Faculty Bibliography

The changing healthcare environment and movement toward team-based care are contemporary challenges confronting health professional education. The primary care workforce must be prepared with recent national interprofessional competencies to practice and lead in this changing environment. From 2012 to 2014, the weekly Beth Israel Deaconess Crimson Care Collaborative Student-Faculty Practice collaborated with Northeastern University to develop, implement and evaluate an innovative model that incorporated interprofessional education into primary care practice with the goal of improving student understanding of, and ability to deliver quality, team-based care. In the monthly interprofessional clinic, an educational curriculum empowered students with evidence-based, team-based care principles. Integration of nursing, pharmacy, medicine, and masters of public health students and faculty into direct patient care, provided the opportunity to practice skills. The TeamSTEPPS® Teamwork Attitudes Questionnaire was administered pre- and post-intervention to assess its perceived impact. Seventeen students completed the post-intervention survey. Survey data indicated very positive attitudes towards team-based care at baseline. Significant improvements were reported in attitudes towards situation monitoring, limiting personal conflict, administration support and communication. However, small, but statistically significant declines were seen on one team structure and two communication items. Our program provides further evidence for the use of interprofessional training in primary care.

PURPOSE:To characterize the first 10 years of intravitreal anti-vascular endothelial growth factor (VEGF) medication use for ophthalmic disease, including bevacizumab, ranibizumab, and aflibercept. DESIGN:A retrospective cohort study using administrative claims data from January 1, 2006 to December 31, 2015. SUBJECTS:Total of 124 835 patients 18 years of age or over in the United States. METHODS:OptumLabs Data Warehouse, which includes administrative claims data for over 100 million commercially insured and Medicare Advantage individuals, was used to identify patients receiving intravitreal anti-VEGF injections based on Current Procedural Terminology codes. MAIN OUTCOME MEASURES:Total and annual numbers of intravitreal anti-VEGF injections, as well as injections per 1000 enrolled patients per general category of ophthalmic disease, overall and for each available medication. RESULTS:There were 959 945 anti-VEGF injections among 124 835 patients from 2006 to 2015. Among all injections, 64.6% were of bevacizumab, 22.0% ranibizumab, and 13.4% aflibercept; 62.7% were performed to treat age-related macular degeneration (AMD), 16.1% to treat diabetic retinal diseases (including 0.9% of all injections that were for proliferative diabetic retinopathy), 8.3% to treat retinal vein occlusions, and 12.9% for all other uses. Use of bevacizumab and ranibizumab for AMD plateaued as of 2011/2012 and decreased thereafter (in 2006, 58.8 and 35.3 injections/1000 AMD patients, respectively; in 2015, 294.4 and 100.7 injections/1000), whereas use of aflibercept increased (1.1 injections/1000 AMD patients in 2011 to 183.0 injections/1000 in 2015). Bevacizumab use increased each year for diabetic retinal disease (2.4 injections/1000 patients with diabetic retinal disease in 2009 to 13.6 per 1000 in 2015) while that of ranibizumab initially increased significantly and then declined after 2014 (0.1 in 2009 to 4.0 in 2015). Aflibercept use increased each year in patients with diabetic retinal diseases and retinal vein occlusions (both <0.1 per 1000 retinal vein occlusion patients in 2011, 5.6 and 140.2 in 2015). CONCLUSIONS:Intravitreal injections of anti-VEGF medications increased annually from 2006 to 2015. Bevacizumab was the most common medication used, despite its lacking U.S. Food and Drug Administration approval to treat ophthalmic disease, and AMD was the most common condition treated. Ranibizumab use declined after 2014 while both the absolute and relative use of bevacizumab and aflibercept increased.

BACKGROUND:Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians--particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured. OBJECTIVE:We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws. RESEARCH DESIGN/METHODS:An observational study. SUBJECTS/METHODS:2013 Area Health Resource File (AHRF) and US Census Bureau county travel data. MEASURES/METHODS:The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC. RESULTS:We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations. CONCLUSIONS:Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains.