Does providing opiate maintenance therapy during incarceration increase participation in community treatment programs after release?

Objective: A question was posed on the Family Practice Inquiry Network "Does providing opiate maintenance therapy during incarceration increase participation in community treatment programs after release?"

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

Results: A 2017 meta-analysis of 8 RCTs, 5 secondary-analyses of RCTs, and 11 quasi-experimental studies evaluated the efficacy of MAT within prisons on patient oriented outcomes, specifically focusing on whether opiate maintenance therapy during incarceration increased participation in community treatment programs after release. Through this meta-analysis, it was demonstrated that incarcerated individuals treated with methadone were significantly more likely to participate in community treatment compared to those without treatment (4 trials, n=407. [OR] = 9.0; 95% CI = 2.5 – 31, Q = 6.3, I 2 = 68%).

Conclusions: Opiate MAT during incarceration does increase participation in community substance use treatment programs following release (SOR: A, meta-analysis of RCTs and quasi-RCTs).

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Development of Medical Spanish Curriculum in Primary Care Residency Program

Background: Language barriers contribute to racial and ethnic disparities in health outcomes for limited English proficiency patients, 66% of which speak Spanish. Language concordance between health care providers and patients improves communication and patient experience. The Northwestern McGaw Family Medicine at Humboldt Park residency serves patients at Erie Family Health Center in the Humboldt Park neighborhood of Chicago, where approximately 60% of patients are primarily Spanish speaking. The need for competent Spanish speaking providers here is evident.

Methods: A multidisciplinary taskforce was created consisting of residents, faculty, an administrator, and a Spanish interpreter. Literature review was performed on medical Spanish curricula for residents. Starting 7/1/2018, interventions for residents were identified including a two-week intensive medical Spanish course, four-week international or domestic immersion rotation, bi-monthly didactic self-study time, a validated interactive online medical Spanish curriculum, and real-time evaluation and feedback by on-site Spanish interpreter during clinic. Effectiveness of these interventions was determined by subjective resident surveys and OSCE examination.

Results: Following one year of participation in curriculum, residents identified a subjective improvement in medical Spanish proficiency. Residents found patient encounters the most valuable teaching resource. They also identified international immersion rotations and the intensive 2-week Spanish language orientation as valuable.

Conclusions:
Intensive orientation course, international electives and exposure to Spanish speaking patients are the most effective teaching tools. Ongoing curriculum development includes incorporating longitudinal Spanish language teaching into didactics and increasing accessibility of Spanish electives. Future directions include identifying an objective measure of Spanish proficiency to assess resident longitudinal improvement.

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Proficiency in Cervical Cancer Screening in Substance Use Disorder Patients vs Non-Substance Use Disorder Patients

Background: Patients with diagnosed substance use disorders (SUD) are more likely to suffer from inequitable access to primary care resources. While there are multiple factors that play into this fact, some of the most prominent involve patient concerns of stigmatization and provider discomfort with screening and management of SUD. Regardless of the reason, the question is raised of how these constraints affect SUD patients’ healthcare outcomes, specifically those deemed preventable? Many studies around the world have shown poorer cervical cancer screening rates and higher prevalence of cervical cancer/cervical dysplasia in SUD patients. Oddly, some of these same studies have shown higher rates of healthcare utilization by patients with SUD. This study aims to examine the rate of cervical cancer screening in females with diagnosed SUD compared to those without SUD within a Federally Qualified Health Center (FQHC).

Methods: This was a retrospective chart review utilizing Erie Health’s electronic medical record (EMR) system, Centricity. Participants were female patients over the age of 20 receiving their care at Erie Health. Inclusion criteria for SUD categorization included patients in this age range with a history of Alcohol Dependence, Opioid Abuse, Opioid Dependence or Other Psychoactive Substance Use. Patients without these diagnoses were placed in the non-SUD category. Exclusion criteria included any patient with documented diagnosis or history of cervical cancer.
Results: Using the discriminants above, 13,869 charts were pulled from the Erie EMR. Of these female patients, 97.8% did not have SUD and 2.2% did have SUD. Of the women without SUD, 75.5% had been screened for cervical cancer compared to 71.8% of women with SUD.

