Impact of the Rural Physician Associate Program on Workforce Outcomes

Background and Objectives: The Rural Physician Associate Program (RPAP) at the University of Minnesota Medical School (UMMS) is a 9-month rural longitudinal integrated clerkship (LIC) for third-year medical students built on a foundation of family medicine. The purpose of this study was to examine the relationships between participation in the RPAP program and the desired workforce outcomes of practice in Minnesota, primary care specialty (particularly family medicine), and rural practice. Methods: We analyzed workforce outcomes for UMMS graduates who completed postgraduate training between 1975 and 2017, comparing RPAP participants (n=1,217) to noparticipants (n=7,928). We identified graduates through internal UMMS databases linked to the American Medical Association (AMA) Physician Masterfile and the National Provider Identifier (NPI) registry. We identified workforce outcomes of rural practice, practice in Minnesota, primary care specialty, and family medicine specialty based on practice specialty and practice location data available through the AMA and NPI data sets. Results: Proportionally, more RPAP graduates practice in state (65.7% vs 54.4%, P<.01), in primary care (69.0% vs 33.4%, P<.01), in family medicine (61.1% vs 17.3%, P<.01), and rurally (41.2% vs 13.9%, P<.01) than non-RPAP graduates. Conclusions: We demonstrate a significant association between participation in RPAP and a career in family medicine, rural practice, and primary care, all outcomes that promote meeting urgent rural workforce needs.

Relationship between AF-risk, ischemic stroke AF related, and cognitive dysfunction in population older than 65 years-old. MIND-COR study

Background The number of individuals with atrial fibrillation (AF) and cognitive impairment (CI) will increase 150% by 2050. Purpose The main objective of this study is to elucidate the relationship between AF-risk, the ischemic stroke, and the cognitive dysfunction. Methods Multicenter, longitudinal and retrospective community-based study of cohort ≥65 year-old without AF between 1/1/2013–31/12/2017 conducted by 11 Primary Care teams. Variables: sociodemographic; Charlson, CHA2DS2VASc score, Pfeiffer and NIHSS scores from records database (primary care, specialty clinics and hospitalizations). Kaplan-Meier to evaluate mortality. Descriptive analysis Cox regression to create an AF risk score was developed: Q1 (lowest AF-risk)-Q4 (highest AF-risk). Incidence density (ID) rate per 1000/people/years of AF and stroke; and CI prevalence were calculated by risk stratum. Approved by Ethics Committee of IDIAP Jordi Gol PP15/047. Results 46706 (women 49%) cases, aged 78.01±11.9 and average follow-up time 4.9±0.7 years. Q4 risk group (Q4) was characterized by women's (85.2%), highest age, AF, stroke, CI and mortality. 1244 AF were diagnosed (ID 10.5/1000/year's IC95% 9.9–11.2). Q3–4 levels included 53.8% of AF in men vs 84.2% in women. 214 strokes were diagnosed and 78.5% happened in Q3–4, especially among women (88.1%). The stroke and AF were diagnosed simultaneously in 9.8% (ID 5.8/1000/year CI95% 3.4–8.1) and showed higher severity (NIHSS 7.25±8.62 vs 4.55±5.74, p=0.002). The cognitive impairment increased from 2.6% (Q1) up to 16.4% (Q4) significantly higher in women (17.6% vs 12.1%) Conclusions Differences were found according to gender and risk groups. The risk-based screening could improve the effectiveness of AF screening in primary care. Funding Acknowledgement Type of funding source: None

The Role of North Carolina Medical Schools in Producing Primary Care Physicians for the State

Introduction: Primary care physicians serve on the front lines of care and provide comprehensive care to patients who may have difficulty accessing subspecialists. However, not enough students are entering residency in primary care fields to meet the primary care physician shortage. The authors sought to compare primary care match rates among graduates of medical schools in the state of North Carolina from 2014 to 2018. Methods: The 4 allopathic medical schools in the state of North Carolina were selected for this study: East Carolina University (ECU) Brody School of Medicine, University of North Carolina (UNC) Chapel Hill, Duke School of Medicine, and Wake Forest School of Medicine. Primary care specialties were defined as family medicine, internal medicine, pediatrics, and internal medicine/pediatrics. The proportion of students matching to a residency in any of these fields, and in each specific field, was compared across schools. Results: Over 2014-2018, 214 ECU Brody School of Medicine graduates, 386 UNC graduates, 165 Duke graduates, and 196 Wake Forest graduates matched to a primary care specialty. ECU had the highest proportion of its graduates match in a primary care specialty (53%, compared with 34% to 45% at other schools; P < .001), and was particularly distinguished by having the highest proportions of graduates match to residencies in family medicine (18%) and pediatrics (16%). Conclusion: During the study period of 2014-2018, the ECU Brody School of Medicine matched more medical students into primary care specialties than the other medical schools in the state. This school’s community-driven mission and rural location, among other characteristics facilitating sustained student commitment to primary care careers, can inform the development of new medical schools in the United States to overcome the primary care physician shortage.

