Addressing social determinants of health in primary care: a quasi-experimental study using unannounced standardised patients to evaluate the impact of audit/feedback on physicians' rates of identifying and responding to social needs
BACKGROUND:Although efforts are underway to address social determinants of health (SDOH), little is known about physicians' SDOH practices despite evidence that failing to fully elicit and respond to social needs can compromise patient safety and undermine both the quality and effectiveness of treatment. In particular, interventions designed to enhance response to social needs have not been assessed using actual practice behaviour. In this study, we evaluate the degree to which providing primary care physicians with feedback on their SDOH practice behaviours is associated with increased rates of eliciting and responding to housing and social isolation needs. METHODS:Unannounced standardised patients (USPs), actors trained to consistently portray clinical scenarios, were sent, incognito, to all five primary care teams in an urban, safety-net healthcare system. Scenarios involved common primary care conditions and each included an underlying housing (eg, mould in the apartment, crowding) and social isolation issue and USPs assessed whether the physician fully elicited these needs and if so, whether or not they addressed them. The intervention consisted of providing physicians with audit/feedback reports of their SDOH practices, along with brief written educational material. A prepost comparison group design was used to evaluate the intervention; four teams received the intervention and one team served as a 'proxy' comparison (no intervention). Preintervention (February 2017 to December 2017) rates of screening for and response to the scripted housing and social needs were compared with intervention period (January 2018 to March 2019) rates for both intervention and comparison teams. RESULTS:108 visits were completed preintervention and 183 during the intervention period. Overall, social needs were not elicited half of the time and fully addressed even less frequently. Rates of identifying the housing issue increased for teams that received audit/feedback reports (46%-60%; p=0.045) and declined for the proxy comparison (61%-42%; p=0.174). Rates of responding to housing needs increased significantly for intervention teams (15%-41%; p=0.004) but not for the comparison team (21%-29%; p=0.663). Social isolation was identified more frequently postintervention (53%) compared with baseline (39%; p=0.041) among the intervention teams but remained unchanged for the comparison team (39% vs 32%; p=0.601). Full exploration of social isolation remained low for both intervention and comparison teams. CONCLUSIONS:Results suggest that physicians may not be consistently screening for or responding to social needs but that receiving feedback on those practices, along with brief targeted education, can improve rates of SDOH screening and response.
Implementing an Experiential Telehealth Training and Needs Assessment for Residents and Faculty at a Veterans Affairs Primary Care Clinic [Case Report]
BACKGROUND/UNASSIGNED:The transition to telehealth during the COVID-19 pandemic revealed a lack of preexisting telehealth training for clinicians. As a workplace-based simulation methodology designed to improve virtual clinical skills, announced standardized patients (ASPs) may help meet evolving educational needs to sustain quality telehealth care. OBJECTIVE/UNASSIGNED:We describe the development and implementation of an ASP program to assess and provide feedback to resident and faculty clinicians in virtual practice, and report on performance, feasibility, and acceptability. METHODS/UNASSIGNED:From June 2021 to April 2022, resident and faculty clinicians at a VA primary care clinic participated in a video visit in which an ASP portrayed either a 70-year-old man with hearing loss and hypertension or a 60-year-old man with hypertension and financial stress. Following the visit, ASPs provided verbal feedback and completed a behaviorally anchored checklist to rate telehealth and communication skills, chronic disease management, and use of resources. Domain summary scores were calculated as the mean percentage of "well done" items. Participants completed a feedback survey on their experience. RESULTS/UNASSIGNED:Seventy-six televisits (60 primary care residents [postgraduate year 1-3], 16 internal medicine faculty) were conducted from August 2021 to April 2022. Clinicians performed well in communication skills: information gathering (79%, 60 of 76, well done), relationship development (67%, 51 of 76), education and counseling (71%, 54 of 76), and patient satisfaction (86%, 65 of 76). They performed less well in telemedicine skills (38%, 29 of 76). Participants agreed that the experience was a good use of their time (88%, 67 of 76). CONCLUSIONS/UNASSIGNED:An ASP-facilitated training for resident and faculty clinicians assessed telehealth skills and clinical practice and identified areas for intervention. Clinicians responded well to the training and feedback.
Educational training to improve opioid overdose response among health center staff: a quality improvement initiative
BACKGROUND:There were seven opioid overdoses in this New York City (NYC) federally qualified health center from December 2018 through February 2019, reflecting the rising rate of overdose deaths in NYC overall at the time. In response to these overdoses, we sought to increase the readiness of health center staff to recognize and respond to opioid overdoses and decrease stigmatizing attitudes around opioid use disorder (OUD). METHODS:An hour-long training focusing on opioid overdose response was administered to clinical and non-clinical staff of all levels at the health center. This training included didactic education on topics such as the overdose epidemic, stigma around OUD, and opioid overdose response, as well as discussion. A structured assessment was administered immediately before and following the training to evaluate change in knowledge and attitudes. Additionally, participants completed a feedback survey immediately after the training to assess acceptability. Paired t-tests and analysis of variance tests were used to assess changes in pre- and post-test scores. RESULTS:Over 76% of the health center staff participated in the training (N = 310). There were large and significant increases in mean knowledge and attitudinal scores from pre- to post-test (p < .001 and p < .001, respectively). While there was no significant effect of profession on attitudinal change scores, profession did have a significant effect on knowledge change scores, with administrative staff, non-clinical support staff, other healthcare staff, and therapists learning significantly more than providers (p < .001). The training had high acceptability among participants from diverse departments and levels. CONCLUSIONS:An interactive educational training increased staff's knowledge and readiness to respond to an overdose as well as improved attitudes toward individuals living with OUD. TRIAL REGISTRATION/BACKGROUND:This project was undertaken as a quality improvement initiative at the health center and as such was not formally supervised by the Institutional Review Board per their policies. Further, per the guidelines of the International Committee of Medical Journal Editors, registration is not necessary for clinical trials whose sole purpose is to assess an intervention's effect on providers.
