Journal of General Internal Medicine

, Volume 27, Issue 11, pp 1438–1444

Outcomes for Resident-Identified High-Risk Patients and Resident Perspectives of Year-End Continuity Clinic Handoffs

  • Amber T. Pincavage
  • Shana Ratner
  • Megan L. Prochaska
  • Meryl Prochaska
  • Julie Oyler
  • Andrew M. Davis
  • Vineet M. Arora
Original Research
  • 243 Downloads

Abstract

BACKGROUND

Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.

OBJECTIVE

To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff

DESIGN

Retrospective cohort

PARTICIPANTS

Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009–2011. PGY2 IM residents surveyed from 2010–2011.

MEASUREMENTS

Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff.

RESULTS

Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P < 0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p < 0.001) and those lost to follow-up (21 % vs. 17 % NSR, p = 0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as “theirs” until they are seen by them in clinic.

CONCLUSIONS

While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.

KEY WORDS

outpatient handoffs signout resident continuity clinic year-end transfer transitions of care 

Supplementary material

11606_2012_2100_MOESM1_ESM.pdf (70 kb)
ESM 1(PDF 69 kb)

References

  1. 1.
    Young JQ, Wachter RM. Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. JAMA. 2009;302(12):1327–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Internal Medicine. Available at: http://www.acgme.org/acWebsite/RRC_140/140_prIndex.asp Accessed March 27, 2012.
  3. 3.
    Young JQ, Eisendrath SJ. Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons from the suicide of a psychiatric patient. Acad Psych. 2011;35(1):54–7.CrossRefGoogle Scholar
  4. 4.
    Wasson JH, Sauvigne AE, Moglelnicki RP, Frey WG, Sox CH, Gaudette C, Rockwell A. Continuity of outpatient medical care in elderly men. A randomized trial. JAMA. 1984;252(17):2413–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Caines LC, Brockmeyer DM, Tess AV, Kim H, Kriegel G, Bates CK. The revolving door of resident continuity practice. Identifying gaps in transitions of care. J Gen Intern Med. 2011;6(9):995–8.CrossRefGoogle Scholar
  6. 6.
    Roy MJ, Kroenke K, Herbers JE Jr. When the physician leaves the patient: predictors of satisfaction with the transfer of primary care in a primary care clinic. J Gen Intern Med. 1995;10(4):206–10.PubMedCrossRefGoogle Scholar
  7. 7.
    Roy MJ, Herbers JE, Seidman A, Kroenke K. Improving patient satisfaction with the transfer of care, a randomized controlled trial. J Gen Intern Med. 2003;18(5):364–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Young JQ, Niehaus B, Lieu SC, O’Sullivan PS. Improving resident education and patient safety: a method to balance caseloads at academic year-end transfer. Acad Med. 2010;85(9):1418–24.PubMedCrossRefGoogle Scholar
  9. 9.
    Young JQ, Pringle Z, Wachter RM. Improving follow-up of high risk psychiatry outpatients at resident year-end transfer. Jt Comm J Qual Patient Safety. 2011;37(7):300–8.Google Scholar
  10. 10.
    Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1:257–66.PubMedCrossRefGoogle Scholar
  11. 11.
    Arora VM, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Safety. 2006;32(11):646–55.Google Scholar
  12. 12.
    Arora VM, Manjarrez E, Dressler D, Basaviah P, Halasyamani L, Kriplani S. Hospitalist Handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7):433–40.PubMedCrossRefGoogle Scholar
  13. 13.
    Babbott SF, Beasley BW, Reddy S, Duffy FD, Nadkarni M, Holmboe ES. Ambulatory Office Organization for Internal Medicine Resident Medical Education. Acad Med. 2010;85(12):1880–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Pincavage AT, Ratner S, Arora VM. Transfer of graduating residents' continuity practices. J Gen Int Med. 2012;27(2):145.CrossRefGoogle Scholar
  15. 15.
    Edelson DP, Retzer E, Weidman EK, Woodruff J, Davis AM, Minsky BD, Meadow W, Hoek TL, Meltzer DO. Patient acuity rating: quantifying clinical judgment regarding inpatient stability. J Hosp Med. 2011;6(8):480–8.CrossRefGoogle Scholar
  16. 16.
    Knaus WA, Harrell FE Jr, Lynn J, Goldman L, Phillips RS, Connors AF Jr, Dawson NV, Fulkerson WJ Jr, Califf RM, Desbiens N, Layde P, Oye RK, Bellamy PE, Hakim RB, Wagner DP. The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Ann Intern Med. 1995;122(3):191–203.PubMedGoogle Scholar
  17. 17.
    Meadow W, Frain L, Ren Y, Lee G, Soneji S, Lantos J. Serial assessment of mortality in the neonatal intensive care unit by algorithm and intuition: certainty, uncertainty, and informed consent. Pediatrics. 2002;109(5):878–86.PubMedCrossRefGoogle Scholar
  18. 18.
    Sinuff T, Adhikari NK, Cook DJ, Schünemann HJ, Griffith LE, Rocker G, Walter SD. Mortality predictions in the intensive care unit: comparing physicians with scoring systems. Crit Care Med. 2006;34(3):878–85.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Amber T. Pincavage
    • 1
  • Shana Ratner
    • 2
  • Megan L. Prochaska
    • 3
  • Meryl Prochaska
    • 4
  • Julie Oyler
    • 1
  • Andrew M. Davis
    • 1
  • Vineet M. Arora
    • 1
  1. 1.Department of MedicineUniversity of ChicagoChicagoUSA
  2. 2.Division of General Medicine and EpidemiologyUniversity of North CarolinaChapel HillUSA
  3. 3.Internal Medicine Residency ProgramUniversity of ChicagoChicagoUSA
  4. 4.School of LawLoyola UniversityChicagoUSA

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