9, P = .04). Knowledge-based test scores also showed significant improvement (increasing from 55% to 78% correct, P ≤ .001). Conclusions Our curriculum integrating core health policy knowledge with advocacy skills represents a novel approach in postgraduate health professional education and resulted in sustained improvement in knowledge and comfort with health policy and advocacy.

Objective To gather qualitative data to elucidate the reasons for readmissions in a high-risk population of underserved patients. Design We created an instrument with 27 open-ended questions based on current interventions. Setting Yale-New Haven Hospital. Patients Patients at the Yale Adult Primary Care Center (PCC). Measurements We conducted semi-structured qualitative interviews of patients who had four or more admissions in the previous 6 months and were currently readmitted to the hospital. Results We completed 17 interviews and identified themes relating to risk of readmission. We found that patients went directly to the emergency department (ED) when they experienced a change in health status without contacting their primary provider. Reasons for this included poor telephone or urgent care access and the belief that the PCC could not treat acute illness. Many patients could not name their primary provider. Conversely, every patient except one reported being able to obtain medications without undue financial burden, and every patient reported receiving adequate home care services. Conclusions These high-risk patients were receiving the formal services that they needed, but were making the decision to go to the ED because of inadequate access to care and fragmented primary care relationships. Formal transitional care services are unlikely to be adequate in reducing readmissions without also addressing primary care access and continuity.

Objective: To evaluate the test characteristics of the urine dipstick as a screening tool for elevated serum creatinine in patients with uncontrolled diabetes mellitus in the emergency department (ED). Methods: Patients with diabetes over the age of 18 who presented to the ED for any complaint over a three-month study period were considered eligible for participation in this study. A finger-stick blood glucose of ≥250 mg/dL at triage was used to confirm the diagnosis of uncontrolled diabetes. After obtaining written consent, each patient had a urine dip performed and a chemistry panel drawn. Any level of proteinuria on the urine dip was considered to be a positive test. Based on the laboratory and clinical guidelines at our institution, renal insufficiency was defined as creatinine concentration of greater than 1.3 mg/dL. Results: Three Hundred ninety-three confirmed patients with uncontrolled diabetes were enrolled in this study, and 49 of these (12.5%) were found to have renal insufficiency. The sensitivity and specificity of the urine dip for predicting renal insufficiency were 69.4% (95% confidence interval [CI] 54.6–81.7%) and 57.8% (95%CI 52.4–63.1%) respectively. The positive predictive value was 19% (95%CI 13.5–25.5%), and the negative predictive value was 93% (95%CI 88.7–96%). The positive likelihood ratio was 1.65 (95%CI 1.32–2.06) and the negative likelihood ratio was 0.53 (95%CI 0.34–0.81). Conclusion: In this cohort of patients with uncontrolled diabetes, the test characteristics of the urine dipstick make it a poor screening tool for renal insufficiency in the ED.