Conclusions: There was no statistically significant difference in screening rates for cervical cancer between females with and without SUD. Interestingly, there was a statistically significant difference in screening rates between females with SUD over age 40 versus those 40 and younger. The prevalence of female patients with SUD was also noted to be significantly lower than the national average (about 5-7%). However, overall cervical cancer screening rates were comparable to national statistics (about 74-76%). This bares the question of whether or not we as providers have been inefficiently screening for SUD or if we are simply doing a poor job at screening for cervical cancer amongst all of our female patients? Further limitations in this study include the scarce number of diagnosis codes used to categorize SUD patients. An additional data pull request was submitted to include patients with Cocaine and Opiate dependence/abuse as well as those patients with a history of cocaine, opiate or alcohol dependence in remission. The results of this new data request is still pending.

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In communities that offer a needle exchange program, does intravenous drug use increase?

Background: Intravenous drug use (IVDU) is associated with increased risk of HIV, Hepatitis C, and other blood-borne viruses, mostly because of the propensity of sharing needles between participants. A needle exchange program is a harm reduction intervention designed to decrease the risk of contracting HIV, Hepatitis C., etc, by allowing participants to receive clean, sterile needles in exchange for used ones. However, there is concern that needle exchange programs increase the amount of IVDU in the area and that they increase the time needed for participants to achieve cessation of IVDU. The purpose of this review was to identify the research on the effects of needle exchange programs on IVDU.

Methods: A literature review was conducted to identify studies on needle exchange programs and their effects on IVDU. Inclusion criteria were 1) observational studies 2) published between 2000 and 2018, 3) primary outcomes included injection cessation and/or injection frequency.

Results: Many studies were identified mentioning effects of IVDU, but only two listed rates of IVDU as primary outcomes. One study shows that 33% of patients using intravenous drugs (IVDs) reported substantially fewer injections at follow-up encounters compared to initial enrollment at NEP. Those injecting every day were significantly more likely to reduce injection frequency (ARR= 3.44, 95% CL 1.46–8.09) (SOR B: cohort study). Another study comparing needle exchange program expansion to IVDU patterns of the surrounding community showed that the proportion reporting injecting cessation increased from 2.4% (95% CI: 0.0–7.0%) in 1996 to 47.9% (95% CI: 46.8–48.9%, P < 0.001) in 2010 (SOR: B, cohort study).

Conclusions: Communities with needle exchange programs (NEP) do not have increased intravenous drug use (IVDU). In fact, they may help decrease injection frequency and decrease the time to cessation. Many needle exchange programs including the ones in the studies above have additional services, such as addiction counseling, medication-assisted therapy, and other resources to aid patients with addictions. It is possible that those extra resources beyond just needle exchange contributed to the decreased rates of injection frequency and increases drug cessation. Because of these positive changes, more money and resources should be dedicated to needle exchange programs.

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Comparing Artificial Intelligence to Routine Monitors in Neonatal Evaluation: The CARE Trial

Purpose: Neonatal respiration is a pivotal marker in routine neonatal care. Continuous monitoring of respiration is critical in detecting early changes in breathing pattern and avoiding worsening outcomes such as apnea, hypoxia, or sudden infant death syndrome (SIDS). Classically, neonatal respiration is monitored by echocardiography (ECG) leads attached to the chest wall to determine thoracic impedance with increasing voltage on inspiration and decreasing voltage on expiration. However, this measurement is not perfect as body positioning and movement, as well as incomplete skin adhesion, can decrease the accuracy of these measurements. Moreover, continuous adhesive can be irritating and damaging to the neonate. Non-contact respiratory rate monitoring, using camera vision and artificial intelligence, offers a less invasive method to record these values in real time.

