Introduction: Nearly 60,000 children receive emergency services each year due to accidental medication ingestion. Since families regularly receive verbal anticipatory guidance about locking up medications during pediatric well child visits, primary care clinics are an opportune place to distribute lock boxes to families who need them. ETSU Pediatrics is an interprofessional outpatient clinic that serves a population with many social, medical, and psychological needs. ETSU Pediatrics partnered with a local non-profit organization to provide medication lock boxes free to charge to families who need one. However, it was not known whether more families would endorse a need for a lock box in response to a systematic effort to screen for this need. We hypothesized that more medication lock boxes would be administered if families were given a written screener asking explicitly about their need for a lock box. Method:ETSU Pediatrics added the question “To increase child safety, is your household in need of a lockbox for medications?” to an existing social determinants of health screener that is given annually to each patient during their well child visit. Social work students imbedded in the clinic gave out lock boxes to families who endorsed a need. Frequency counts of the number of medication lock boxes given out were compared 6 months before and after the initiation of the screener. Results: Out of the 2,018 well child visits that occurred in the 6 months after screener initiation, 5.5% (111) of families endorsed a need for a medication lock box. Of those 106 were given a lock box. This was a substantial increase in demand for lock boxes compared to the 6 months prior to screener initiation in which only 16 lock boxes were given out. Conclusions: Systematic screening for medication lock box need resulted in more lock boxes being administered to families over a 6-month period, compared to care as usual. An embedded interprofessional student team helped facilitate this process. These results show promise for other healthcare organizations aimed at reducing accidental medication ingestions in children.

Introduction The U.S. South has higher rates of unintended pregnancy than other regions of the nation. Rurality and limited supply of medical providers and reproductive health services contribute to these disparities. Layered on this are restrictive reproductive health policies that are changing rapidly. Many rural areas in the South are "maternity care deserts” with no OB/GYNs, midwives, or obstetric care. In these areas, family physicians are often the only providers of reproductive health services. While family physicians commonly counsel about and prescribe oral contraceptives, little is known about their counseling practices for long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and contraceptive implants. This study examines attitudes and practices of family physicians in two Southern states related to counseling for IUDs and implants. Methods Statewide representative surveys of family physicians (FPs) were administered in South Carolina and Alabama in 2018. The survey questionnaire, informed by in-depth interviews with providers and a systematic literature review, collected data about providers’ knowledge, attitudes and practices related to contraceptive counseling and provision. The questionnaire was pilot tested, revised and finalized. Random samples of FPs from each state were selected, with oversampling of rural providers. Sampled providers were web traced and phone screened to verify eligibility and contact information. The IRB-approved survey protocol involved mixed-mode administration (electronic and mail surveys), participation incentives for providers and office managers, and extensive follow-up with non-respondents. Survey data were weighted to account for the sampling design and to generate robust estimates. Data were cleaned and analyzed in STATA using t-tests and chi-square tests for independence. Results Five hundred and ten (510) FPs responded to the survey. The majority of FPs (70%) were in private medical practice and one-fourth in rural areas. Among FPs in Alabama, 39.3% reported not counseling any of their reproductive-aged female patients in the past year about IUDs, and 53.1% reported not counseling about the implant. Prevalence of counseling did not differ significantly between AL and SC providers. While a majority of FPs in both states (88.7%) reported general training in contraceptive counseling during their formal education, fewer reported training specific to IUDs (61.7%) and implants (43.9%), and only 28% had received recent training in contraceptive counseling in the past 2 years. Risk perceptions of providers varied. Contrary to medical eligibility criteria, the majority of FPs considered IUDs unsafe for women who had an STI (sexually transmitted infection) in the past 2 years (62.4%) and unsafe immediately post-partum (69.4%). Contraceptive training was positively associated with counseling provision, whereas risk perceptions were negatively associated with counseling provision. Conclusion Substantial training gaps and needs were noted among FPs. While the scope of practice of FPs is broad and demanding, their engagement in comprehensive contraceptive counseling is essential for their patients’ health and well-being. This is particularly true in the U.S. south where contraceptive services are not always available or accessible. FPs must be supported through evidence-based training programs and clinic-level interventions that facilitate their contraceptive counseling and, ultimately, their patients’ contraceptive choices and outcomes.

