Faculty Bibliography

BACKGROUND: Unannounced Standardized Patients (USPs) provide opportunity to measure residents' clinical skills in actual practice. USPs, or secret shoppers, are trained to ensure accurate case portrayal across encounters, making them optimal for tracking changes in skills longitudinally. At present, little is known about how residents handle USP visits with repeat cases. This study examines variation in resident communication and global domain scores when visited by the sameUSPcase at two separate time points during residency training.
METHOD(S): Primary care residents (n=46) were assessed twice by one of six standardized cases (asthma, fatigue, Hepatitis B concern, back pain, shoulder pain, or well visit) during the course of their residency, typically during their first and third training year. Upon visit completion, residents were rated using a behaviorally-anchored checklist. Communication domains assessed included info gathering (4 items), relationship development (5 items), and patient education (4 items). Other domains included patient activation (4 items) and satisfaction (4 items). Responses were scored as not done, partly done, or well done. Summary scores (mean % well done) were calculated by domain. All cases were combined to create composite scores, due to small sample sizes per case. First and second visit domain scores were compared using a t-test. Finally, we grouped high performers (80% or higher on communication scores during their first visit) because this measure demonstrated competency.
RESULT(S): With cases combined, there were no significant differences based on time of assessment and changes in score between first and second visit were small. 14/46 (30%) learners who performed well on composite overall communication scores (80% or higher) during their first visit outperformed poorer communicators in patient satisfaction (93% vs 61%, P<.001) and activation (48% vs 18%, P<.001). In subsequent visits, these high performers performed at a similar level to their fellow residents, with no significant differences noted. Further, when looking at individual trajectories, individual learner scores in the communication domain increased between visits for 21 learners (46%), decreased for 19 (41%), and stayed same for 7 (15%).
CONCLUSION(S): Results suggest that a learning curve occurs between assessments during the first year in residency and subsequent assessments. This could be due to an increased capacity to engage with a patient occurring training progression, or due to a better understanding of addressing common chief complaints presented with our USP cases. Understanding causes of individual-level score decreases will enable tailoring of educational interventions suitable for specific learner trajectories, as will a deeper dive into the impact of the clinical microsystem on performance. We predict a more nuanced understanding of these mediating factors through our plan of increasing our repeat visit sample size

BACKGROUND: While much is known about the importance of addressing Social Determinants of Health (SDoH), less is known about how physicians elicit, respond to, and act upon their patients' SDoH information. We report on the results of a study that 1) sent Unannounced Standardized Patients (USPs) with programmed SDoH into clinics to assess whether providers uncovered, explored and acted upon the SDoH, 2) provided audit/feedback reports with educational components to clinical teams, and 3) tracked the impact of that intervention on provider response to SDoH.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well-visit), each with specific housing (overcrowding, late rent, and mold) and social isolation (shyness, recent break up, and anxiety) concerns that they shared if asked broadly about. USPs assessed team and provider SDoH practices (eliciting, acknowledging/exploring, and providing resources and/or referrals). 383 USP visits were made to residents in 5 primary care teams in 2 urban, safety- net clinics. 123 visits were fielded during baseline period (Feb 2017-Jan 2018); 185 visits during intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed; and 75 follow-up phase visits were fielded (Apr-Dec 2019). Analyses compared rates of eliciting and responding to SDoH across the 3 periods (chi- square, z-scores). One team, by design, did not receive the intervention and serves as a comparison group.
RESULT(S): Among the intervention teams, the rate of eliciting the housing SDoH increased from 46% at baseline to 59% during the intervention period (p=.045) and also increased, but not significantly, for the social issue (40% to 52%, p=.077). There was a significant increase from baseline to intervention in providing resources/referrals for housing (from 7% to 24%, p=.001) and for social isolation (from 13% to 24%, p=.042) (mostly resources, very few referrals were made). The comparison team's rates followed a different pattern: eliciting the housing issue and the social isolation issue decreased from baseline to the intervention period (housing: 61% to 45%; social isolation: 39% to 33% of visits) and the rate of providing resources/referrals stayed steady at 13% for both. In the cases where SDoH were most clinically relevant, baseline rates of identifying the SDoH were high (>70%) but rates of acting on the SDoH increased significantly from baseline to intervention. Increases seen in the intervention period were not sustained in the follow-up period.
CONCLUSION(S): Giving providers SDoH data along with targeted education was associated with increased but unsustained rates of eliciting and responding to housing and social issues. The USP methodology was an effective means of presenting controlled SDoH and providing audit/feedback data. Ongoing education and feedback may be needed

