Lipid-lowering therapies are essential for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The aim of this study is to identify discrepancies between cholesterol management guidelines and current practice with a focus on statin treatment in an underserved population based in a large single urban medical center. Among 1042 reviewed records, we identified 464 statin-eligible patients. Age was 61.0 ± 10.4 years and 53.9% were female. Most patients were black (47.2%), followed by Hispanic (45.7%) and white (5.0%). In total, 82.1% of patients were prescribed a statin. An appropriate statin was not prescribed in 32.4% of statin-eligible patients who qualified based only on a 10-year ASCVD risk of ≥7.5%. After adjustment for gender and health insurance status, appropriate statin treatment was independently associated with age >55 years (OR = 4.59 (95% CI 1.09–16.66), p = 0.026), hypertension (OR = 2.38 (95% CI 1.29–4.38), p = 0.005) and chronic kidney disease (OR = 3.95 (95% CI 1.42–14.30), p = 0.017). Factors independently associated with statin undertreatment were black race (OR = 0.42 (95% CI 0.23–0.77), p = 0.005) and statin-eligibility based solely on an elevated 10-year ASCVD risk (OR = 0.14 (95% CI 0.07–0.25), p < 0.001). Hispanic patients were more likely to be on appropriate statin therapy when compared to black patients (86.8% vs. 77.2%). Statin underprescription is seen in approximately one out of five eligible patients and is independently associated with black race, younger age, fewer comorbidities and eligibility via 10-year ASCVD risk only. Hispanic patients are more likely to be on appropriate statin therapy compared to black patients.
Introduction It is estimated that approximately one-tenth of the US population suffers from substance use disorders (SUD), a problem that is compounded when one considers the impact that drug addiction could have on treatment outcomes for many other chronic diseases. Thus, addiction medicine has become an important component of many successful urban primary care practices and residencies across the country. Our program sought to improve the confidence of our residents in managing SUD by instituting a team-based learning (TBL) activity that focused on the diagnosis and medication-assisted treatment of these illnesses. Methods The class of 80 internal medicine residents were divided into groups of approximately 16 residents, and during the TBL sessions further divided into teams of three to four. Each TBL session consisted of an individual readiness assurance test, a group discussion of the correct answers, and a PowerPoint-based team application activity. Surveys were conducted for each group to assess the residents' attitudes after completing the activity. Results Of residents, 69 of 80 completed the survey. The response to the TBL exercise was overwhelmingly positive, with most residents in agreement that the activity increased their knowledge and confidence in diagnosing and treating patients with SUD. Discussion Overall, this TBL activity was well received by the residents and subjectively increased their competence in managing patients with SUD. In addition, our modification to the traditional TBL format suggested that the theories and spirit behind TBL can be successfully adapted to meet the challenges and intricacies of internal medicine residency education.
Background State medical licensing boards ask program directors (PDs) to complete verification of training (VOT) forms for licensure. While residency programs use Accreditation Council for Graduate Medical Education core competencies, there is no uniform process or set of metrics that licensing boards use to ascertain if academic competency was achieved. Objective We determined the performance metrics PDs are required to disclose on state licensing VOT forms. Methods VOT forms for allopathic medical licensing boards for all 50 states, Washington, DC, and 5 US territories were obtained via online search and reviewed. Questions were categorized by disciplinary action (investigated, disciplined, placed on probation, expelled, terminated); documents placed on file; resident actions (leave of absence, request for transfer, unexcused absences); and non-disciplinary actions (remediation, partial or no credit, non-renewal, non-promotion, extra training required). Three individuals reviewed all forms independently, compared results, and jointly resolved discrepancies. A fourth independent reviewer confirmed all results. Results Most states and territories (45 of 56) accept the Federation Credentials Verification Service (FCVS), but 33 states have their own VOT forms. Ten states require FCVS use. Most states ask questions regarding probation (43), disciplinary action (41), and investigation (37). Thirty-four states and territories ask about documents placed on file, 36 ask about resident actions, and 7 ask about non-disciplinary actions. Eight states' VOT forms ask no questions regarding resident performance. Conclusions Among the states and territories, there is great variability in VOT forms required for allopathic physicians. These forms focus on disciplinary actions and do not ask questions PDs use to assess resident performance.
Objective: To implement a modified team-based learning (TBL) approach in ambulatory care education-for a large Internal Medicine residency program with limited resources-and to evaluate its effectiveness.Methods: 91 medicine residents were exposed to a modified TBL curriculum, composed of high-yield topics for ambulatory medicine. All residents participated in 10 TBL sessions per academic year. One faculty and one chief resident developed the pre-session reading requirements, readiness assurance tests, and clinical case scenarios for each session and facilitated the TBL exercises. At the end of the academic year, residents were asked to complete an anonymous survey online.Results: 72.5% of residents completed the survey. 96% reported being actively engaged in the sessions and contributing substantially to the discussions. A majority expressed preference for future TBL sessions. Educational effectiveness of TBL was at least as good or better compared to traditional lectures. Both faculty and residents expressed very high satisfaction with our TBL format. Conclusion:We successfully implemented a one year modified TBL curriculum to teach high yield topics in outpatient internal medicine in a large, multi-site residency program. TBL resulted in high resident engagement in the classroom and high satisfaction with the format by both residents and faculty.
Heart failure (HF) affects approximately 6 million adults in the United States. Among those, 45-76% have comorbid obstructive sleep apnea (OSA). OSA leads to intermittent hypoxia and hypertension, resulting in an increased incidence of myocardial ischemia and accelerating the progression of HF.OSA is believed to be underdiagnosed in 85% of the patients. There is currently no guideline for screening for comorbid OSA in HF patients. Because of the potential adverse effects of untreated OSA, it is crucial to use a screening tool to identify HF patients who may have comorbid OSA early on. We chose STOP BANG Questionnaire to evaluate the likelihood of OSA based on symptoms, blood pressure, BMI, neck circumference, age and gender.Our Internal Medicine Resident Clinic provides care to a medically underserved population with above national average illiteracy rate (52%), poverty rate (27.4%), and uninsured rate (19.1%). Medical conditions are often diagnosed at later stages, poorly controlled and often progress to end stage disease. This progression is costly in terms of quality of life, financial burden, and mortality. Identifying heart failure patients with OSA is a critical step in alleviating some of the burden. METHODS:We generated a random list of 91 adult patients who were seen in the Internal Medicine Resident Clinic in 2020 who had diagnosis of systolic heart failure or diastolic heart failure. No exclusion criteria were used. Data was manually extracted from each of the 91 patients' charts with respect to age, gender, ethnicity, neck circumference, medication regimen, answers to the STOP BANG questionnaire if they were asked, HF classification, and history of OSA screening and referral.RESULTS: Among 91 patients, 19 (21%) patients were screened for OSA, 67 (74%) patients were not screened, and 5 patients were previously diagnosed with OSA. Among those screened for OSA, all (100%) patients had high risk of OSA based on STOP BANG questionnaire. Among eight patients referred to sleep study, four patients were later diagnosed with OSA and 4 patients did not proceed with sleep study. CONCLUSIONS:No studies yet have been done to evaluate the screening rate of comorbid OSA in HF patients in primary care setting. Studies done on evaluating screening rate of OSA in HTN and epileptic patients in primary care academic clinics show a screening rate between 1-3.3%. Our clinic has a higher rate of screening at 21%. With all patients screened having high risk of OSA, we are likely only screening for patients for whom we already have a high suspicion. However, there is a potential of underscreening symptomatic patients and delaying their diagnosis and treatment.
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