Background: The continuity provided by longitudinal clerkships has documented benefits to medical student education. Yet, little quantitative data exist on the association between longitudinal clerkships and patient outcomes.Objective: This study compares screening metrics of a longitudinal clerkship called the education-centered medical home (ECMH) with the standard clinical model at a student-volunteer free clinic (SVFC). In the ECMH model, the same attending physician staffs one half-day of clinic with same group of students weekly for 4 years. Standard clinical models are staffed with students and physicians who come to the SVFC based on availability.Design: ECMH students aimed to increase human immunodeficiency virus (HIV) screening rates in their patient panel as part of a quality improvement project. Students prepared individualized care plans prior to patient visits that included whether screening had been performed. They were also reminded to confirm completion of testing. Percentages of patients screened for HIV before and after establishment of the ECMH were compared with four standard clinical models. Screening rates for breast, colon, and cervical cancer, as well as hepatitis C, served as secondary endpoints.Results: While screening rates were initially similar between models (43.2% and 34.8% for the ECMH and standard clinical panels, respectively, p = 0.32), HIV screening rates increased from 43.2% to 95.0% in the ECMH compared with a significantly smaller increase from 35.0% to 50.0% in the standard clinical panel (p < 0.0001). Additionally, the ECMH resulted in statistically significantly increased screening rates for cervical cancer (p < 0.001) and hepatitis C (p < 0.0001).Conclusions: This study demonstrates an association between a longitudinal ECMH clerkship and improved quality metrics at an SVFC. Even measures not targeted for intervention, such as colorectal cancer and hepatitis C, showed significant improvement in screening rates when compared with the standard clinical model.
Background Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics. Methods A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews. Results Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools’ ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools’ diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools’ prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge. Conclusions The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear ‘gold-standard’ singular prehospital triage tool for acute undifferentiated patients. Trial registration Not applicable.
Tobacco cessation is an important intervention to reduce mortality from ischemic heart disease, the leading cause of death in India. In this study, we explored facilitators, barriers, and cultural context to tobacco cessation among acute coronary syndrome (ACS, or heart attack) patients and providers in a tertiary care institution in the south Indian state of Kerala, with a focus on patient trajectories. Patients who quit tobacco after ACS expressed greater understanding about the link between tobacco and ACS, exerted more willpower at the time of discharge, and held less fatalistic beliefs about their health compared to those who continued tobacco use. The former were motivated by the fear of recurrent ACS, strong advice to quit from providers, and determination to survive and financially provide for their families. Systemic barriers included inadequate training, infrequent prescription of cessation pharmacotherapy, lack of ancillary staff to deliver counseling, and stigma against mental health services.
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