Community Medicine

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    Approach to End-of-Life Care Planning in the Outpatient Setting
    (2022) Jackson, Garrett; Randell, David; Hadley, Lesca; Gibson, John
    Purpose: Advance care planning (ACP) can prepare individuals to receive medical care aligned with their values and experience; however, ACP can be uncomfortable and taboo topic for many patients and thus, a time-consuming conversation for providers. As of 2017, only 1 in 3 of U.S. adults had any type of advanced care directive. Family Practice Associates of Abilene is a primary care clinic that serves an aging demographic with an increased need to address the issues of end-of-life care. Their short-term goal was to increase the initiation of advanced care planning (ACP) by patients 65+ years from October 1, 2021- December 17, 2021; the long-term goal is to see an increased follow-through of patients creating their ACP directives and documents. Methods: For the month of October all patients 65+ years were questioned regarding their ACP status and documented as: complete, desire to initiate, do not wish to initiate. Starting November 1, 2021, all patients 65+ years were first engaged with an educational pamphlet or conversation via the certified medical assistant or medical student prior to the physician encounter. Verbal confirmation of their ACP status was documented as: complete, desire to initiate, do not wish to initiate. Results: From November 1st - December 17th, there was a >70% increase in the verbal confirmation of the desire to initiate ACP from among eligible patients as compared to prior the implementation. In addition, many of the patients were encouraged to initiate follow-up of their concerns or questions by scheduling their Medicare Annual Wellness visit with the front office post-visit. Conclusion: This approach allowed for brief, multidisciplinary interactions around ACP that adapted to the time-limited care model seen in the outpatient setting1. Future steps could include reviewing the EMR system to quantify how many of the patients followed up on their verbal desire by scheduling a Medicare Annual Wellness exam.
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    Providing healthcare to rural populations with Real Time Remote Telementored Ultrasound
    (2022) Wyszynski, Katy; Hadley, Lesca; Gibson, John
    Introduction University of North Texas HSC medical students learn Point of Care Ultrasound (POCUS) in clinical settings as part of their curriculum. In 2021, students provided healthcare screenings and ultrasound scans to hundreds of patients in underserved rural communities in West Texas. Students utilized Butterfly's teleguidance technology to perform complex scans for the first time by using Remote Telementored Ultrasound (RTMUS) which allows a two-way video call, so that a remote practitioner visualizes the ultrasound scan and the probe location on the patient in real time. Methods We encountered a 62-year-old female with a 2/6 systolic ejection murmur. She noted a history of congenital heart disease diagnosed at birth, but the patient was unsure of the diagnosis and has not seen a cardiologist in many years. POCUS was performed on the patient. Results This patient had grossly normal cardiac POCUS examination. However, one anatomical location at the base of the patient's interventricular septum appeared thin. From her medical history and cardiac imaging, the remote practitioner approximated that she had a previous ventricular septal defect at birth that closed spontaneously. Discussion POCUS is a valuable tool in rural settings for patient management. Using RTMUS, trained physicians and students can bring advanced technology to remote settings using experts in distant locations, allowing ultrasound to serve as an adjunct to the physical exam even in places where healthcare inequalities commonly exist. With the expansion of this technology, RTMUS has the potential to provide ultrasound technology to underserved populations globally.
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    Quality Improvement Project: Advanced Care Planning in a Rural Family Practice Clinic
    (2022) West, Lauren
    Purpose: Advanced Directives are a crucial means of ensuring patient's autonomy at the end of life. However, despite their importance, studies have continued to find that they are significantly underused in the United States. This project determined the prevalence of patients with Advance Care Directives in a rural family practice clinic. The primary purpose of this project was to provide patients over age 65 with an educational resource discussing Advance Care Planning. Methods: Patients eligible for this study were identified by nursing staff during check-in for office visits. All patients over the age of 65 were deemed eligible to receive the intervention. The nursing staff then performed a chart review to determine if the patient already had an Advance Care Plan created within the last 5 years on file. The nursing staff briefly discussed code status and living wills with all patients. The patient then received a 2-page Advance Care Planning handout from the American Academy of Family Physicians. Results: During the study period, a total of 77 patients were eligible and 91% of them received the intervention. Of the patients who participated in the study 71% did not have an up-to-date Advance Care Plan already documented in the EMR. Conclusions: This project demonstrates the lack of documented Advanced Directives and the great need for Advance Care Planning education among those aged 65 years and older in rural family practices. Future interventions should involve adding flags in the EMR to help identify patients who lack an Advanced Directive, and to prompt the provider to discuss Advanced Care Planning. Further follow up in 1 year is necessary to determine the true impact of the quality improvement project.
