Faculty Bibliography

BACKGROUND: Patient experience is an important quality indicator, and healthcare organizations spend considerable resources assessing patient satisfaction. Yet a view of patient experience gleaned from patient satisfaction measures tends to show high levels of reported satisfaction, with little variation. Unannounced standardized patients (USPs) have been used to assess providers' clinical skills, but can also provide other information about the healthcare encounter. This study examined the concordance between USP and patient reports of care at the same site. METHODS: Data was gathered at Bellevue Hospital Primary Care Clinic, a city safety-net hospital. USPs assess internal medicine residents training there, and complete a behaviorally anchored checklist of resident skills and interactions with other staff, wait times, ease of clinic navigation, and perceptions of team functioning. Data from 155 USP visits from July 2015-Oct 2016 was used in this study. Independently, as part of team-training efforts in the Primary Care Clinic, patient satisfaction surveys were collected, addressing similar issues. At the end of a clinic visit, research assistants unrelated to patient care asked patients to complete a 30-item survey. 118 surveys were completed between July-November 2016. 11 items appeared on both scales (though worded slightly different) and were used in this comparison. These included questions about clerical (CA) and patient care associates (PCA), and providers (MDs, NPs, PAs), provision of information, team functioning and clinic environment. Of the 11 items, 4 had the same response choices. 7 had differing numbers of responses (eg 4 vs 3 point Likert scales), evenly distributed across patient and USP scales. For each of these items, we collapsed items so to maximize positive ratings (eg. on a 4 point scale from poor to excellent, "good" and "excellent" were combined rather than "good" and "fair"). Chi-square analyses were computed to examine group differences. RESULTS: On chi-square analyses, 9 of the 11 items significantly differed between the USP and patient groups, with patients more likely to have positive ratings. These included rating PCAs as friendlier (x² = 8.67(1,206), p = .003) and providers better at answering questions (x² = 11.75 (2,265), p = .003); reporting that they received sufficient/clear instructions about medication refills and follow-up (x² = 29.5(2,264), p = .0001); finding the clinic atmosphere calmer than did USPs (x² = 10.5 (2,265), p=.005) and noting that the team functioned better (x² = 7.31(2,268), p = .026). There were no significant differences in willingness to recommend the clinic or on clarity of CAs' communication. CONCLUSIONS: Results of this study document the differing perspectives of patients and USPs. Consistent with previous work, patients in our study tended to rate most items higher than did the USPs. USPs provide a different, and likely a more critical look at the clinical setting and this information can enhance efforts to improve patient experience. (Table Presented)

BACKGROUND: At Bellevue Hospital Center (BHC), we have a robust Unannounced Standardized Patient (USP) program, where trained actors portraying real patients in the clinical setting, incognito, assess the residents' skills following their visit. We sought to determine the relationship between USP ratings of residents' skills and clinical outcomes among the residents' continuity patient panels to define educationally sensitive patient outcomes. METHODS: We assembled a retrospective cohort of PGY 2 internal medicine residents with at least 2 USP visits between 7/1/14-6/30/15 and ambulatory care patient panels at BHC. The two outcome variables were the percentage of hypertensive patients in the residents' panel with blood pressure (BP) <140/90, and the average of the most recent glycosylated hemoglobin (HbA1C) result among the residents' patients with diabetes. The predictor variables included mean USP ratings of residents' clinical skills and mean faculty rating of the residents' clinic notes (scored for quality on a 0 to 3 scale). USPs used a behaviorally anchored checklist (not done, partly done, well done) for the following domains: communication, case specific assessment, patient education, physical examination, professionalism, management plan, patient satisfaction, and patient activation measure. We tested the correlations between USP scores with BP and HbA1C control, and then developed multivariate, linear regression models of USP scores on BP and HbA1C scores, respectively, each controlling for Avg. Chronic health score (ACHS, derived by scoring different clinical conditions by acuity and used to determine if the panel is getting sicker over time) and total number of patients in the panel (TNPP) because these variables were correlated with both the outcome and predictor variables. RESULTS: 29 PGY 2 residents had a mean of 2.5 (SD 1.0) USP visits during the study period. Residents' patient panels size varied (median 124, range 62- 171) and mean patient age was 48 years (SD 1.4). Patient Activation scores were correlated with Average Chronic Health Score (r = .482, p = .008) and Panel Average last A1c (r = -.311, p = .10). Patient activation scores explained 16% variance in the mean panel last HgA1c, (adjusted R2 .137, p = .08). Case specific Assessment & Patient Education skills across USP cases explained 21.5% of the variance and the Average Chart Note Score explained 14.4% of the variance in % of Hypertension controlled (adjusted R2.378, p < .009). CONCLUSIONS: This exploratory study suggests that learnable resident clinical skills are associated with quality of care indicators for HTN and DM control. In particular, being able to activate patients, assess and educate them and write high quality notes are pathways to quality care. Next steps are to confirm these findings in a larger dataset. Doing so will help align medical education with patient safety and care quality and provide guidance for educational and clinical research aimed at improving the health of populations served