Comparison of Primary Care Patients"™ and Unannounced Standardized Patients"™ Perceptions of Care
The objective of this study was to compare unannounced standardized patient (USP) and patient reports of care. Patient satisfaction surveys and USP checklist results collected at an urban, public hospital were compared to identify items included in both surveys. Qualitative commentary was reviewed to better understand USP and patient satisfaction survey data. Analyses included Ï‡2 and Mann-Whitney U test. Patients provided significantly higher ratings on 10 of the 11 items when compared to USPs. USPs may provide a more objective perspective on a clinical encounter than a real patient, reinforcing the notion that real patients skew overly positive or negative.
Understanding medical student paths to communication skills expertise using latent profile analysis
Purpose: To describe patterns of clinical communication skills that inform curriculum enhancement and guide coaching of medical students. Materials and methods: Performance data from 1182 consenting third year medical students in 9 cohorts (2011"“2019), on a 17-item Clinical Communication Skills Assessment Tool (CCSAT) completed by trained Standardized Patients as part of an eight case high stakes Comprehensive Clinical Skills Exam (CCSE) were analyzed using latent profile analysis (LPA). Assessment domains included: information gathering (6 items), relationship development (5 items), patient education (3 items), and organization/time management (3 items). LPA clustered learners with similar strength/weakness into profiles based on item response patterns across cases. One-way analysis of variance (ANOVA) assessed for significant differences by profile for CCSAT items. Results: Student performance clustered into six profiles in three groups, high performing (HP1 and HP2-Low Patient Education, 15.7%), average performing (AP1 and AP2-Interrupters, 40.9%), and lower performing profiles (LP1-Non-interrupters and LP2, 43.4%) with adequate model fit estimations and similar distribution in each cohort. We identified 3 CCSAT items that discriminated among learner"™s skill profiles. Conclusion: Clinical communication skill performance profiles provide nuanced, benchmarked guidance for curriculum improvement and tailoring of communication skills coaching.
Using Latent Profile Analysis to Describe and Understand Medical Student Paths to Communication Skills Expertise
Using Latent Profile Analysis to Describe and Understand Medical Student Paths to Communication Skills Expertise
Does it get better? An ongoing exploration of physician experiences with and acceptance of telehealth utilization
INTRODUCTION/BACKGROUND:COVID-19 forced health systems to rapidly implement telehealth for routine practice, often without sufficient training or standards. We conducted a longitudinal survey of physicians to explore changes in their perceptions of the challenges and benefits of telehealth and identify recommendations for future practice. METHODS:An anonymous online survey was distributed to a cohort of internal medicine physicians in May to June 2020 and March to June 2021. Changes in responses between 2020 and 2021 and by site (private vs. public) were described. These findings, along with those of a thematic analysis of open-ended responses to questions on telehealth experiences, informed a set of recommendations. RESULTS:â€‰=â€‰0.027). Physicians' open-ended responses identified recommendations for further improving the design and use of telehealth. DISCUSSION/CONCLUSIONS:Results suggest that physician experience with telehealth improved but opportunities for training and improved integration remain. Longitudinal assessment can deepen understanding of the evolution of telehealth care.
A novel simulation-based approach to training for recruitment of older adults to clinical trials
BACKGROUND:The need to engage adults, age 65 and older, in clinical trials of conditions typical in older populations, (e.g. hypertension, diabetes mellitus, Alzheimer's disease and related dementia) is exponentially increasing. Older adults have been markedly underrepresented in clinical trials, often exacerbated by exclusionary study criteria as well as functional dependencies that preclude participation. Such dependencies may further exacerbate communication challenges. Consequently, the evidence of what works in subject recruitment is less generalizable to older populations, even more so for those from racial and ethnic minority and low-income communities. METHODS:To support capacity of research staff, we developed a virtual, three station simulation (Group Objective Structured Clinical Experience-GOSCE) to teach research staff communication skills. This 2-h course included a discussion of challenges in recruiting older adults; skills practice with Standardized Participants (SPs) and faculty observer who provided immediate feedback; and debrief to highlight best practices. Each learner had opportunities for active learning and observational learning. Learners completed a retrospective pre-post survey about the experience. SP completed an 11-item communication checklist evaluating the learner on a series of established behaviorally anchored communication skills (29). RESULTS:In the research staff survey, 92% reported the overall activity taught them something new; 98% reported it provided valuable feedback; 100% said they would like to participate again. In the SP evaluation there was significant variation: the percent well-done of items by case ranged from 25-85%. CONCLUSIONS:Results from this pilot suggest that GOSCEs are a (1) acceptable; (2) low cost; and (3) differentiating mechanism for training and assessing research staff in communication skills and structural competency necessary for participant research recruitment.
The Telemedicine Takeover: Lessons Learned During an Emerging Pandemic