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    The Associations between Physician-Patient Encounter Characteristics and Chronic Low Back Pain Outcomes
    (2022) Nyalakonda, Ramyashree; Kandukuri, Prathima; Patel, Salman; Licciardone, John C.
    PURPOSE Low back pain is the leading cause of disability, affecting 577 million persons worldwide. As there are relevant clinical practice guidelines from the Centers for Disease Control and Prevention and the American College of Physicians that have been widely implemented in the United States, factors other than treatment may have an important impact on clinical outcomes. This study aimed to determine if aspects of the physician-patient encounter affect long-term outcomes among patients with chronic low back pain (CLBP). METHODS Participants in this retrospective cohort study were recruited from the PRECISION Pain Research Registry from April 2016 through December 2021. Eligible participants reported CLBP according to criteria established by the National Institutes of Health, were 21-79 years of age, and had a physician who regularly treated their low back pain. Characteristics of the physician-patient encounter were measured with the Communication Behavior Questionnaire, Consultation and Relational Empathy Measure, and the Patient Satisfaction Questionnaire (PSQ) and classified according to tercile cut points. The PSQ measure included the five scales most closely related to physician behavior during medical care (general satisfaction, technical quality, interpersonal manner, communication, and time spent with patient). Outcomes were measured at quarterly encounters over 12 months using a numerical rating scale (NRS) for pain intensity, the Roland-Morris Disability Questionnaire (RMDQ), and the SPADE cluster (sleep disturbance, pain interference, anxiety, depression, and low energy/fatigue) derived from the Patient-Reported Outcomes Measurement Information System. The latter measures health-related quality of life. Higher scores represent worse outcomes on each measure. Longitudinal outcomes were assessed using repeated measures analysis of variance. RESULTS Patient satisfaction most consistently and strongly predicted outcomes (P< 0.001). Health-related quality of life was strongly associated with each aspect of the physician-patient encounter. Participants who rated their physicians in the highest tercile for satisfaction reported lower scores for NRS (mean, 5.77; 95% CI, 5.56-5.98 vs mean, 6.11; 95% CI, 5.91-6.32 for reference category), RMDQ (mean, 13.22; 95% CI, 12.50-13.94 vs mean, 15.33 95% CI, 14.63-16.02), and SPADE (mean, 56.06; 95% CI, 55.25-56.87 vs mean, 59.22; 95% CI, 58.44-60.00). Similarly, participants who rated their physicians in the highest tercile for empathy reported lower scores for SPADE (mean, 56.30; 95% CI, 55.45-57.15 vs mean, 58.75; 95% CI, 57.95-59.55). CONCLUSIONS Various aspects of the physician-patient encounter may impact long-term outcomes of patients with CLBP. Most notably, patient satisfaction was consistently and strongly associated with all outcomes. The PSQ, a composite measure including satisfaction with such factors as physician communication and interpersonal manner, appears to be a stronger predictor of clinical outcomes than two other instruments that each focused specifically on physician communication or empathy. These findings have potentially important public health implications because CLBP management in the United States is driven by widely accepted clinical practice guidelines. Thus, it appears that the physician-patient encounter offers a mechanism for augmenting the effects of recommended CLBP treatments.