BACKGROUND: Social determinants of health (SDoH) play a significant role in health outcomes, but little is known about care teams' attitudes about addressing SDoH. Our safety-net clinic has begun to implement SDoH screening and referral systems, but efforts to increase clinical responses to SDoH necessitates an understanding of how providers and clinical teams see their roles in responding to particular SDoH concerns.
METHOD(S): An annual survey was administered (anonymously) to clinical care teams in an urban safety-net clinic from 2017-2019, asking about ten SDoH conditions (mental health, health insurance, food, housing, transportation, finances, employment, child care, education and legal Aid). For each, respondents rated with a 4-point Likert-scale whether they agreed that health systems should address it (not at all, a little, somewhat, a great deal). They also indicated their agreement (using strongly disagree, somewhat disagree, somewhat agree, strongly agree) with two statements 1) resources are available for SDoH and 2) I can make appropriate referrals.
RESULT(S): 232 surveys were collected (103 residents, 125 faculty and staff (F/S), 5 unknown) over three years. Of note, mental health (84%) and health insurance (79%) were seen as very important for health systems to address, with other SDoH items seen as very important by fewer respondents. They reported little confidence that the health system had adequate resources (51%) and were unsure how to connect patients with services (39%). When these results were broken out by year, we found the following: In 2017 (n=77), approximately 35% of respondents thought the issues of employment, childcare, legal aid, and adult education should be addressed "a little," but in 2018 (n=81) and 2019 (n=74) respondents found the health system should be more responsible, with over 35% of respondents stating that these four issues should be addressed "somewhat" by health systems. In addition, half of respondents in 2019 felt that financial problems should be addressed "a great deal," up from 31% in 2017. Across all years, food, housing, mental health, and health insurance were seen as SDoH that should be addressed "a great deal". It is of note that respondents across all years reported limited understanding of referral methods and options available to their patients.
CONCLUSION(S): Many of the SDoH conditions were seen by respondents as outside the purview of health systems. However, over the three years, more members increased the number of SDoH conditions that should be addressed a "great deal." Responses also indicated that many of the team members do not feel prepared to deal with "unmet social needs". Additional examination of clinic SDoH coding, referral rates, resources, and team member perspectives will deepen our understanding of how we can cultivate a culture that enables team members to respond to SDoH in a way that is sensitive to their needs and patient needs

BACKGROUND: Race, ethnicity, and language have been identified as factors impacting uptake of HIV testing. This project sought to compare testing rates between predominant and non-predominant ethnic, racial, or language populations within neighborhood FQHCs.
METHOD(S): We identified Family Health Center network locations at which more than 50% of patients served identified as the same race, and/ or had the same preferred language, and focused our analysis on these sites. We used Excel and SPSS to compare HIV testing rates between predominant and non-predominant population groups at each clinic.
RESULT(S): At 2 of 5 sites with a predominant non-English preferred language, speakers of the predominant language were more likely to receive an HIV test than speakers of other languages (p<0.001 for both sites). The other sites showed no difference by language. Of 2 clinics with a predominant racial population, there was no difference between predominant and non-predominant populations in terms of HIV testing. At all included sites, with one exception, Hispanic ethnicity was associated with a significantly higher rate of HIV testing.
CONCLUSION(S): Predominant/non-predominant race did not affect HIV testing rates, but language and ethnicity did. One mechanism for this may be increased trust associated with patient-provider language concordance, resulting in greater uptake of tests. There is a need for future research to further explore the factors associated with these findings