Methods: In the IRB approved CARE Trial, neonates admitted to the Lake Forest Hospital Neonatal Intensive Care Unit (NICU) were monitored with a camera connected to an artificial intelligence algorithm for analysis while simultaneously recording the respiratory rate display from classical ECG recording.

Results: This recorded data is under further review and algorithm refinement to determine non-inferiority when compared to the ECG monitor with results expected Spring, 2021. Preliminary results indicate that the camera vision was able to identify a reliable rhythm. Correlation to the ECG recording is currently underway.

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Implementation of an Osteopathic Manipulative Treatment Curriculum in an Allopathic Family Medicine Residency

Background: With the single graduate medical education accreditation system and the rising number of osteopathic physicians in the United States, there is a need to increase education dedicated to osteopathic philosophy, principles, and specific treatments. 

Purpose: This curriculum, led by osteopathic resident physicians, aims to educate allopathic resident physicians on the osteopathic philosophy, anatomy, and introductory manipulation techniques through didactic lectures and hands-on workshops.

Methods: A 9-item pre-curriculum survey was developed to gauge familiarity and comfortability of osteopathic manipulative treatment among the family medicine allopathic and osteopathic residents. A three lecture and three workshop series was presented to the residents during the scheduled didactics time, where each session lasted about 45 minutes. After completion of the lectures/workshops, a post-curriculum survey was conducted and pre/post curriculum survey answers were compared using a Wilcoxon matched-pair sign rank test.

Results: A total of two osteopathic residents and eleven allopathic residents completed the pre-curriculum survey. At baseline, 42.6% of residents were either uncomfortable or very uncomfortable diagnosing musculoskeletal complaints using palpatory skills. Only 30.8% reported they were likely or extremely likely to use OMT for their patients. Pending completion of the curriculum, full results will be presented at research day.

Conclusion: Preliminary data suggest residents are interested in OMT learning opportunities, and the curriculum was well received. Full evaluation findings will be used to refine and improve curricular content in subsequent academic years.

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An Evaluation of Provider Continuity In Relation to Diabetic A1c Control

Purpose: While there is copious research on the benefits of continuity of care on diabetic control, there is minimal data on the role of provider alignment in diabetic outcomes. This study aims to examine the impact of consistent provider alignment on glycemic control in Type II diabetic patients.

Methods: We conducted a multi-site, retrospective cohort study. Patient data was extracted from the thirteen FQHC sites that comprise Erie Family Health Centers, in Chicago, Evanston and Waukegan, Illinois. 4,478 patients met the following inclusion criteria: a) diagnosis of Type II diabetes mellitus (non-pregnant and without active substance misuse disorder) receiving care between 2008 and 2017. Our chart review assessed: a) hemoglobin A1C value at the time the diagnosis of DM was first used as the billing code for an office visit and 36 months after this index visit and b) provider alignment, defined as the number of different medical providers the patients saw for office visits related to diabetes during the 36 months after the DM diagnosis was first associated with an office visit. This study was reviewed by the Northwestern University Institutional Review Board (00210813).

Results:  Analysis of covariance (ANCOVA) was conducted to determine whether patients’ most recent A1C values are related to provider alignment after controlling for baseline A1C values. The overall model was significant (F=531.9, p<.001, r2=0.33), however the fixed factor representing provider alignment was not a significant term (F=2099.79, p=0.821). Baseline A1C was a significant predictor (F=.306, p<.001, partial eta squared=.323), suggesting a stronger association with final A1C than provider alignment.

Conclusion: Our retrospective review of a cohort of type II DM patients receiving outpatient services at urban FQHCs demonstrated a descriptive relationship between provider continuity and glycemic control, however this association was not statistically significant. More research would be beneficial to refine our understanding of these variables, and to determine not only the impact of provider consistency on hemoglobin A1c but the overall impact on quality of life.