Health System Implementation of a Tobacco Quitline eReferral

Background Proactive referrals through electronic orders (eReferrals) can increase patient connection with tobacco quitlines. More information is needed on “real-world” implementation of electronic health record tools to promote tobacco cessation while minimizing provider burden. Objectives This paper examines the health system implementation of an eReferral to a tobacco quitline without best practice alerts in primary care, specialty, and hospital settings in an academic health system. Methods This is a prospective implementation study of a health system tobacco eReferral to a state quitline that was completed with an approach to minimize provider cognitive burden. Data are drawn from electronic health record data at University of California, Davis Health Systems (March 2013–February 2016). Results Over 3 years, 16,083 encounters with smokers resulted in 1,137 eReferral orders (7.1%). Treatment reach was 1.6% for quitline services and 2.3% for outpatient group classes. While the group classes were offered to outpatient smokers, the eReferral order was included in an outpatient order set and eventually an automated inpatient discharge order set; no provider alerts were implemented. Referrals were sustained and doubled after inpatient order set implementation. Among all first time eReferral patients, 12.2% had a 6 to 12 month follow-up visit at which they were documented as nonsmoking. Conclusion This study demonstrates a quitline eReferral order can be successfully implemented and sustained with minimal promotion, without provider alerts and in conjunction with group classes. Reach and effectiveness were similar to previously described literature.

Early psychosis initiative in Japan

Psychiatric services in Japan have been dominantly hospital-based, and the largest task for psychiatry in Japan today remains the deinstitutionalization of patients, rather than early intervention. Individuals with mental health problems and their families are often reluctant to seek help for various reasons, including a lack of knowledge regarding the features and treatability of mental disorders. These obstacles may explain the long duration of untreated psychosis (DUP) and the social stigma of mental disorders in Japan. The concept of an at-risk mental state (ARMS)/prodromal state might not yet be widely recognized among Japanese psychiatrists. Competency in treating and diagnosing mild and moderate disorders should be integrated into training for the primary care specialty, and building the community-based network for early detection is the key strategy in Japan.

Effect of Regional Medical Campus Education on Student Pursuit of Primary Care Specialties

Purpose To investigate whether education at a regional medical campus (RMC) affects the likelihood of University of Washington School of Medicine (UWSOM) students choosing a primary care specialty. Method Two approaches were taken to answer the study question. First, the percentage of UWSOM students who matched to a primary care residency program between 1996-2016 was compared between two groups of students: those educated at an RMC and those educated at the academic medical center (a non-RMC). Second, physician specialty data was obtained from the AMA Physician Masterfile for UWSOM graduates from 1996-2011. Physicians were again split into RMC and non-RMC groups, and the percentage of primary care physicians was compared between the two groups. This study was completed in 2016. Results Among graduates from 1996-2016, 33% (564/1707) of those educated at an RMC were matched to a primary care residency program compared to 39% (787/2003) of students educated at the non-RMC (P < 0.001). Graduates from 1996-2011 had similar likelihoods of becoming a primary care physician regardless of first year education site (37% [395/1078] versus 39% [551/1403], P = 0.18, Figure 2). Conclusions The results of this study did not support the hypothesis that the WWAMI RMCs produce more primary care physicians than the non-RMC. A greater percentage of students who attended the non-RMC matched into a primary care residency program compared to the RMC group, while the percentage of students who ultimately chose a primary care specialty was quite similar. Financial support: Mr. Collins was supported in part for this study by the Smith Family Endowed Chair in Medicine. Ethical Approval: The University of Washington Institutional Review Board approved the acquisition and analysis of subject data. Application #52065. Approval date 5/24/2016.