Faculty Bibliography

Background: The New York University (NYU) internal medicine residency program converted to block schedule in July 2015. Sixty-five NYU residents have their continuity clinic site at New York Harbor VA (VA). Here, we practice in the medical home model (termed PACT), with NYU residents divided into 3 PACT teams. When we implement block scheduling, we also developed team-based group practices within these PACTs. Cohorts of resident providers serve as coverage for their fellow PACT residents when they are busy with inpatient responsibilities. Methods: This study evaluates the impact of a scheduling change and the implementation of group practices among residents at the VA from April 2015-June 2016; we surveyed residents from Bellevue Hospital over the same period for comparison. We estimated the impact of interventions on the following clinical outcomes: hypertension control, diabetes control, smoking cessation rates, influenza vaccination rates, and age-appropriate cancer screening rates for patients empaneled in the VA residents' clinics by comparing FY2014 data to FY2016 data. For each outcome, we estimated changes using linear regression models. We also estimated the impact of the intervention on residents' perceptions of self-efficacy, knowledge, and clinic workload & coordination. These were measured by factor scores generated from confirmatory factor analysis of answers to 23 survey questions administered before and after the intervention. The confirmatory factor model fit the data well according to standard metrics (RMSEA = 0.00; NNFI = 1.0). Results: Influenza vaccination rates and hypertension control increased significantly during the study period. Change in the other outcomes-smoking cessation, mammogram screening, colorectal cancer screening, hypertension control and diabetes control-was in the predicted direction but not significant. In terms of changesin attitudes over the study period, we used linear regression models from three specifications-the full sample with no controls, the full sample with a control for cohort, and the paired sample of pre-and post-tests. We found that the intervention positively impacted residents' perceptions of clinic workload & coordination as well as their perceptions of relevant knowledge. The impact on self-efficacy is less clear, since the difference was only significant among the full sample, but not in the other two specifications. Conclusions: The transition to block scheduling and the creation of group practices within the VA resident clinics has had a positive impact both on resident attitudes towards VA clinic and on clinical outcomes. Specifically, residents' knowledge of clinic functioning and perception of clinic workload & coordination improved. We also saw statistically significant improvements in influenza vaccination rates and hypertension control and no worsening in tobacco cessation rates, diabetes control, or age-appropriate cancer screening rates. Thus, this change improved training and had an impact on health outcomes

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): Primary care providers need a way to formalize and simplify complicated follow-up instructions so patients can successfully navigate the health-care system in between visits with their doctor. OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): The individualized Electronic Primary Care Follow-up Plan is designed to maximize the efficiency and utility of face-to-face visits; encourage patient participation; and facilitate communication between the patient and health care team. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): Using the Veterans Affairs (VA) electronic medical record we designed a Follow-up Plan that translates physician follow-up orders into a single page, individualized instruction sheet for the patient to take home at the end of each primary-care visit. This templated note not only supplies the patient with an instruction tool; it also provides the physician with the convenience of ordering all referrals from one place. Physicians view a checklist of all possible relevant follow-up orders, expandable when prompted to offer additional, more specific options. For instance, if a physician orders imaging, a menu box of options appears with different imaging modalities; if a referral is required, a list of specialty clinics appears. The selected follow-up then automatically links to electronic orders. The final chart note pulls in only patient-relevant data. The patient leaves the primary care visit with a one-page personalized instruction sheet explaining how, when and why to accomplish each follow-up task. Checkout lines are minimized as patients no longer wait in line to schedule appointments. The note, which documents that patient communication took place with an electronic signature, remains in the medical record and can be consulted and reprinted at any time between visits by any member of Patient Aligned Care Team (PACT!

This article is designed for the general cardiologist, endocrinologist, and internist caring for patients with diabetes and coronary artery disease. Despite the burden of coronary disease in diabetics, little is known about the impact of commonly used oral hypoglycemic agents on cardiovascular outcomes. As the untoward effects of insulin resistance (IR) are increasingly recognized, there is interest in targeting this defect. Insulin resistance contributes to dyslipidemia, hypertension, inflammation, hypercoagulability, and endothelial dysfunction. The aggregate impact of this process is progression of systemic atherosclerosis and an increased risk of adverse cardiovascular outcomes. As such, much attention has been paid to the peroxisome-proliferator-activated receptor gamma (PPARg) agonists rosiglitazone and pioglitazone (thiazolidinediones [TZDs]). Many studies have demonstrated a beneficial effect on the atherosclerotic process; specifically, these agents have been shown to reduce markers of inflammation, retard progression of carotid intimal thickness, prevent restenosis after coronary stenting, and prevent cardiovascular death and myocardial infarction in 1 large trial. Such benefits come at the risk of fluid retention and heart failure (HF) exacerbation, and the net effect on plasma lipids is still poorly understood. Thus, the aggregate risk-benefit ratio is poorly defined. A recent meta-analysis has raised significant concerns regarding the overall cardiovascular safety of 1 particular PPARg agonist (rosiglitazone), prompting international debate and regulatory changes. This review scrutinizes the clinical evidence regarding the cardiovascular risks and benefits of PPARg agonists. Future studies of PPARg agonists, and other emerging drugs that treat IR and diabetes, must be designed to look at cardiovascular outcomes