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Evaluation of a Novel Newborn Feeding Assessment Tool to Increase Resident Comfort and Skill in Providing Basic Breastfeeding Support to Patients

Purpose:  The American Academy of Family Physicians, along with the AAP, recommends that all babies, with rare exceptions, be exclusively breastfed for approximately six months and continue breastfeeding with appropriate complementary foods for at least one year. Family physicians are uniquely positioned to champion breastfeeding efforts, as we provide comprehensive care to the whole family. Despite the growing evidence of the health risks of not breastfeeding, family physicians do not often receive adequate training about supporting breastfeeding. 

Methods: Study design: Cross-sectional survey. Participants: Family medicine residents at Northwestern Family Medicine at Humboldt Park, Lake Forest and Delnor campuses. Measures: Outcomes were measured through quantitative and qualitative survey items.

Results: Data collection and review is currently underway, however preliminary results suggest that the implementation of a Newborn Feeding Assessment Tool did improve resident comfort and skill in providing basic breastfeeding support to patients. Survey results also did illustrate remaining knowledge gaps in the area of breastfeeding medicine which support the argument that one training session is not sufficient. Residents, and subsequently their patients, would benefit from a longitudinal curriculum for breastfeeding medicine. 

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The Impact of a Structured Inpatient Medicine Curriculum on Volume of Formal Teaching and Resident Satisfaction

Background: Resident education takes place in a variety of settings and through myriad modalities.  At one academically-affiliated, community-based Family Medicine residency program, residents identified the Adult Inpatient Medicine rotation as an area of the curriculum with the most potential for improvement.  In the spirit of continued improvement, one proposed solution was a formal curriculum structured into the typical day on service as a way to limit barriers to teaching that had been identified by residents.  This project was intended to evaluate impact of a structured inpatient medicine teaching curriculum on the level of satisfaction of these Family Medicine residents regarding teaching on the Inpatient Medicine service.  Furthermore, the project will evaluate the contact time the residents spend in a structured teaching setting and if a formal curriculum affects this amount.
 
Methods: This was a cross-sectional study conducted over the course of Academic Year 2019-2020 and was extended to December of Academic Year 2020-2021 in light of curriculum interruptions in the setting of the COVID-19 pandemic.  Participants consisted of former and current Family Medicine residents at the McGaw Northwestern Lake Forest Family Medicine residency program.  Surveys were administered before and after the implementation of a structured curriculum.  The main outcome measures were time spent in a formal teaching setting and resident attitudes toward a formal teaching curriculum.
 
Results: A total of n=22 residents completed the pre-curriculum survey and n=10 completed the post-survey.   Of all residents who participated in at least one of the surveys, only 4.5% of respondents reported spending at least 30 minutes per week participating in formal teaching, compared to 83% of respondents at the time of the post-survey.  Likewise, after the implementation of the curriculum 70% of all respondents reported participating in 4-5 formal teaching sessions per week compared to 0% in the pre-implementation survey.

The Wilcoxon signed rank test was used to gauge improvement among matched pre/post pairs among the following domains: learning high yield topics (z=1.73, p=.083, n=6), sense of enhanced education (z=1.89, p=.059, n=6), improving skills as a teacher (z=1.89, p=.059, n=6), and adequate teaching on the inpatient service (z=1.89, p=.059, n=6). Though results were not significant at the .05 alpha level threshold, several tests were approaching .05 and thus a larger sample may provide more power to detect significant differences.
 
Conclusion: The implementation of a formal, structured teaching curriculum during the Adult Inpatient Medicine service at one academically-affiliated community-based Family Medicine residency program resulted in an increase in both the number of formal teaching sessions that occurred each week and the contact time spent in a structured teaching setting.  Furthermore, a positive trend was observed for resident perspectives regarding the amount of teaching, learning the necessary high-yield topics, and overall enhancement in their education.

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A 10,000 Foot View: A Spanish Immersion and Clinical Global Health Experience for the Family Medicine Resident in Quito, Ecuador

Background: This presentation is a review of a 4-week Spanish immersion elective in Quito, Ecuador through Child and Family Health International (CFHI) and Northwestern University. 