Introduction: Health service organizations and their partners are increasingly under pressure to collaborate to deliver integrated patient care. The Collective Impact framework aligns well with respectful engagement and decision making between an organization and its partners, ensuring long-term change at the systems level. Shared vision, mutually reinforcing activities, and continuous communication are key components of a collective impact effort. Communication, in particular, plays an important role in all aspects of an organization, both internally and externally. Thoughtful feedback from partners and collaborative efforts can achieve collective impact and improved patient and population outcomes. Choose Well (CW), a statewide contraceptive access initiative in South Carolina, was developed using Collective Impact principles. CW launched in 2017 and continued through 2022. CW aimed to implement best practices for contraceptive access and provision. This study examined the perceptions of CW staff towards shared vision for contraceptive access, mutually reinforced activities, and communication strategies between CW and its partners. Methods: Data were collected in 2022 via exit key-informant interviews with CW staff to reflect across-all-years of their involvement with the initiative. A semi-structured interview guide was used, and the interviews were recorded, transcribed, and coded. A codebook was developed based on the interview guide. Data from questions related to 1) shared vision, 2) communication, and 3) mutually reinforcing activities between CW staff and partners were analyzed for this study. Coding was conducted with NVivo software version 1.7. Results: A total of eight CW staff participated in the interviews. Findings indicate that participants were very satisfied with the shared vision for contraceptive access between CW and its partners. The most prevalent facilitators for shared vision were constant and ongoing communication, collaboration with partners, and CW changes in framing for the initiative. Regarding communication, most participants perceived that the level of communication and coordination among various CW partners was consistent and streamlined. Integration of communication into daily processes, open communication with partners, and use of an online communication tool were mentioned as strategies that facilitated communication. Lack of administrative and partner buy-in among some partners, staff turnover, and pandemic-related challenges were commonly mentioned by participants as barriers to communication. Most participants perceived mutually reinforcing activities to be adaptability to partner needs, funding for the full range of contraceptive methods, collaboration efforts, and feedback from the partners. Conclusion: While lack of buy-in among some partners and the pandemic posed challenges, most participants perceived that constant and consistent communication facilitated a shared vision among the CW partners. Through adaptability, collaboration, and open communication with partners, CW adjusted its work to align with their partners’ goals. The findings of this study indicate that CW has coordinated their efforts around a common goal that aligns with their partners. CW maintained effective and consistent communication and integrated partner feedback as a Collective Impact approach towards improving contraceptive access and provision in SC. Shared vision and understanding of the health issue between the organization and partners can lead to a collective impact towards solving community health problems such as contraceptive access.

Valvular disease affects the heart's valves and can lead to complications if left untreated. In 2017, about 2.7% (U. S) of the population had a valvular disease. The Centers for Disease Control and Prevention (CDC) also estimated that about 2500 Americans die yearly due to valvular disease. Several factors, such as the type of valvular disease, can affect the outcome of this disease. However, the hospital type, insurance status, and location of the patients may determine the quality of care and valvular disease outcome. Teaching hospitals are often in urban regions and house various well-grounded specialists as well as tools and equipment that may be a significant contributory factor to the outcome of Valvular heart disease. This study aims at determining the importance of quality of healthcare access in the outcome of valvular disease. At the bivariate analysis level, it was hypothesized that the type of hospital, location of patients, and age at diagnosis are significantly related to the outcome of valvular disease. At the multivariate level, it was hypothesized that after controlling for every other variable, the predictor variables were significantly related to the outcome of valvular disease. Data analysis was conducted on cross-2012 sectional National Inpatient Survey (NIS) data. The Core, severity, and hospital data were used for this analysis. Descriptive statistics and bivariate and multivariate logistic regressions were conducted to assess the association between the outcome of valvular disease and the type of hospital (teaching or non-teaching), patient location, age at diagnosis, insurance, income, and sex. All analysis was performed using the Statistical Analysis System (SAS). The results of the descriptive study showed about 2.9% of patients had comorbidity from valvular disease. Patients attending teaching hospitals had a 0.3% comorbidity present (P =.001). At the multivariate analysis level, patients at the teaching hospital were less likely to have comorbidity compared to individuals at non-teaching (AOR = 0.735; CI = 0.549, 0.970, P = 0.0303). Patients with public or no insurance were less likely to have a comorbidity of valvular disease as compared to patients with private insurance (AOR =0.596, AOR =0.288; CI = 0.393, 0.904 CI= 0.120, 0.692 P= 0.0149 P= 0.0054 respectively). Also, males were less likely to have valvular heart disease comorbidity as compared to females. All other variables not mentioned were not significant in the multivariate analysis. Accreditation programs can ensure that non-teaching hospitals have the necessary resources, equipment, and personnel to manage the valvular disease. Furthermore, providing incentives, such as financial support or performance-based incentives, can encourage non-teaching hospitals to invest in the necessary resources and personnel to manage valvular heart disease. We also recommend awareness campaigns and screening programs for patients in rural regions.

Thesis (M.S.)--University of Michigan, 1990.

