Musculoskeletal Injury Visits at a University Health Center after the Formation of a Sports Medicine Clinic

Purpose:  University based health centers are used by students as both primary care offices and urgent care centers given their ease of access. Our study is aimed at evaluating the variety and percentage of musculoskeletal injury visits at a university based sports medicine clinic between the first year (2013-2014 academic year) and fifth year (2017-2018 academic year) of its creation.

Methods:  Study design: Retrospective chart review. Setting: Sports medicine clinic (NU Health Service) at Northwestern University in Evanston, IL. Source of data: Point N Click (PnC) electronic health record system. Method: Using PnC, a search of the clinical database was conducted to obtain diagnoses of patients seen at the sports medicine clinic for musculoskeletal injuries. Inclusion criteria: Patients enrolled as undergraduate or graduate students at Northwestern University, Evanston Campus, who were seen in the sports medicine clinic at any time during the 2013-2014 academic year (September 1, 2013 through August 31, 2014) and the 2017-2018 academic year (September 1, 2017 through August 31, 2018). Exclusion criteria: patients who were varsity student athletes at the time of their visit, subsequent clinic visits for the same musculoskeletal injury, clinical encounters for reasons other than a musculoskeletal injury. Demographics included the patient age range, median and average age, race, and sex. Descriptive statistics were performed for distribution of musculoskeletal injuries anatomical location and specific diagnoses.

Results:  During the 2013-2014 academic year, there were 1,549 unique patient encounters for new musculoskeletal injuries or conditions. Patient age ranged from 16 to 65 with a median of 22 years and mean of 24.21 years and 45.1% identified as female while 54.9% identified as male. Ankle/foot (28.0%), knee (16.3%), wrist/hand (14.4%), and shoulder injuries (9.6%) were seen with the highest frequency.  During the 2017-2018 academic year, there were 2,080 unique patient encounters for musculoskeletal injuries or conditions. Patient age ranged from 18 to 64 with a median of 24 years and a mean of 24.80 years and 49.3% identified as female, 50.5% identified as male, and 0.1% were listed as unknown sex. Ankle/foot (23.3%), back (17.0%), knee (13.9%), and wrist/hand (12.8%) injuries were seen with the highest frequency.

Conclusions:  Between the 2013- 2014 academic year and the 2017- 2018 academic year, both the number of unique patient encounters for musculoskeletal injuries and the percentage of female patients increased, while the age range and mean remained similar between the two years. In addition, three of the top four diagnoses by injury location for both years included: ankle/foot, knee, and wrist/hand. This data describes the frequency and types of musculoskeletal injuries seen at a university health center, which may lead to improved knowledge and treatment strategies for health care providers practicing in similar clinical settings.

Evaluation of monthly nutrition based series, Food As Medicine (FAM), at a Federally Qualified Health Center (FQHC)

Purpose: Federally Qualified Health Centers engage the community to provide comprehensive health care and provide patient centered interventions to improve population health. This Food as Medicine Series is a partnership between the Erie Family Health Centers FQHC and the YWCA of Lake County, IL. This FAM series reviews basic nutritional concepts, including how macronutrients and phytonutrients influence physiology. Presentations and hands-on cooking demonstrations are conducted for a bilingual audience in English and Spanish. This study aimed to determine whether Food As Medicine was useful and applicable in learning about nutrition through hands-on cooking demonstrations and focused nutrition content.

Methods: Study design: Mixed methods quality improvement survey. Setting/Intervention: Monthly presentations with focused content and hands on cooking of prepared recipes conducted at full test kitchen in a FQHC. Participants: Community members, including FQHC patients and YWCA members. Measure/Main Outcome: Anonymous evaluation survey items assessing participation, cultural appropriateness of content, and reproducibility of recipes.

Results: Fourteen participants completed surveys. 100% of participants reported they learned nutrition information from the presentations. 78% of participants reported the nutritional information was very useful. 57% of participants reported they were very likely to make the recipes at home. Qualitative feedback indicates the series was well received.

Conclusion: Initial evaluation demonstrates increased utility and accessibility of community based nutrition information. More research is needed to determine the full impact of nutrition bases presentations on population health. Future research could examine the impact of community based nutrition on health outcomes, particularly chronic disease management.