Methods: Objectives include 1. Fostering local partnerships, 2. Improving healthcare access, and 3. Increasing Spanish language proficiency.  Time was spent providing direct care to patients in clinic and observation in family medicine, inpatient obstetrics, and a rural indigenous clinic.  Daily Spanish lessons and home-stay were integral to the program.

Results: Twenty-four patients were examined in clinic. The resident’s medical Spanish competency increased from baseline.  All learning objectives were met and as a summary, a checklist was developed to guide medical residents planning similar immersion rotations. 

Conclusions: Based on this experience, key considerations for success include: an emphasis on local-partnership, medical supervision, bioethics, and continuity of care. This case highlights the value of global medical education and helps providers serve patients in increasingly diverse settings. 

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Development of Medical Spanish Curriculum in Primary Care Residency Program

Background: Language barriers contribute to racial and ethnic disparities in health outcomes for limited English proficiency patients, 66% of which speak Spanish. Language concordance between health care providers and patients improves communication and patient experience. The Northwestern McGaw Family Medicine at Humboldt Park residency serves patients at Erie Family Health Center in the Humboldt Park neighborhood of Chicago, where approximately 60% of patients are primarily Spanish speaking. The need for competent Spanish speaking providers here is evident.

Methods: A multidisciplinary taskforce was created consisting of residents, faculty, an administrator, and a Spanish interpreter. Literature review was performed on medical Spanish curricula for residents. Starting 7/1/2018, interventions for residents were identified including a two-week intensive medical Spanish course, four-week international or domestic immersion rotation, bi-monthly didactic self-study time, a validated interactive online medical Spanish curriculum, and real-time evaluation and feedback by on-site Spanish interpreter during clinic. Effectiveness of these interventions was determined by subjective resident surveys and OSCE examination.

Results: Following one year of participation in curriculum, residents identified a subjective improvement in medical Spanish proficiency. Residents found patient encounters the most valuable teaching resource. They also identified international immersion rotations and the intensive 2-week Spanish language orientation as valuable.

Conclusions: Intensive orientation course, international electives and exposure to Spanish speaking patients are the most effective teaching tools. Ongoing curriculum development includes incorporating longitudinal Spanish language teaching into didactics and increasing accessibility of Spanish electives. Future directions include identifying an objective measure of Spanish proficiency to assess resident longitudinal improvement.

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An Evaluation of Provider Continuity In Relation to Diabetic A1c Control

Purpose: While there is copious research on the benefits of continuity of care on diabetic control, there is minimal data on the role of provider alignment in diabetic outcomes. This study aims to examine the impact of consistent provider alignment on glycemic control in Type II diabetic patients.

Methods: We conducted a multi-site, retrospective cohort study. Patient data was extracted from the thirteen FQHC sites that comprise Erie Family Health Centers, in Chicago, Evanston and Waukegan, Illinois. 4,478 patients met the following inclusion criteria: a) diagnosis of Type II diabetes mellitus (non-pregnant and without active substance misuse disorder) receiving care between 2008 and 2017. Our chart review assessed: a) hemoglobin A1C value at the time the diagnosis of DM was first used as the billing code for an office visit and 36 months after this index visit and b) provider alignment, defined as the number of different medical providers the patients saw for office visits related to diabetes during the 36 months after the DM diagnosis was first associated with an office visit. This study was reviewed by the Northwestern University Institutional Review Board (00210813).

Results:  Analysis of covariance (ANCOVA) was conducted to determine whether patients’ most recent A1C values are related to provider alignment after controlling for baseline A1C values. The overall model was significant (F=531.9, p<.001, r2=0.33), however the fixed factor representing provider alignment was not a significant term (F=2099.79, p=0.821). Baseline A1C was a significant predictor (F=.306, p<.001, partial eta squared=.323), suggesting a stronger association with final A1C than provider alignment.