BACKGROUND: Effective smoking cessation counseling improves smokers' health and quality of life. As part of our assessment program, an Unannounced Standardized Patient (USP) case was developed to measure residents' performance in a routine visit with a smoker. METHODS: The USP was a 40 year-old male new patient presenting with heartburn. He began smoking up to two packs/day at 22 years old; at the time of the visit, he reports having cut down to one pack/day and quitting cold turkey twice in the past only to return to smoking. If the resident engages him, he discusses his relationship with smoking and the possibility of quitting. TheUSP received 6 hours of character and checklist training to ensure standardized portrayal and evaluation. Data was collected using 2 forms of assessment: a post-visit USP checklist and a systematic review of the EMR (lab orders, prescriptions, and referrals). The 170- item USP checklist measured communication, patient education, assessment skills, and case-specific items. Each response option included descriptive behavioral anchors and was rated as not done, partly done, or well done. RESULTS: Data was examined from 73 USP visits from 2009-2015. Mean visit length = 37 min, SD = 15 min (range: 15 to 95 min). Overall communication scores ranged from 17 to 100% with an average of 62% (Cronbach's alpha = 0.75). All residents documented History of Tobacco Use or Tobacco Use Disorder in the EMR, and the majority (82%) prescribed smoking cessation medication. There was variation in the sophistication of smoking cessation-counseling approach. Whilemost residents (78%) discussed the risks of smoking and/or the benefits to quitting, significantly fewer (48%) explored the patient's view of the pros and cons of his smoking (p = 0.00). Residents who prescribed smoking cessation medication and discussed risks/benefits to smoking/quitting (N = 31) were compared to residents who did the same but also invited the patient to discuss his personal pros and cons of smoking (N = 29). Groups were not significantly different by PGY or gender. Patients who were asked to discuss their pros/cons rated the resident higher on patient activation questions (0-2 point scale), including "Helped you understand the importance of quitting smoking" (1.38 vs 0.90, p = 0.00), "Made you want to change your smoking" (1.10 vs 0.52, p = 0.00), and "Made you feel like you would be able to quit smoking" (1.07 vs 0.35, p = 0.00). There were no significant differences in labs ordered, referrals to a smoking cessation program, or quality of documentation. CONCLUSIONS: While all residents ask about tobacco use and most appropriately prescribe medication, fewer than half demonstrate the skills known to motivate patients to quit smoking. Curricula needs to reinforce the importance of a patient discussing their personal relationship with smoking in order to feel activated and willing to engage in cessation