LEARNING OBJECTIVE #1: Recognize the acute neurologic manifestations of non-ketotic hyperglycemia in adults with type 2 diabetes. LEARNING OBJECTIVE #2: Management of chronic disease in non- English speaking patient populations with low health literacy. CASE: 44 year old Mandarin speaking male with a history of hypertension and type 2 diabetes (DM2) presented with five days of intermittent episodes of involuntary right arm movement associated with urinary incontinence. Episodes occurred at least ten times daily and were not associated with alteration of consciousness. Of note, he was diagnosed with DM2 in the past year, but had limited understanding of the disease and was not taking any medications. The patient takes no medication. He has no family history of seizures or other neurological problems. He smokes rarely and does not drink alcohol or use drugs. On presentation he had stable vital signs and physical exam revealed no focal neurological deficits and was otherwise normal. Labs including a blood count, hepatic panel, urine toxicology, and metabolic panel were normal apart from a glucose at 616 mg/dL with a HbA1C at 14.1%. After a normal non-contrast head CT, these episodes were confirmed as focal seizures on EEG and were refractory to 1500mg levetiracetamtwice daily. He was placed on a basal-bolus regimen of insulin, with improvement of his glucose and cessation of his seizures with no further abnormal activity on EEG. Before discharge, the patient was counseled on his diagnosis of DM2 with culturally appropriate, Mandarin based educational materials as well as individual teaching on glucose monitoring and insulin administration using an interpreter. IMPACT/DISCUSSION: Non-ketotic hyperglycemia (NKHG) is a complication of DM2, and often is triggered by metabolic stressors. Classically, this presents as polyuria, polydipsia, lethargy, confusion, and ataxia. Other neurologic findings such as increased motor tone, hemiparesis, or focal seizures are rare. The pathophysiology of focal seizures in NKHG is not fully understood. Hypertonicity is unlikely to be the cause as these seizures are not present in diabetic ketoacidosis, and serum osmolarity is normal during these seizures. A prominent theory is that there may be increased metabolism of the neurotransmitter GABA, decreasing the seizure threshold. Managing these focal seizures is often difficult due to delay in diagnosis and treatment. Focal seizures tend to be refractory to antiepileptic drugs, and phenytoin can worsen these seizures by reducing insulin secretion. Management of focal seizures in NKHG is control of the hyperglycemic state, with insulin and rehydration.
CONCLUSION(S): In our patient, treatment of hyperglycemia was successful in terminating seizure activity, representing a rare case of focal seizures presenting as a symptom NKHG. In addition, usage of culturally and language specific educational materials is vital for the proper management of chronic conditions such as DM2, in order to prevent further complications of chronic disease

Introduction/UNASSIGNED:Adherence to cardioprotective dietary patterns can reduce risk for developing cardiometabolic disease. Rates of diet assessment and counselling by physicians are low. Use of a diet screener that rapidly identifies individuals at higher risk due to suboptimal dietary choices could increase diet assessment and brief counselling in clinical care. Methods/UNASSIGNED:We evaluated the relative validity and reliability of a 9-item diet risk score (DRS) based on the Healthy Eating Index (HEI)-2015, a comprehensive measure of diet quality calculated from a 160-item, validated food frequency questionnaire (FFQ). We hypothesised that DRS (0 (low risk) to 27 (high risk)) would inversely correlate with HEI-2015 score. Adults aged 35 to 75 years were recruited from a national research volunteer registry (ResearchMatch.org) and completed the DRS and FFQ in random order on one occasion. To measure reliability, participants repeated the DRS within 3 months. Results/UNASSIGNED:=0.36). The DRS ranked 37% (n=47) of subjects in the same quintile, 41% (n=52) within ±1 quintile of the HEI-2015 (weighted κ: 0.28). The DRS had high reliability (n=102, ICC: 0.83). DRS mean completion time was 2 min. Conclusions/UNASSIGNED:ClinicalTrials.gov (NCT03805373).