Advisory Committee on Training in Primary Care Medicine and Dentistry

MINUTES OF MEETING, MAY 17-18, 2004

Approved on August 20, 2004

Advisory Committee Members Present

Gregory Strayhorn, MD, PhD, Chair
David P. Asprey, PhD, PA-C, Vice Chair
Margaret I. Aguwa, DO, MPH, Member
Rudolfo R. Burquez, DDS, Member
Tina L. Cheng, MD, MPH, Member
Alan K. David, MD, Member
Michael W. Donohoo, DDS, Member
Sanford J. Fenton, DDS, MDS, Member
Charles H. Griffith III, MD, MSPH, Member
Bonnie Head, MD, Member
Warren A. Heffron, MD, Member
Christopher M. Howard, MD, Member
Matilde M. Irigoyen, MD, Member
Man Wai Ng, DDS, MPH, Member
Rubens J. Pamies, MD, Member
Joseph L. Price, PhD, Member
Eugene C. Rich, MD, Member
Jimmy L. Simon, MD, FAAP, Member
Raymond J. Tseng, Member
Craig Whiting, DO, FACFP, Member

Others Present
Stephen Smith, Senior Advisor, Health Resources and Services Administration
David Rutstein, MD, Deputy Associate Administrator for the Bureau of Health Professions
Donald L. Weaver, MD, Assistant Surgeon General
Jerilyn K. Glass, MD, PhD, Acting Deputy Executive Secretary

Monday, May 17, 2004

The Advisory Committee on Training in Primary Care Me dicine and Dentistry (Advisory Committee) convened at 8:38 a.m. in the Versailles I Room of the Holiday Inn Select, 8120 Wisconsin Avenue , Bethesda , Maryland 20814 . Gregory Strayhorn, MD, PhD, Chair, opened the meeting and introduced Stephen Smith, Senior Advisor, Health Resources and Services Administration (HRSA). Mr. Smith, on behalf of Dr. Elizabeth M. Duke, HRSA Administrator, thanked retiring members of the Advisory Committee and welcomed new members. Referring to the Advisory Committee's fifth report, Mr. Smith underscored the importance of measuring program outcomes. The better HRSA is able to demonstrate a tangible strengthening of the

health care workforce so as to improve the health of the Nation, the better it will be able to determine the direction and funding levels of its health programs. Mr. Smith reviewed a number of Agency initiatives including expansion of the country's health centers. HRSA now supports nearly 3,700 sites across the country. The National Health Service Corps continues to expand with an estimated 4,000 or more clinicians anticipated to be in the field in 2004. He described

the National Bioterrorism Hospital Preparedness Program, funded at approximately 500 million dollars a year, which increases the surge capacity of hospitals. Mr. Smith outlined an increased emphasis on oral health care, including new requirements for health centers to provide primary, preventive, and supplemental oral health services. He described training programs for service providers in sub-Saharan Africa and the Caribbean who treat patients with HIV/AIDS, efforts to increase organ donation, and collaborations with health agencies in Me xico .

Dr. Strayhorn introduced David Rutstein, MD, Deputy Associate Administrator for HRSA's Bureau of Health Professions. He updated the Advisory Committee on the Bureau's efforts to document program outcomes. Because the Bureau's programs vary in purpose, constituents, and effect on institutions, the aim is to find a common means of measuring program performance at the grantee level. The Bureau wants to be able to aggregate outcomes across programs in order

to describe their impact on the Nation's health, a goal for which individual grantees will not be held accountable. Eight common areas have been identified, including training professionals, increasing diversity in the workforce, and increasing access to care. Strategic planning will continue with an all-grantee meeting in June, 2005.

Donald L. Weaver, MD, Acting Director of the Division of Me dicine and Dentistry, thanked staff for their work and gave an update on the Division's efforts to fill three key management positions. In his review of Title VII, section 747 grant programs, Dr. Weaver stated that of 254 grant applications, 191 were recommended for approval, and between 90 and 100 of them most likely will be funded. He highlighted the results of a recent National Oral Health Conference where dental public health residents presented projects. He described the purpose of the Children's Hospital Graduate Me dical Education Program and stated that payments have been made to more than 60 participating hospitals. In reference to previous comments on outcomes of educational programs, Dr. Weaver stressed the value of documenting and disseminating curricular change.

Dr. Strayhorn welcomed new members and asked all members of the Advisory Committee to introduce themselves. Staff members were thanked and asked, too, to introduce themselves.

To begin the discussion on the Advisory Committee's fourth report, Eugene Rich, MD, gave a report of the Writing Group's one-day meeting in Rockville on March 30, 2004 . The Advisory Committee finalized the recommendations of the report and determined the types of accomplishment data for Title VII, section 747 grant programs to be included.

David P. Asprey, PhD, PA-C, led the selection process for a new vice chair for the Advisory Committee to fill the seat vacated by Frank Catalanotto, DMD. Man Wai Ng, DDS, MPH Committee, was unanimously elected vice chair.

After lunch, the meeting reconvened at 12:39 p.m to continue discussion on the fourth report, including consideration of an appropriate title and changes to the abstract. The membership was asked to e-mail staff any further changes to the report within one week of the meeting.

Dr. Asprey described the Outcomes Subcommittee's work since the last meeting. Discussion continued on the development of a conceptual framework that would help others understand what Title VII, section 747 programs do and their impact. The Subcommittee recommended that the fifth report focus primarily on education-related outcomes. Workforce-related outcomes should be included, but receive less emphasis. Dr. Asprey presented potential strategies for framing outcomes. He showed a conceptual matrix that had didactic and clinical experience categories for student knowledge, skills, and attitudes. Another approach would be examination of effects on curricula, learners, teachers/preceptors, and community. He showed a depiction of educational experience as but one element that influences a clinician to choose to practice in an underserved, primary care setting.