BACKGROUND: Training residents to effectively practice value-based care is challenging. We hypothesized that residents with better communication skills would order fewer unnecessary tests and prescribe more appropriate care. We used a USP case of a patient with uncontrolled asthma to examine the relationship between value-based care and communication skills. METHODS: A 25 year-old female USP presented as a new patient to a medicine resident's clinic, reporting asthma since childhood with worsening symptoms over the past few months. At the time of the visit, she was using her albuterol inhaler multiple times daily, without any additional asthma treatment, and was unsure whether she was using it properly. Data was collected using two forms of assessment: a post-visit USP checklist and a systematic review of the corresponding clinic note to examine treatment recommendations including referrals and quality of documentation. The USP checklist measured communication, patient education, and assessment skills. Each response option included descriptive behavioral anchors and was rated as not done, partly done, or well done. Domain scores were calculated as percent items rated well done. RESULTS: 141 USP visits were made from 2009 to 2016 with a mean visit length = 88 min, SD= 28 min (range: 40 to 180 min). Almost all residents (92%) evaluated the patient's asthma with a pulmonary examination. The most common treatment prescribed was albuterol and an inhaled steroid, with or without a spacer (79%). The majority of residents (53%) did not order any additional studies; 21% ordered one study, and 26% ordered two or more studies. Study orders fell into one of three categories: gold (appropriate/recommended: PFTs, flu shot, HIV), grey (pulmonary consult, HCG), or inappropriate (TSH, A1C). Across the 141 visits, 129 studies were ordered; 46% were gold, 5% were grey, and 49% were inappropriate. The most common study ordered was a PFT (31%). 87% of single study orders were gold, but 92% of multiple orders included at least one inappropriate study. Residents who did not order any studies had significantly higher patient education and counseling skills than residents who ordered one or more studies (54% vs 34%, p = 0.00) and were more likely to explain how to correctly use an inhaler than residents who ordered one or more studies (48% vs 27%, p = 0.01). These residents also had significantly higher management and treatment skills (61% vs 39%, p = 0.00) and overall communication skills (68% vs 55%, p = 0.01). There were no significant differences between groups in medications prescribed or in quality of documentation. CONCLUSIONS: Effective communication skills may contribute to valuebased care through appropriate patient education and ordering of fewer inappropriate studies. Rigorous curricula and assessment of resident's patient education skills should be in place to help both patients and health care system achieve value-based care

BACKGROUND: All physicians need to be skilled at diagnosing, treating, and managing depression. We designed an unannounced standard patient (USP) case to assess residents' clinical skills in addressing depression and explored how those skills are associated with residents' general clinical skills in order to design targeted curriculum on depression. METHODS: The USP was a 26 y.o. male presenting as a new patient to a clinic complaining of fatigue and problems sleeping. Goals of the case were to diagnose a common presentation of depression and make a treatment/follow-up plan. The USP was trained to have a positive PHQ 2 &PHQ 9, family history of depression, and be willing to engage in medication and/or therapy if offered. A post-visit checklist was used by the SPs to assess communication, patient education, and assessment skills using behaviorally anchored items rated as not done, partly done, or well done. A systematic chart review was conducted to examine treatment, quality of documentation, and referrals. Case fidelity was checked by audiotape and confirmed by PHQ 9 score in the EHR. Evidence based treatment was defined as prescribing an SSRI and/or providing a psychiatric referral; if neither of those, scheduling follow-up for within 2 weeks. RESULTS: 122 residents saw the USP case from 2009-2015. Mean visit length = 45 min, SD 25 (14 to 183 min). The patient was screened for depression with a PHQ 2 in 93% of visits; 82% also had a PHQ 9. Overall, 77 residents (63%) provided appropriate treatment: 8% prescribed an SRRI, 23% provided a referral, 19% did both, 7% prescribed a sleep aid and <2 week follow-up, and 43% provided a combination of these treatments. 45 residents (37%) did not provide appropriate treatment: 27 (60%) prescribed a sleep aid and follow-up >2 weeks and 18 (40%) provided no treatment/referral and follow-up >2 weeks. There were no differences in exploration of medical history or substance use, but 83% of residents who treated appropriately had a PHQ 9 compared to 62% of residents who did not treat appropriately. 71% also included depression on the problem list compared to 13%of residents who did not treat appropriately. Residents who treated appropriately had significantly better clinical skills assessed by the USP including: overall communication (71% vs. 54%, p = 0.00), information gathering (72% vs. 55%, p = 0.01), relationship development (75% vs. 60%, p = 0.03), patient education (55% vs. 21%, p = 0.00), and patient activation skills (33% vs. 13%, p = 0.01). CONCLUSIONS: Although almost all residents obtained the relevant information, only about 50% of residents diagnosed depression. PHQ 9 appears to be associated with providing more effective treatment, supporting the importance of health system screening protocols. Residents' communication and depression-specific patient education and activation skills seem to be related to how they identify and manage depression, suggesting that interventions to build these skills may lead to higher quality care