Conclusion: Our retrospective review of a cohort of type II DM patients receiving outpatient services at urban FQHCs demonstrated a descriptive relationship between provider continuity and glycemic control, however this association was not statistically significant. More research would be beneficial to refine our understanding of these variables, and to determine not only the impact of provider consistency on hemoglobin A1c but the overall impact on quality of life.

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Facilitators and Barriers to Family Medicine Resident Engagement in Global Health: A Secondary Data Analysis of a CERA Study

Background: Interest in global health has been increasing over the years. Many family medicine residency programs have been incorporating abroad training opportunities for their residents. An analysis was done to identify facilitators and barriers to resident engagement in global health.

Methods: A secondary data analysis of a cross-sectional, national family medicine residency program director survey was conducted (CERA Survey PD-6). Data were obtained from the Council of Academic Family Medicine Educational Research Alliance (CAFM) data clearinghouse. The sampling frame for the survey was all ACGME accredited US family medicine residency program directors as identified by the Association of Family Medicine Residency Directors (AFMRD). This project was approved by the American Academy of Family Physicians Institutional Review Board.

Results: The overall response rate for the survey was 60.62% (274/452), and a total of n=257 (56.9%) answered questions related to global health. Seventy four percent of respondents indicated their program offered global health experiences. No significant differences were detected between university-affiliated and community-based programs in regards to the principle goal of the program in offering a global health experience. Both identified preparing physicians to practice underserved medicine and teaching community medicine or public health as primary goals. Resident engagement in global health activities was significantly correlated with faculty engagement in global health activities (r=.52, p<.01).  The most common type of preparation residents received prior to going abroad was individual mentoring. Funding and time restraints were identified as primary barriers to implementing global health programs.

Conclusions: For family medicine residency programs, resident engagement in global health activities is correlated with faculty engagement in global health activities. Further work should examine whether this correlation leads to more ethical collaboration in global health practices as increasing numbers of residents engage in global health.

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From Chaos to Coordination: Strategies for Implementing and Residency Team-based Complexity Care Model

Background: Providing effective primary care to complex patients is a critical component of an effective healthcare system, yet teams struggle to effectively manage these patients. There are emerging innovative models of complexity care that incorporate social determinants into biopsychosocial models of healthcare. These innovative models are in the beginning stages of evaluating best practices. Our model prioritizes the service-oriented education and training of resident physicians within a complexity care model. The purpose of this study is to evaluate the team process and patient outcomes of a residency-based complexity care initiative.

Method: Our protocol includes bi-monthly multidisciplinary case conference reviews for our high-risk patients. These patients are identified by Medical Home Network’s algorithm and provider identified complex patients. These patients are reviewed by the team using a risk assessment framework that focuses on the patient’s barriers and assets. Data is collected on patient characteristics and interventions, team attendance, and team communication. The individualized care plans are regularly reviewed.

Results:  Number of conferences, team members in attendance, patient characteristics, treatment plans, and team communication will be shared. Successful protocols, systemic obstacles and the evolution of our model will be discussed through a qualitative lens.

Discussion: Key stakeholders are engaged and committed to our case review process. Residents feel more prepared to treat complex patients. Case conferences are successfully used to generate treatment plans for the identified patients. Efficacy of these plans are still being evaluated. We have identified problems: duplicate documentation, lack of protected time, scheduling barriers, and inconsistent treatment plan implementation. 

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Implementation of an Osteopathic Manipulative Treatment Curriculum in an Allopathic Family Medicine Residency

Background: With the single graduate medical education accreditation system and the rising number of osteopathic physicians in the United States, there is a need to increase education dedicated to osteopathic philosophy, principles, and specific treatments. 

Purpose: This curriculum, led by osteopathic resident physicians, aims to educate allopathic resident physicians on the osteopathic philosophy, anatomy, and introductory manipulation techniques through didactic lectures and hands-on workshops.

Methods: A 9-item pre-curriculum survey was developed to gauge familiarity and comfortability of osteopathic manipulative treatment among the family medicine allopathic and osteopathic residents. A three lecture and three workshop series was presented to the residents during the scheduled didactics time, where each session lasted about 45 minutes. After completion of the lectures/workshops, a post-curriculum survey was conducted and pre/post curriculum survey answers were compared using a Wilcoxon matched-pair sign rank test.