Does scheduling a new PCP visit at the end of an ED visit increase the establishment of primary care?  Evaluating the effectiveness of a program providing PCP appointments at a nearby FQHC prior to discharge from a community hospital ED

As the healthcare system continues to face many challenges, physicians and others who work in healthcare are seeking ways to improve health outcomes while additionally cutting costs to the system at large. Many patients in the United States do not have a Primary Care Provider (PCP), due to lack of financial resources, lack of insurance, or simply not having established one for a number of reasons. Frequently as a result, patients present to the Emergency Department (ED) and end up with a diagnosis that does not require hospitalization but should be followed in the outpatient setting. Even those with a benign diagnosis are recommended to establish care with a PCP in order to attend to preventative care needs and any health issues that arise. To help facilitate the process of establishing care with a PCP after an ED visit, the Swedish Covenant Hospital (SCH) ED now can arrange follow up appointments for patients at Erie Family Health Centers just across the street. This study will analyze the effectiveness of this strategy and if eliminating logistical barriers by arranging appointments for patients results in increased compliance for PCP follow up. This retrospective chart review study reviewed patient data from August 1, 2018 through November 30, 2018 comparing follow up rates for patients who were given a referral for the Federally Qualified Health Center (FQHC) across the street versus those of patients given appointments at the same clinic on ED-discharge. This study shows that having an appointment prior to ED discharge significantly increases the likelihood of post-ED follow up. 

Mapping the Health Status of Prenatal Patients with Neighborhood Resources and Risks

With this study we aim to explore the relationship between disease and location with an underserved, primarily Latino population. Furthermore, we will investigate where patients with similar prenatal/delivery complications are geographical clustered to improve community outreach, access to care and resources, and identify the environmental obstacles to care (e.g. access to transportation, neighborhood crime rates, etc.). We are particularly focused identifying geographic regions where there are high rates of common prenatal and delivery complications. We studied pregnant patients who have been seen at Erie Health Centers who have been seen between February 2017 - October 2019. We specifically pulled information regarding patient demographics, pregnancy complications, and delivery complications. By aggregating the data from the clinic’s electronic medical records system, we hope to identify neighborhoods where there are high concentrations of prenatal patients with common pregnancy complications who are patients at this health center. This information will be helpful targeting specific community outreach, community resources, and increasing awareness of the relationship between health status and location.

Complexity in Primary Care: Evaluation of Team-Based Complexity Care

Providing effective care to complex patients within primary care is a critical component of a healthcare system that addresses the goals of the quadruple aims. Yet, teams struggle to effectively identify and manage these patients. While there are a variety of models of complexity that incorporate social determinant of health into biopsychosocial models of complexity, few of these models have been adapted to educational and service oriented goals of a primary care residency clinic.

Goals: The purpose of this study is to evaluate the team process and patient outcomes of a residency specific-complexity care initiative. We will describe the structure, process, resources and evaluation of a bimonthly multidisciplinary case conference in a Family Medicine residency clinic. This clinic incorporates foundational concepts from population health and complexity care to both improve care for complex patients and increase resident knowledge of and ability to identify and care for complex patients. We will also evaluate the team process and the patient outcomes.

Design: This is a quality improvement project—PDSA design.

Participants: The complexity care team participants will include 8-16 R2 and R3 Family Medicine residents, 2-3 Family Medicine attendings, 1-2 nurses, 1-2 medical assistants, 1-2 behavioral health providers, and 1-2 care managers.

Measurements: Teamwork survey; patient characteristics and outcomes, including number of diagnoses, number of providers, number of behavioral health visits, number of health education visits, number of care management touch points, number of ED visits, and age.

Protocol: Our protocol includes bi-monthly multidisciplinary case conference review for patients who have been identified from MHN’s (Medical Home Network) ED patient visit algorithm and provider identified complex patients. During each session, the multiprofessional team reviews complex patient issues (medical, systems, and social determinant), barriers, and assets. The team then creates and documents strategies to address those issues through coordinated treatment plans.

Results: We will generate process improvement measures on the number of conferences, team attendance, quality of team communication, and resident confidence in caring for complex patients in a team based setting. We will also describe patient characteristics and outcomes (including number of diagnoses, number of providers, number of behavioral health visits, number of health education visits, number of care management touch points, number of ED visits, and age). We will focus on analyzing teamwork responses, describing characteristics of reviewed patient care, and identify structural and systemic obstacles in implementing this model. The results will help identify the organizational structures, team communication and patient care strategies and recommendations that support complexity care initiatives in medical residencies.

Supporting Development of Comprehensive Family Planning Curriculum in a Family Medicine Training Program

Purpose: Travel and transportation can pose significant barriers to care for many patients seeking abortion services, and these barriers disproportionately impact rural and suburban patients. Distant referrals may place undue stress on already vulnerable patients to travel elsewhere for treatment well within the scope of Family Medicine. Given that abortion care is often stigmatized, many providers will not openly advertise their service. As a result, limited objective data exist to demonstrate the capacity/need for local abortion services.

Methods: Study design: Cross-sectional survey. Participants: OB/GYN physicians and family medicine residents providing care to women of reproductive age at a large academic medical center. Measures: Outcomes were measured through quantitative and qualitative survey items.

