Faculty Bibliography

BACKGROUND: Advanced ("open") access scheduling, which promotes patient-driven scheduling in lieu of prearranged appointments, has been proposed as a more patient-centered appointment method and has been widely adopted throughout the United Kingdom, within the US Veterans Health Administration, and among US private practices. OBJECTIVE: To describe patient and physician and/or practice outcomes resulting from implementation of advanced access scheduling in the primary care setting. DATA SOURCES: Comprehensive search of electronic databases (MEDLINE, Scopus, Web of Science) through August, 2010, supplemented by reference lists and gray literature. STUDY SELECTION: Studies were assessed in duplicate, and reviewers were blinded to author, journal, and date of publication. Controlled and uncontrolled English-language studies of advanced access implementation in primary care were eligible if they specified methods and reported outcomes data. DATA EXTRACTION: Two reviewers collaboratively assessed risk for bias by using the Cochrane Effective Practice and Organisation of Care Group Risk of Bias criteria. Data were independently extracted in duplicate. DATA SYNTHESIS: Twenty-eight articles describing 24 studies met eligibility criteria. All studies had at least 1 source of potential bias. All 8 studies evaluating time to third-next-available appointment showed reductions (range of decrease, 1.1-32 days), but only 2 achieved a third-next-available appointment in less than 48 hours (25%). No-show rates improved only in practices with baseline no-show rates higher than 15%. Effects on patient satisfaction were variable. Limited data addressed clinical outcomes and loss to follow-up. CONCLUSIONS: Studies of advanced access support benefits to wait time and no-show rate. However, effects on patient satisfaction were mixed, and data about clinical outcomes and loss to follow-up were lacking.

OBJECTIVE: To evaluate the accuracy of a computerized clinical decision-support system (CDSS) designed to support assessment and management of pediatric asthma in a subspecialty clinic. DESIGN: Cohort study of all asthma visits to pediatric pulmonology from January to December, 2009. MEASUREMENTS: CDSS and physician assessments of asthma severity, control, and treatment step. RESULTS: Both the clinician and the computerized CDSS generated assessments of asthma control in 767/1032 (74.3%) return patients, assessments of asthma severity in 100/167 (59.9%) new patients, and recommendations for treatment step in 66/167 (39.5%) new patients. Clinicians agreed with the CDSS in 543/767 (70.8%) of control assessments, 37/100 (37%) of severity assessments, and 19/66 (29%) of step recommendations. External review classified 72% of control disagreements (21% of all control assessments), 56% of severity disagreements (37% of all severity assessments), and 76% of step disagreements (54% of all step recommendations) as CDSS errors. The remaining disagreements resulted from pulmonologist error or ambiguous guidelines. Many CDSS flaws, such as attributing all 'cough' to asthma, were easily remediable. Pediatric pulmonologists failed to follow guidelines in 8% of return visits and 18% of new visits. LIMITATIONS: The authors relied on chart notes to determine clinical reasoning. Physicians may have changed their assessments after seeing CDSS recommendations. CONCLUSIONS: A computerized CDSS performed relatively accurately compared to clinicians for assessment of asthma control but was inaccurate for treatment. Pediatric pulmonologists failed to follow guideline-based care in a small proportion of patients.

Background: Hospital discharge is a critical transition in care, yet recent data show much room for improvement: 1 in 5 patients experiences an adverse event or readmission within 30 days of discharge. Presently, metrics for the quality of discharge care are limited, and little is known about factors affecting the quality of hospital discharge from the perspective of physicians. Residents' perceptions are particularly important given their unique viewpoint of the discharge process as trainees and their role as primary care givers at teaching hospitals, which collectively provide 20% of all hospital care in the United States. Methods: We employed qualitative methods to describe the dischargeprocess from the resident's perspective and generate hypotheses about quality-limiting factors and key strategies for improvement through in-depth in-person interviews. We developed a purposeful sample of participants with attention to postgraduate year and experience in different hospital settings. Our study design included 2 internal medicine training programs-Yale and New York University (NYU)-to ensure a wide breadth of experiences. To date, we have completed 17 interviews with Yale residents and have begun enrollment at NYU. Interviews were professionally transcribed and independently coded by 2 investigators, and discrepancies were resolved by consensus. Thematic analysis was performed by a diverse research team using the constant comparative method. Results: We have analyzed interviews with 17 Yale residents to date: 10 (59%) were seniors (PGY-2 or PGY-3), 7 were interns (41%), and 10 were female (59%). Based on these interviews, we have identified 5 unifying themes representing factors perceived to limit the quality of discharge care: (1) competing priorities of timely versus thorough discharge, (2) lack of communication between discharge team members, (3) uncertainty about provider roles and patient readiness for discharge, (4) lack of standardization in discharge procedures, and (5) poor patient communication and postdischarge feedback. Representative excerpts from interview transcripts will be presented to illustrate conceptual variations of these quality-limiting factors as well as to support the overall consistency and robustness of each theme above. Conclusions: Quality-limiting factors identified by residents may generate hypotheses to develop novel quantitative measures of quality that are grounded in the experiences of physicians providing discharge care. Residents' insights on this topic may also help shape training and practice to improve the quality of discharge care at teaching hospitals