Results: A total of two osteopathic residents and eleven allopathic residents completed the pre-curriculum survey. At baseline, 42.6% of residents were either uncomfortable or very uncomfortable diagnosing musculoskeletal complaints using palpatory skills. Only 30.8% reported they were likely or extremely likely to use OMT for their patients. Pending completion of the curriculum, full results will be presented at research day.

Conclusion: Preliminary data suggest residents are interested in OMT learning opportunities, and the curriculum was well received. Full evaluation findings will be used to refine and improve curricular content in subsequent academic years.

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An Evaluation of Provider Continuity In Relation to Diabetic A1c Control

Purpose: While there is copious research on the benefits of continuity of care on diabetic control, there is minimal data on the role of provider alignment in diabetic outcomes. This study aims to examine the impact of consistent provider alignment on glycemic control in Type II diabetic patients.

Methods: We conducted a multi-site, retrospective cohort study. Patient data was extracted from the thirteen FQHC sites that comprise Erie Family Health Centers, in Chicago, Evanston and Waukegan, Illinois. 4,478 patients met the following inclusion criteria: a) diagnosis of Type II diabetes mellitus (non-pregnant and without active substance misuse disorder) receiving care between 2008 and 2017. Our chart review assessed: a) hemoglobin A1C value at the time the diagnosis of DM was first used as the billing code for an office visit and 36 months after this index visit and b) provider alignment, defined as the number of different medical providers the patients saw for office visits related to diabetes during the 36 months after the DM diagnosis was first associated with an office visit. This study was reviewed by the Northwestern University Institutional Review Board (00210813).

Results:  Analysis of covariance (ANCOVA) was conducted to determine whether patients’ most recent A1C values are related to provider alignment after controlling for baseline A1C values. The overall model was significant (F=531.9, p<.001, r2=0.33), however the fixed factor representing provider alignment was not a significant term (F=2099.79, p=0.821). Baseline A1C was a significant predictor (F=.306, p<.001, partial eta squared=.323), suggesting a stronger association with final A1C than provider alignment.

Conclusion: Our retrospective review of a cohort of type II DM patients receiving outpatient services at urban FQHCs demonstrated a descriptive relationship between provider continuity and glycemic control, however this association was not statistically significant. More research would be beneficial to refine our understanding of these variables, and to determine not only the impact of provider consistency on hemoglobin A1c but the overall impact on quality of life.

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Same Day Antiretroviral Therapy Initiation in a Chicago Federally Qualified Health Center

Over the past few decades, HIV incidence in the Unites States has down trended. However, in recent years, reductions in new HIV cases have remained somewhat stagnant. Additionally, several parts of the country demonstrate disproportionately high HIV incidence including the southern United States having an estimated 52% of new HIV diagnoses in 2018. Similarly, HIV incidence rates that have historically affected non-Hispanic Black and Latinx patients are stably elevated; specifically Black and Latinx patients demonstrated rates of 42% and 27% of new diagnoses.  Populations in these areas are key demographics to benefit from efforts to reduce HIV incidence. In keeping with the aims of the current U.S. Ending the HIV Epidemic: A Plan for America initiative, efforts must continue to address the disparities in HIV acquisition in the Unites States. To address these disparities, investigations have been conducted and demonstrated new antiretroviral therapy (ART) regimens involving rapid initiation and linkage to care have shown promise in the campaign to reduce HIV incidence.

This study proposes that the newer same day start ART initiation strategy will achieve viral suppression faster than convention methodology and that it will improve HIV retention in care. This retrospective chart review study will review data from January 1, 2015-January 1, 2021 comparing rates of HIV suppression and retention in care at Erie Family Health Centers.

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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.

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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.

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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. 

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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.

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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.

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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.

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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.

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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.

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

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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.

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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.

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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.

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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.

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