Results: Data collection is currently underway, however preliminary results show gaps in available resources for abortion services within our sample. A majority of respondents refer to locations that may pose a geographic barrier to patients. Survey responses suggest family medicine residents are well positioned to meet the need for additional services to better care for vulnerable patients. Additional findings will be presented at research day.

Realizing the full potential of maps and spatial analysis for a community health center – a qualitative approach.

Context:  In underserved communities, location is a well-recognized factor influencing health. Geographic information systems (GIS) permit the generation of maps and spatial analyses of a wide array of biological and social determinants of health and have historically enabled some successful public health interventions. However, evidence is sparse regarding sustained use of GIS-based population health strategies at the community health center (CHC) level. In primary care, the full analytical potential of GIS has yet to be realized. Objective: Main objective is to understand how stakeholders in a CHC and its surrounding community would use maps and spatial analytics in their work. Additionally, measure organizational capacity for technology adoption. Human Subjects Review: IRB exemption submission pending.

Design:  Qualitative study. Setting: 1 federally qualified health center (FQHC); the surrounding urban, underserved community. Participants will include the practitioners and leadership at the FQHC, its patients, and surrounding community-based organizations.

Intervention/Instrument:  Interviews, focus groups, and validated surveys that measure organizational capacity for adopting new technologies, i.e. innovative capacity. All interviews and focus groups will begin with a shared prompt - maps highlighting hotspots for chronic diseases, maternal and infant morbidity and mortality, and social determinants of health.

Main and Secondary Outcome Measures:  The main outcome measure will be themes identified from interviews and focus groups about strategies for incorporating GIS.

Secondary Outcome:  Innovative capacity scores.

Anticipated Results: Themes may include the use of spatial analyses to address local hazards to public health, to automate the identification of accessible health promoting resources, and to support community development and advocacy work, etc. This CHC will likely score highly in innovative capacity.

Conclusions: Sustainable use of GIS and spatial analysis to inform CHC service delivery and development can be limited by time, expense, and expertise. By posing the question of strategy to diverse stakeholders, our research may highlight future directions for development of GIS-based health tools and discern whether adoption lag owes more to a paucity of actionable ideas, funding, or low innovative capacity all the while simultaneously augmenting organizational change management resources as a product of the interchange.

Supporting Development of Comprehensive Family Planning Curriculum in a Family Medicine Training Program

Purpose: Travel and transportation can pose significant barriers to care for many patients seeking abortion services, and these barriers disproportionately impact rural and suburban patients. Distant referrals may place undue stress on already vulnerable patients to travel elsewhere for treatment well within the scope of Family Medicine. Given that abortion care is often stigmatized, many providers will not openly advertise their service. As a result, limited objective data exist to demonstrate the capacity/need for local abortion services.

Methods: Study design: Cross-sectional survey. Participants: OB/GYN physicians and family medicine residents providing care to women of reproductive age at a large academic medical center. Measures: Outcomes were measured through quantitative and qualitative survey items.

Results: Data collection is currently underway, however preliminary results show gaps in available resources for abortion services within our sample. A majority of respondents refer to locations that may pose a geographic barrier to patients. Survey responses suggest family medicine residents are well positioned to meet the need for additional services to better care for vulnerable patients. Additional findings will be presented at research day.

Undefeating the Defeated: The Empathic Modeling and Evolution of Social Defeat

Utilization of the Neighborhood Navigator tool in Clinical Practice

Purpose: Neighborhood Navigator (NN) is a tool designed through the AAFP to help clinicians identify social resources for patients and provide them with access to said resources. This study aimed to determine resident attitudes and impressions of its use in point-of-care settings in clinical practice.

Methods: Over the course of a 3 month trial period, PGY1, 2, and 3 residents were tasked with identifying 10 patients who would benefit from additional social resources available through NN and offer these to the patient (the agencies independently contacted the patients via phone or email). The trial included all resident-training clinical sites: Erie HealthReach Waukegan Health Center (a Federally Qualified Health Center), Northwestern Medicine Family Medicine Grayslake Outpatient Center, and Northwestern Medicine Lake Forest Hospital. At the conclusion of the trial period, the residents participated in a survey featuring both Likert scale and free response questions to assess usability and impressions of the tool in clinical practice.

Results: 11 of 24 residents responded to the survey. 63.6% felt “neutral” on the ability of NN to facilitate conversations with patients. 90.9% “disagreed” or “strongly disagreed” that NN was easily incorporated into a clinical encounter. 27.3% “agreed” that they would continue to use NN in future clinical encounters. 54% of referrals came from the Waukegan site and 40% from the Grayslake site; mental health represented the largest single category at both sites (27% and 23%, respectively)

Conclusions: A majority of residents did not feel that the NN facilitated conversations with patients, with a still-larger majority expressing that the tool was not easily incorporated into clinical encounters. Providing clinicians with resources is just the first step in better addressing social determinants of health in patient care.

For Patients with Nonischmeic Heart Failure, are Statins Indicated for the Prevention of Sudden Cardiac Death

Objectives: A question was posed on the Family Practice Inquiry Network "are statins indicated for the prevention of sudden cardiac death in patients with heart failure without coronary artery disease"

Methods: A literature search was performed using the research support of Northwestern Galter Library support staff.

Results: Early (2004) observational trials suggested survival benefit for patients with nonischemic heart failure taking statins as well as a modest but not significant benefit for prevention of sudden cardiac death. A 2017 meta-analysis of randomized controlled trials included 8 trials which evaluated the effect of statins on sudden cardiac death. Of these 8 trials, only one trial, the GISSI-HF trial, specifically included patients with nonischemic heart failure. This 2008 trial of 4574 patients found that SCD occurred more often in those patients taking statins (n = 220, 9.6%) compared with the control group (n=196, 8.6%), although in adjusted analyses there was no significant difference between groups (adjusted hazard ratio (aHR) 1.12, 95% CI 0.92-1.36).

Conclusion: Although previous observational studies have suggested a survival benefit for heart failure patients taking statin therapy, high quality RCTs have failed to reproduce this effect.

A Pilot Curriculum of Bioethics Education for Family Medicine Residents

Objectives/Introduction:  Studies consistently show that a medical ethics curriculum in residency is useful and beneficial to the training and growth of an ethical competent physician. There is currently no medical ethics curriculum at Northwestern McGaw Family Medicine Residency at Lake Forest. This project aims to introduce a pilot curriculum to the program and assess its impact on the education and training of the residents. Goals of the curriculum are for the residents to be familiar with basic concepts in medical ethics and familiarize them with a framework of how to identify and navigate ethical problems in medical practice.

Research Question:  How effective is a pilot bioethics curriculum (consisting of a hybrid of lectures and case discussions) on the knowledge, confidence, and skill of family medicine residents to identify and navigate ethical problems of decision making capacity and informed consent.

Primary Outcome:  Resident performance on the post curriculum knowledge assessment.

Secondary Outcome: Perceived confidence in identifying and assessing ethical issues around decision making capacity and informed consent.

Methods:  The study group will consist of first, second, and third year family medicine residents at Northwestern Family Medicine at Lake Forest. Prior to the start of the pilot curriculum, a pre-test knowledge assessment will be administered to the residents. The pilot curriculum will consist of three sessions consisting of lecture presentations and case discussions. A post-test knowledge assessment feedback survey will be distributed upon completion of the lecture and presentation curriculum in order to assess the primary and secondary outcomes. Outcomes of the knowledge assessments will be compared using statistical analysis. 

Results:  Pending

Conclusion:  The project will seek to answer if the pilot curriculum design and content was effective in expanding the knowledge and confidence of the family medicine residents with regards to identifying and navigating ethical problems in practice. Depending on the results and feedback the pilot curriculum can be expanded to cover more topics over time. The study can be further strengthened by using a family medicine program that does not have an ethics curriculum as a control.

Focused Negotiating Cultural and Religious Difference

An emerging body of literature on what professional health care chaplains do identifies involvement in medical decision making and goals of care conversations as a key component of this role. In addition to several published articles documenting the frequency of chaplain involvement in medical decision making, a recent national survey of board-certified chaplains described and measured the discrete activities included in that role and discussed chaplains’ perception of their contribution to medical decision making as members of the health care team. To augment this knowledge, a book of case studies was proposed. The need for a robust body of case studies for the profession of healthcare chaplaincy has been effectively established by leaders in research and education. Case studies highlighting and reflecting upon the specific role of chaplains in medical decision making, however, are virtually non-existent to date.

The book will focus specifically on cases where the chaplain had a key role in supporting patients and families in the medical decision making process. Participation in this project was solicited as part of a national survey of board-certified chaplains. Guidelines for submitting a summary of a case were provided to potential authors who identified themselves as interested at the end of the survey. The editorial team reviewed submissions and issued invitations to nine chaplains to expand their summaries into case studies. The categorization for the case studies emerged from qualitative analysis of data from the larger research project and from close reading of the case summaries submitted for possible inclusion. The structure for this volume categorized case studies into three parts each part followed by a chaplain respondent and a non-chaplain respondent selected for their expertise in the category of cases.

This book has the potential to be foundational to the training of chaplains as well as to future research on the effectiveness of chaplaincy care, specifically in the area of how chaplains support the emotional processing of decision making, serve as a bridge and translator with the medical team, and integrate the patient’s story, religious beliefs, and values into the medical decision making process.

My response to the three cases, focused on negotiating cultural and religious differences, discussed a metaphysical framework of understanding language and normative trajectories. I highlight through the cases how chaplains serve as cultural brokers and interpreters between the patient/family and medical team in the process of decision making.