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Internal medicine residents identify gaps in medical education on outpatient referrals

Slavin, Masha J; Rajan, Mangala; Kern, Lisa M
BACKGROUND:Relevant clinical information is often missing when a patient sees a specialist after being referred by another physician in the ambulatory setting. This can result in missed or delayed diagnoses, delayed treatment, unnecessary testing, and drug interactions. Residents' attitudes toward providing clinical information at the time of referral and their perspectives toward training on referral skills are not clear. We sought to assess internal medicine residents' attitudes toward and experiences with outpatient referrals. METHODS:We conducted a cross-sectional survey in October-December 2018 of all internal medicine interns and residents affiliated with a large, urban internal medicine residency program in New York, NY. We used a novel survey instrument that included 13 questions about attitudes toward and experiences with outpatient referrals. We used descriptive statistics to characterize the results. RESULTS:Overall, 122 of 132 residents participated (92% response rate). Respondents were approximately equally distributed across post-graduate years 1-3. Although 83% of residents reported that it is "always" important to provide the clinical reason for a referral, only 11% stated that they "always" provide a sufficient amount of clinical information for the consulting provider when making a referral. Only 9% of residents "strongly agree" that residency provides sufficient training in knowing when to refer patients, and only 8% "strongly agree" that residency provides sufficient training in what information to provide the consulting physician. CONCLUSIONS:These results suggest a substantial discrepancy between the amount of information residents believe they should provide at the time of a referral and the amount they actually provide. Many residents report not receiving adequate training during residency on when to refer patients and what clinical information to provide at the time of referral. Improvements to medical education regarding outpatient referrals are urgently needed.
PMID: 32731856
ISSN: 1472-6920
CID: 4745292

Patients' and Providers' Views on Causes and Consequences of Healthcare Fragmentation in the Ambulatory Setting: a Qualitative Study

Kern, Lisa M; Safford, Monika M; Slavin, Masha J; Makovkina, Evguenia; Fudl, Ahd; Carrillo, J Emilio; Abramson, Erika L
BACKGROUND:Patients with chronic conditions routinely see multiple outpatient providers, who may or may not communicate with each other. Gaps in information across providers caring for the same patient can lead to harm for patients. However, the exact causes and consequences of healthcare fragmentation are not understood well enough to design interventions to address them. OBJECTIVE:We sought to elicit patients' and providers' views on the causes and consequences of healthcare fragmentation. DESIGN AND PARTICIPANTS:We conducted a qualitative study with focus groups of patients and, separately, of providers (attending physicians and nurse practitioners) at an academic hospital-based primary care practice in New York City in June-August 2017. Patient participants were English-speaking adults with ≥ 2 chronic conditions. APPROACH:Each focus group lasted 1 h and asked the same two questions: "Why do you think some patients receive care from many different providers and others do not?" and "What do you think happens as a result of patients receiving care from many different providers?" Data collection continued until a point of data saturation was reached. Thematic analysis was used to identify themes and subthemes. KEY RESULTS:We conducted 6 focus groups with a total of 46 participants (25 patients and 21 providers). Study participants identified 41 unique causes of fragmentation, which originate from 4 different levels of the healthcare system (patient, provider, healthcare organization, and healthcare environment); most causes were not related to medical need. Participants also identified 24 unique consequences of fragmentation, of which 3 were desirable and 21 were undesirable. CONCLUSIONS:The results of this study offer a granular roadmap for how to decrease healthcare fragmentation. The large number and severity of negative consequences (including medical errors, misdiagnosis, increased cost, and provider burnout) underscore the urgent need for interventions to address this problem directly.
PMID: 30783883
ISSN: 1525-1497
CID: 4745282


Slavin, Masha J.; Buckholz, Adam P.; Siegler, Eugenia
ISSN: 0884-8734
CID: 4745322


Kern, Lisa M.; Safford, Monika M.; Slavin, Masha J.; Makovkina, Evguenia; Fudl, Ahd; Carrillo, J. Emilio; Abramson, Erika
ISSN: 0884-8734
CID: 4745312

Twist on a classic: vitamin D and hypercalcaemia of malignancy [Case Report]

