Faculty Bibliography

OBJECTIVE: Food label use is associated with better food choices, an essential part of the management of many chronic diseases. Previous studies suggest lack of comprehension of food labels. We studied a multimedia intervention to improve food label comprehension in a sample of low income patients in New York City. METHODS: This randomized study took place at Gouverneur Healthcare Services from 2005 until 2007. The intervention group (n=29) received a Nutrition Facts Label pocket card and viewed a video explaining card use. The control group (n=27) received written materials. Participants completed a 12-item pre- and post-intervention nutrition food label quiz. Quiz scores were analyzed using repeated measures analysis of variance. RESULTS: The intervention group had greater improvement on the quiz than the control group (p<0.001). There was a three way interaction by time with health literacy and treatment group where the greatest improvement occurred in patients with adequate health literacy in the intervention group (p<0.05). There was no improvement in patients with limited health literacy. CONCLUSION: A multimedia intervention is an effective way to improve short-term food label comprehension in patients with adequate health literacy. Further research is necessary to improve understanding of food labels in patients with limited health literacy

Research Objective: For a subset of fee-for-service Medicaid patients with frequent hospital admissions, contact with the health care system remains acute and episodic at high cost to Medicaid, while less costly outpatient primary and preventive care services are underutilized. Previous work validated the accuracy of a predictive case-finding algorithm to identify complex Medicaid patients at risk for future high costs who might benefit from more intensive services, and identified remediable risk factors such as substance use, homelessness, and lack of social support associated with frequent hospital admissions. We aimed to pilot an intervention for a limited number of high-cost patients to address unmet health and social needs in both the hospital and community, to improve care while reducing hospital admissions and associated costs in this population. Our intention was to expand the program based on pilot success. Study Design: Community and hospital-based care management intervention with process and implementation evaluation, and pre-post cost analysis. Eligible patients were offered intervention enrollment during an admission to an urban public hospital. Patients underwent in-depth psychosocial interviews by study social workers to identify immediate and long-term needs such as housing, primary care, transportation to and advocacy during appointments, medication management, entitlements enrollment, improved connections to psychiatric and substance use treatment, and home visits. Patients who met criteria for chronic homelessness were evaluated in-hospital by a community-housing partner who initiated housing applications based on a housing first model. Pre-paid cell phones were provided to patients when needed to maintain close contact with study staff for reminder calls and crisis management. Study staff worked closely with inpatient providers to facilitate appropriate discharge planning and follow-up. Population Studied: Consecutive English-speaking Medicaid fee-for-service patients aged 18-64 identified as high-cost and high-risk for readmission in the following 12 months by a validated predictive case-finding algorithm. Principal Findings: Over the past year, 19 patients have enrolled. 100% are male. 17/19 were chronic substance users at enrollment. 5/19 were lost to follow-up. Of the remaining patients, 8 met criteria for chronic homelessness that would facilitate expedited placement into permanent housing. Of these 8, 2 were placed in nursing homes and 2 died. The remaining 4 chronically homeless patients are now in transitional or permanent housing. Hospitalizations and ED visits have decreased, while establishment of an outpatient medical home has increased. Comparing the 9-12 months after the intervention to the 12 months before intervention revealed a decrease in average monthly inpatient Medicaid costs per patient ranging from $1205-$2881. This resulted in an average annual inpatient cost reduction from $14,464 to $34,568.52. Prior research indicates without intervention, Medicaid costs for these patients in the following 12 months will increase. Conclusion: A pilot intervention to improve care for medically, socially complex high-cost Medicaid patients shows savings to Medicaid and decreased hospitalizations and ED visits by addressing issues that are challenging for the traditional health care system to manage. Implications for Policy, Delivery or Practice: Our model will be expanded to serve a greater number of patients across additional hospitals to determine if the success of our pilot can be replicated, and will include a more detailed cost analysis. Funding Source(s): The United Hospital Fund

PURPOSE: To assess 23 years of Health Resources and Services Administration (HRSA) Title VII Training in Primary Care Medicine and Dentistry funding to the New York University School of Medicine/Bellevue Primary Care Internal Medicine Residency Program. The program, begun in 1983 within a traditional, inner-city, subspecialty-oriented internal medicine program, evolved into a crucible of systematic innovation, catalyzed and made feasible by initiatives funded by the HRSA. The curriculum stressed three pillars of generalism: psychosocial medicine, clinical epidemiology, and health policy. It developed tight, objectives-driven, effective, nonmedical specialty blocks and five weekly primary care activities that created a paradigm-driven, community-based, role-modeling matrix. Innovation was built in. Every block and activity was evaluated immediately and in an annual, program-wide retreat. Evaluation evolved from behavioral checklists of taped interviews to performance-based, systematic, annual objective structured clinical examinations. METHOD: The authors reviewed eight grant proposals, project reports, and curriculum and program evaluations. They also quantitatively and qualitatively surveyed the 122 reachable graduates from the first 20 graduating classes of the program. RESULTS: Analysis of program documents revealed recurring emphases on the use of proven educational models, strategic innovation, and assessment and evaluation to design and refine the program. There were 104 respondents (85%) to the survey. A total of 87% of the graduates practice as primary care physicians, 83% teach, and 90% work with the underserved; 54% do research, 36% actively advocate on health issues for their patients, programs, and other constituencies, and 30% publish. Graduates cited work in the community and faculty excitement and energy as essential elements of the program's impact; overall, graduates reported high personal and career satisfaction and low burnout. CONCLUSIONS: With HRSA support, a focused, innovative program evolved which has already met each of the six recommendations for future innovation of the Alliance for Academic Internal Medicine Education Redesign Task Force. This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs

INTRODUCTION/AIMS: We designed an interactive web module to improve medical student competence in screening and interventions for hazardous drinking. We assessed its impact on performance with a standardized patient (SP) vs. traditional lecture. SETTING: First year medical school curriculum. PROGRAM DESCRIPTION: The web module included pre/posttests, Flash(c), and text didactics. It centered on videos of two alcohol cases, each contrasting a novice with an experienced physician interviewer. The learner free-text critiqued each clip then reviewed expert analysis. PROGRAM EVALUATION: First year medical students conveniently assigned to voluntarily complete a web module (N = 82) or lecture (N = 81) were rated by a SP in a later alcohol case. Participation trended higher (82% vs. 72%, p < .07) among web students, with an additional 4 lecture-assigned students crossing to the web module. The web group had higher mean scores on scales of individual components of brief intervention (assessment and decisional balance) and a brief intervention composite score (1-13 pt.; 9 vs. 7.8, p < .02) and self-reported as better prepared for the SP case. CONCLUSIONS: A web module for alcohol use interview skills reached a greater proportion of voluntary learners and was associated with equivalent overall performance scores and higher brief intervention skills scores on a standardized patient encounter