The Advisory Committee made a number of points about appropriate outcomes for Title VII, section 747 programs. Perhaps programs should be held accountable only for what program directors could plausibly do with the resources they receive. Perhaps the focus should be on curricular innovations of these programs, the impact the curriculum has on the institution, and how curricula are disseminated. The key will be to determine outcomes that should be measured and recommend a standard measurement so that evaluation can be done across programs. A major difficulty is that programs have not been asked to track graduates. One part of the report might review the literature that cites the impact of Title VII, section 747 programs.

Dr. Strayhorn suggested further development of the conceptual model to include all elements that should be operationalized, in order to evaluate program outcomes. The components of the model should reflect training of medical students, residents, and faculty. He stressed that the legislative language authorizing Title VII, section 747 programs should be kept in mind. There was discussion about the difference between the measurement of short-term and long-term goals.

There was no public comment. The meeting was adjourned at 4:23 p.m.

Tuesday, May 18, 2004

The Advisory Committee re-convened at 8:06 a.m. Dr. Asprey led the continued discussion on outcomes, first summarizing key ideas from the preceding day. The Advisory Committee liked the theme of “training the workforce.” There was support for 1) proposing an ideal evaluation of outcomes as opposed to the current paradigm, 2) developing a theoretical framework for Title VII, section 747 programs, 3) developing a conceptual model or matrix that would further delineate the educational activities associated with programs, 4) proposing a new evaluation method for educational interventions within grant programs, and 5) reporting on the dissemination of curricular innovations. Reference should be made to studies in the literature that indicate a link between what primary care clinicians do and specific improved National health outcomes and health expenditures.

The discussion focused on three categories of outcomes: educational outcomes, workforce- related outcomes, and quality of healthcare outcomes. While the primary focus should be on educational outcomes, attention should be given to the others indirectly. For example, data that already exists that shows that primary care clinicians have a significant impact where they are practicing should be linked indirectly to the training they received because Title VII, section 747 programs are the only funded programs that develop curricula to train primary care physicians. Consideration might be given to the evaluation of the impact of these training programs within the institution where they were developed. To determine how results are being disseminated, evaluation might be directed to the number of manuscripts and National meeting presentations on Title VII, section 747 programs.

Among the things that program directors could be expected to accomplish is student aspiration to practice primary care or practice in an underserved area. While actual career choice is influenced by many factors, aspiration may be considered predictive. While practice location may be important in medicine, in dentistry it's the nature of the practice; in other words, the percentage of patients who are Me dicaid patients. It may be important to keep in mind data that indicate that the strongest predictors of whether students will go into primary care are what they did prior to getting into medical school, particularly the amount of serious service work. Also predictive is the area from which students come; the best example is students from rural areas serving in rural areas after graduation. The Advisory Committee recognized that the link to practice location might be more easily made with residency programs as opposed to pre-doctoral programs.

It was suggested that studies that have looked at primary care physicians in certain areas and their quality outcomes as compared to non-primary care physicians might be useful. A consideration might be given to anecdotal information about a specific piece of the curriculum that has been funded by Title VII, section 747 and linking it to better health outcomes. There was discussion about examining whether placement of primary physicians and dentists has an impact on a reduction in emergency room care that should be more appropriately delivered in clinics and doctors' offices and tying educational programs in general to societal priorities. As far as educational outcomes, it was deemed important to go beyond the measurement of knowledge, skills, and attitudes and include competencies. One notion was to use standardized patients in the evaluation, although the cost involved might be prohibitive.

Specific examples of outcomes were discussed. It may be valuable to emphasize the responsiveness of Title VII, section 747 programs to emerging issues showing how programs have incorporated the needed training into curricula. For example, an outcome would be the number of professionals these programs train in the area of cultural competence. A suggestion to the Agency would be to require these data from grantees. The notion of using workforce outcomes was re-visited and not everyone was in agreement. Some felt that Title VII programs should not be held accountable for where graduate ultimately go to practice because there are too many other determinants of career choice. It was emphasized that uniform definitions for outcomes and their measurement would be needed in any assessment of outcomes.

Possible speakers with expertise in outcomes measurement were suggested for the October meeting. The Executive Committee will work with staff to formulate the meeting's agenda.

The Advisory Committee returned to the recommendations set forth in the fourth report on the future of primary care. It was decided to change the first recommendation to read “Specifically, funding for Title VII, section 747 programs should be doubled over the next 5 years to assure adequate funding to meet critical health care needs.”

The recommendations for the fourth report are as follows:

1. To prepare future primary health care providers with the training to adequately meet the emerging challenges to the health of the public, Title VII, section 747 grant programs require expanded financial resources. Specifically, funding for Title VII, section 747 programs should be doubled over the next 5 years to assure adequate funding to meet critical health care needs.
2. Title VII, section 747 training programs should develop and disseminate educational innovations in the use of information technology for quality care, prevention of medical errors, evidence based practice, and patient and provider communication.
3. Title VII, section 747 funding should support primary care medical and dental training programs that utilize integrated interdisciplinary team models and innovative health care designs.
4. Title VII, section 747 funding should support primary care medical and dental faculty development programs that incorporate concepts and skills related to interdisciplinary practice models and innovative health care designs.
5. Title VII, section 747 funded programs should ensure future primary care providers have the knowledge, skills and competencies to deliver culturally effective and community oriented care.
6. Title VII, section 747 programs should develop and support primary care educational infrastructures that focus on community collaborations and outreach.
7. Title VII, section 747 programs should develop innovative educational strategies that address emerging population needs and scientific advances, such as patient safety, prevention, chronic illness care, health disparities, genomics and first response strategies to public health hazards.

There were no comments from the public. The meeting was adjourned at 11:07 a.m.