Osorio, Juan C; Jones, Masha G; Schatz-Siemers, Nina; Tang, Stephanie J
Malignancy is the most common cause of hypercalcaemia in the inpatient setting. Most cases are caused by tumour production of parathyroid hormone-related protein and osseous metastases. In less than 1% of cases, hypercalcaemia is driven by increased production of 1,25-dihydroxyvitamin D (1,25(OH)2D), a mechanism most commonly seen in haematological malignancies. Here, we describe a woman with metastatic small cell cervical carcinoma who developed hypercalcaemia secondary to paraneoplastic overproduction of 1,25(OH)2D, a finding that, to our knowledge, has not been previously associated with this cancer. We also review the current cases of solid tumours reported to have this mechanism of hypercalcaemia and the evidence behind multiple therapeutic approaches.
PMID: 29170170
ISSN: 1757-790x
CID: 4745302

Using Nurse Practitioner Co-Management to Reduce Hospitalizations and Readmissions Within a Home-Based Primary Care Program

Jones, Masha G; DeCherrie, Linda V; Meah, Yasmin S; Hernandez, Cameron R; Lee, Eric J; Skovran, David M; Soriano, Theresa A; Ornstein, Katherine A
Nurse practitioner (NP) co-management involves an NP and physician sharing responsibility for the care of a patient. This study evaluates the impact of NP co-management for clinically complex patients in a home-based primary care program on hospitalizations, 30-day hospital readmissions, and provider satisfaction. We compared preenrollment and postenrollment hospitalization and 30-day readmission rates of home-bound patients active in the Nurse Practitioner Co-Management Program within the Mount Sinai Visiting Doctors Program (MSVD) (n = 87) between January 1, 2012, and July 1, 2013. Data were collected from electronic medical records. An anonymous online survey was administered to all physicians active in the MSVD in July 2013 (n = 13).After enrollment in co-management, patients have lower annual hospitalization rates (1.26 vs. 2.27, p = .005) and fewer patients have 30-day readmissions (5.8% vs. 17.2%, p = .004). Eight of 13 physicians feel "much" or "somewhat" less burned out by their work after implementation of co-management. The high level of provider satisfaction and reductions in annual hospitalization and readmission rates among high-risk home-bound patients associated with NP co-management may yield not only benefits for patients, caregivers, and providers but also cost savings for institutions.
PMID: 27631706
ISSN: 1945-1474
CID: 3858952

Characterizing the high-risk homebound patients in need of nurse practitioner co-management

Jones, Masha G; Ornstein, Katherine A; Skovran, David M; Soriano, Theresa A; DeCherrie, Linda V
By providing more frequent provider visits, prompt responses to acute issues, and care coordination, nurse practitioner (NP) co-management has been beneficial for the care of chronically ill older adults. This paper describes the homebound patients with high symptom burden and healthcare utilization who were referred to an NP co-management intervention and outlines key features of the intervention. We compared demographic, clinical, and healthcare utilization data of patients referred for NP co-management within a large home-based primary care (HBPC) program (n = 87) to patients in the HBPC program not referred for co-management (n = 1027). A physician survey found recurrent hospitalizations to be the top reason for co-management referral and a focus group with nurses and social workers noted that co-management patients are typically those with active medical issues more so than psychosocial needs. Co-management patients are younger than non-co-management patients (72.31 vs. 80.30 years old, P < 0.001), with a higher mean Charlson comorbidity score (3.53 vs. 2.47, P = 0.0001). They have higher baseline annual hospitalization rates (2.27 vs. 0.61, P = 0.0005) and total annual home visit rates (13.1 vs. 6.60, P = 0.0001). NP co-management can be utilized in HBPC to provide intensive medical management to high-risk homebound patients.
PMID: 27876403
ISSN: 1528-3984
CID: 3858962

Inappropriate Prescription of Proton Pump Inhibitors in the Setting of Steroid Use: A Teachable Moment [Case Report]

Jones, Masha G; Tsega, Surafel; Cho, Hyung J
PMID: 27065299
ISSN: 2168-6114
CID: 3545692