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    Pharmacist's Role in Interdisciplinary Clinic Model for Patient-Centered Care of Chronic Pediatric Asthma
    (2022) Tran, Kimberly
    Asthma is a chronic inflammatory disease of the airways affecting millions of adults and children worldwide that typically presents with wheezing, dyspnea, chest tightness, cough, and sputum. Pharmacists play a critical role in the management of asthma through patient education, medication training, and medication adjustment. The UNTHSC Health Pediatrics Asthma Clinic Protocol team, using a collaborative interdisciplinary model, consisted of a medical assistant, medical student/resident physician/attending physician, and pharmacy student/pharmacy resident/clinic pharmacist. The workflow diagram was modified for COVID-19 with virtual visits for management, allowing for less time constraints and higher volume and provider availability for patients. A hybrid patient-centered asthma clinic can be proposed to merge both models to streamline accessibility to care and facilitate provider-patient partnering.
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    Evaluating cardiovascular disease risk among African Americans in the Fruit and Veggies for Health Study
    (2022) Shah, Jil; Khan, Mahbuba; Dodgen, Leilani; Kitzman, Heather
    Purpose: Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Elevated blood pressure, blood glucose, cholesterol, and low high-density lipoprotein (HDL) are well-accepted markers of CVD risk. The prevalence of CVD in the US is expected to rise 10% by 2030 attributed to a dramatic rise in obesity, blood pressure, and diabetes. African Americans are at a greater risk for CVD incidence and progression. Fruit and vegetable (F&V) consumption is considered to be protective against CVD. The Fruit and Veggies for Health study conducted at Baylor Scott & White Health and Wellness Center, Dallas, was a randomized trial that prospectively compared changes in markers of chronic kidney disease (CKD) in African Americans randomized to either receiving a weekly supply of F&V or to a cooking class plus a weekly supply of F&V. This project aims to evaluate the effect of the intervention on the secondary outcomes of the study related to CVD namely blood pressure, blood glucose, and cholesterol. In addition, differential rates of change across intervention groups may be explored. Methods: African American adults identified to have an increased risk of CKD by urine dipstick (n=142) were randomized to either receiving weekly F&V for 6 weeks with cooking class (n=70) or weekly F&V only (n=72). Both groups received 18 weeks of farm stand vouchers to continue getting F&V after the 6 weeks of prepackaged F&V. Blood pressure, fasting blood glucose, HbA1c, cholesterol (total, HDL, LDL, TRG), and body-mass-index were measured at baseline, 6-weeks, and 6-months. Descriptive statistics for demographic variables and metabolic markers at baseline were performed using chi-square tests and t-tests. Changes in secondary outcome measures between two measurement times, overall and by group, were analyzed using paired t-tests. Mixed-effects models, adjusted for age, gender, education, and income were conducted with a per-protocol analysis to evaluate the changes in each outcome over the three measurement times. Multiple imputation methods were used to avoid bias due to list-wise deletion. All analyses were performed using SAS version 9.4 with a 0.05 level of significance. Results: Participants' mean age was 57 years (SD=11.8); (22.5% Male, 77.5% Female). The distribution of age, gender, marital status, and income was similar across both groups. Mean HbA1c among all participants decreased significantly by 0.2% (SD=0.5, p-value< 0.0001) from baseline to 6-weeks, and by 0.2% (SD=0.6, p-value< 0.0001) from baseline to 6-months. Mean HDL increased significantly by 2.2 mg/dL (SD=9.3, p-value=0.005) from baseline to 6-months and by 3.9 mg/dL (SD=10, p-value< 0.0001) from 6-weeks to 6-months among all participants. The analysis is ongoing and complete results by intervention group will be ready for the presentation. Conclusion: Interventions that provide access to F&V and assist in skills to increase F&V intake by African Americans are needed, and may significantly help in lowering markers of CVD risk. Intervening in early stages might help reduce CVD incidence, its progression to advanced stages, and associated mortality.