Introduction: Burnout is an occupational condition characterized by emotional exhaustion, depersonalization, and a low sense of personal accomplishment. While medical students begin schooling with mental health profiles similar to or better than peers who pursue other careers, there is a downward trajectory throughout school suggesting this phenomenon often originates in medical school. For physicians and residents, burnout has been linked to poor outcomes such as patient safety, might contribute to suicidal ideation and substance abuse, and may undermine professional development. Furthermore, there is a lack of surveillance of the prevalence of medical student burnout in a small-sized school setting. Methods: The Maslach Burnout Inventory (MBI), a 22-question survey, is largely accepted as the gold standard for assessment; however, we utilized the 7-question, Well-Being Index (WBI), which has been shown equal efficacy as the full MBI. Eligible participants were currently enrolled in their respective class at the East Tennessee State University Quillen College of Medicine. Each year, a participant was given a WBI survey during the winter season (overall response rate 83%, n = 239). Results: Overall the self-reported burnout rate over the two-year study period was 65.2% and was significantly higher in those reporting as female (71%). There was also variation tracking the class from one year to the next. The second year at this institution showed the highest reported amount of burnout (75%, n=145) while the lowest amount of burnout reported was during the fourth year at 47%. Conclusions: Burnout experienced at this institution was reportedly higher than national average. There are limitations to this study as the periods in which medical students were asked to answer the survey were consistently at the same time in the calendar year, but the host institution’s curriculum had been changed so that it might not match up accordingly. Furthermore, class sizes changed from year to year and might skew the data. This information suggests that burnout prevalence is higher at Quillen College of Medicine and intervention strategies to address burnout should be pursued.

Introduction: Drug dependence is a chronic medical illness that often requires multiple treatment episodes and the use of health services. However, patterns related to substance use and abuse treatment are not well known. Two critical factors that have not been explored in relation to the number of prior substance use treatment episodes (PSUTEs) are multiple age groups and waiting periods. Hence, the first aim of this study was to examine if the frequency of prior substance use treatment episodes varies by different age categories. The second aim was to assess the extent to which the waiting period prior to receipt of substance use treatment services influences the likelihood of experiencing multiple treatment episodes. Methods: Data used for this research was the 2018 Treatment Episodes Data Set— Admissions (TEDS-A) (N= 1,935,541), which comprised of admissions to alcohol or drug treatment facilities across the United States. Descriptive statistics of participants was conducted. Bivariate and Zero-Inflated Poisson regression (ZIPR) analyses were performed to evaluate the number of PSUTEs associated with age and days waiting to enter a treatment facility while adjusting for other potential confounders. Andersen's healthcare utilization model was used to categorize covariates into predisposing, enabling, needs, and environmental factors. P-value ≤ 0.01 was considered the criteria for rejection of all null hypotheses. Results: Among participants, the average frequency of PSUTE was 1.60. About 34.2% were 25-32 years old, while 19.2% had a waiting period of between 1 to 7 days. Bivariate analysis showed that the number of PSUTEs (0 to ≥ 5) was significantly associated with all age groups and waiting periods, respectively. The results for age showed that 1.4% (12-17 years old), 8.4% (18-24 years old), 14.7% (25-34 years old), 16.7% (35-49 years old), and 18.1% (≥ 50 years old) reported ≥ 5 PUSTEs. For individuals with a waiting period of ≥ 31 days, the number of PSUTEs included 36.5% (no PUSTE), 20.2% (1 PUSTE), 12.3% (2 PUSTEs), 6.8% (3 PUSTEs), 4.2% (4 PUSTEs), and 20.0% (≥ 5 PUSTEs). ZIPR analysis demonstrated that the predicted log count of PSUTE increased significantly for every increase in age category. While for every increase in the number of days waiting to enter treatment, the predicted log count of PSUTEs significantly decreased. All potential confounders including, gender, race, living arrangement, type of treatment or service setting at admission, primary substance used, presence of co-occurring mental & substance use disorder, health insurance, and census region, were significantly associated with the frequency of previous substance use treatment episodes (P-value ≤0.01). Conclusion: This study demonstrated that multiple age categories and wait periods are significant predictors of the number of previous substance use treatment episodes. Notably, younger participants showed fewer prior episodes than older participants. These factors should be considered in order to develop effective strategies to improve treatment use and access to substance use treatment facilities. Therefore, more research is needed to explore these factors as well as other unknown predictors influencing multiple substance use treatment episodes.