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    Social Determinants of Health: Learner-integrated Outreach, Screening, and Intervention in a Primary Care Clinic
    (2022) Chu, Jevon; Kunchay, Gayatri; Ebert-Blackburn, Didi; Crompton, Maria
    Introduction: Whether knowingly or unknowingly, clinical learners interact with factors in the social determinants of health model (SDoH) everyday; however, students often have tenuous grasps on identifying and managing these factors in clinical settings. These factors include education, employment, access to food and health care, neighborhoods and built environments, and social support networks. There is a growing recognition in primary care practices of the importance in educating students on treating patients' immediate health concerns and SDoH factors contributing to patients' presentations to improve health outcomes. At the Central Family Medicine (CFM) Clinic of the University of North Texas Health Science Center, clinical preceptors piloted the integration of SDoH resource navigation into clinical duties for students. Methods: In addition to traditional chart reviewing, students identified gaps in preventative screenings and SDoH needs. Patient encounters included administering the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) questionnaire to assess SDoH needs. After the encounter, students followed up with patients, linked patients to resources based on the questionnaire results, and involved social work for complex SDoH needs. Finally, descriptive data analysis was conducted on the questionnaire results to provide insight into the leading SDoH needs at the CFM clinic compared to that of the state's. Qualitative data analysis was conducted on student feedback testimonials to provide guidance on identifying areas of strengths and weaknesses to determine future goals for clinical learners. Results: Education levels in the clinic patient population were lower than that of the state's, with 23.6% of the patients having less than a high school degree, compared to 14.3% of Texas residents. Similarly, the unemployment level of the patient population is almost 3 times that of the state. 12.1% of the patient population experienced food insecurity, compared to 14% of Texas residents. Trends in clinical learner testimonials included active engagement in the process of addressing social needs, improved focused patient interviewing skills, and understanding the gravity of SDoH issues. Clinical learners found difficulty in conversing with SDoH resource representatives due to unfamiliarity with resource navigation and terminology. Conclusion: Based on the results from the PRAPARE questionnaire and student testimonials, there is a clear need for improving SDoH factors in the patient population, and for medical education to include SDoH training by involving students as a value-add to clinical operations in improving patients' health outcomes. With involvement in this work, students address the Accreditation Council for Graduate Medical Education competencies for family medicine in the domains of health promotion and wellness, advocacy, and physician role in healthcare systems. Future directions include recruiting clinical preceptors who promote training in using SDoH resources, a practice that is supported with financial incentives in recent policy, developing a toolkit for integration of students into preceptors' practices, and advocating for students to have clinical administrative time to work on patient care tasks that focus on improving SDoH.
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    Educating Rural Communities About Advance Directives
    (2022) Ali, Arkoon; Molina, Alyssa; Hadley, Lesca
    Introduction: Advance directives are legal documents that allow patients to convey end-of-life care to their family, medical community, and other important people in their lives. However, a meta-analysis of 150 studies found that only 36.7 percent of the 795,909 sample population had advance directives completed. Limited healthcare resources and low levels of health literacy in rural communities can create challenging medical situations that can be abated by advance directives. Thus, it is imperative to find unique ways to educate and increase the number of advance directives within rural communities. Methods: A presentation and question-and-answer session about advance directives was conducted for adult residents of Eagle Lake, Texas. This occurred in public spaces such community centers and local places of worship. Afterwards, a survey was administered to assess the likelihood of patients creating advance directives. Results: There were 29 participants in the study of which 17 did not have advance directives. Of the 17, 10 were moderately considering or higher to create advance directives prior to the presentation and question-and-answer session. After the enhancement activity, 12 of the 17 were moderately considering or higher to create advance directives. Conclusion: Due to the small population size of the study, the effectiveness of community education on likelihood of completion of advance directives cannot be made. Expanding the population size should be considered in a future study to determine statistical significance. Furthermore, from conversations with participants in the study, several said they would update their existing advance directives due to the presentation. In the future, data should be collected about revaluations of prior written advance directives to have a more complete understanding of the impact of the intervention. From the data gathered, there is a significant percentage of participants that were considering making advance directives but had not done so. A study should be conducted to determine what is limiting rural populations from completing their advance directives.