Moving to a pass/fail curriculum has generally been associated with decreased levels of stress and increased medical student well-being. However, not much research has been done to identify the specific effect of retaining class rank in a pass/fail curriculum and how this might affect student stress levels. The purpose of the current study was to fill in current research gaps in this area and to provide further insight into some of the factors that contribute to medical student burnout. The study was carried out using the Medical Student Well-Being Index (MSWBI), a self-reported survey that evaluates medical student fatigue, depression, burnout, anxiety/stress, and mental/physical QOL on a weighted and unweighted basis. Additionally, a set of add-on questions developed by the research team were distributed to participants along with the MSWBI. These questions asked the students to determine whether the change to a pass/fail curriculum increased, decreased, or did not change their perceived stress levels and to identify the major sources of their perceived stress. Participants were full-time medical students enrolled at ETSU Quillen College of Medicine from the Fall 2019 to Spring 2020 terms. They were divided by graduation year and asked to complete the MSWBI and IRB-approved add-on questions once per school year during this period. The number of add-on question respondents from each class reporting an increased or unchanged level of stress since switching to a pass-fail system encompassed 62.6% of all respondents. The most common reason provided by respondents for either increased or unchanged levels of stress after switching to a pass/fail curriculum was the continued reporting of class rank. This work will be useful in determining the true sources of student stress within the medical education system. While a pass/fail curriculum may reduce medical students’ perceived stress, this data indicates that class rank remains burdensome for many. Understanding the underlying factors that influence poor medical student well-being can lead to better targeted interventions.

Home visits are a required training component of many Family Medicine residency programs in the United States. However, they are becoming less popular due to such factors as increasing resident responsibilities, decreasing reimbursement, and a decline in resident intention to incorporate home visits into future practice. This study’s aims are: (1) to evaluate the current practices of one Family Medicine residency training program’s time and resource expenditure to conduct home visits, and (2) to evaluate resident and faculty experiences of home visits. Residents and faculty in a Family Medicine training program were provided with a 12- question survey immediately after completing a home visit. A total of 19 surveys from residents and faculty were collected and analyzed. Average reported time spent per home visit was 90 minutes (range = 50-180 minutes), and the home visit teams included an average of 4 members (range = 2-6 members). The providers felt that they knew their patients and the patients’ circumstances better after the home visit with a score of 4.1 (on a 1-5 scale with 5 being a positively framed statement). Resident opinions were neutral (average score 3.1 on a 1-5 scale) regarding whether they found home visits to be educational to their residency training in Family Medicine. Residents also had mixed feelings (average score 2.9) regarding whether they would perform more home visits during their residency training if given the opportunity. Most faculty members (5/7) indicated they had done home visits during their residency training and all faculty (7/7) felt that home visits added value to their training in Family Medicine. Finally, qualitative recommendations were collected from respondents which may allow this training program to improve home visits in the future. Overall, significant time is currently being spent conducting home visits, with a difference in perceived efficacy between residents and faculty. Future research may include a cost analysis to quantify financial value, as well as expanding data collection to other Family Medicine residency training programs to improve generalizability.

The implementation of Electronic Health Records (EHR) has improved medical documentation in terms of accuracy, team communication, and ease of ordering tests and prescriptions; however, charting in an EHR strains the provider/patient relationship and contributes to physician burnout. Medical scribes are a promising potential solution to these problems. Our study aims to demonstrate that implementation of scribes into a medical residency program positively affects provider/patient satisfaction and improves quality and efficiency of EHR documentation. Our study evaluated the effectiveness and utility of scribes in a residency training program utilizing the established implementation framework “RE-AIM,” or Reach, Effectiveness, Adoption, Implementation (quality), and Maintenance. During the study’s initial “Training Phase,” 11 first and second-year Family Medicine residents conducted scribe-facilitated patient visits. Patient and provider satisfaction ratings were collected, note quality was evaluated, and time to note closure was measured. During the subsequent “Choice Phase,” residents were given the option of whether to utilize scribes, and the same data measures were collected. Resident satisfaction ratings during the Training Phase showed an average score of 6.03 (on a 1-7 scale where “7” = “strongly agree” with positive statements), and a pilot sample of 9 patients showed an average patient satisfaction rating of 4.77 (on a 1-5 scale where “5” = “strongly agree” with positive statements). Scribe-facilitated notes coded for quality had an average score of 3.375 (on a 1-5 scale where 5 is “extremely” high quality). Finally, residents’ average time to note closure was decreased by more than 8 hours in scribe-facilitated visits. During the Choice Phase, all 11 participating residents requested scribe-facilitated visits, again with very high patient satisfaction scores (4.67 on a 1-5 scale) as well as high clinician satisfaction scores (6.06 on a 1-7 scale). Choice Phase note quality and note-closure time are currently being assessed. These results demonstrate that scribes improve clinician and patient satisfaction, as well as quality and efficiency of EHR documentation. Limitations include a small sample size of clinicians and patients. Further research is needed with larger sample sizes to determine whether scribes in a medical residency program represent a sustainable and effective intervention.