Location, Location, Location: Where We Teach Primary Care Makes All the Difference

Creating a new model to train a high-quality primary care workforce is of great interest to American health care stakeholders. There is consensus that effective educational approaches need to be combined with a rewarding work environment, emphasize a good work/life balance, and a focus on achieving meaningful outcomes that center on patients and the public. Still, significant barriers limit the numbers of clinicians interested in pursuing careers in primary care, including low earning potential, heavy medical school debt, lack of respect from physician colleagues, and enormous burdens of record keeping. To enlarge and energize the pool of primary care trainees, we look especially at changes that focus on institutions and the practice environment. Students and residents need training environments where primary care clinicians and interdisciplinary teams play a crucially important role in patient care. For a variety of reasons, many academic medical centers cannot easily meet these standards. The authors propose that a major part of primary care education and training be re-located to settings in high-performing health systems built on comprehensive integrated care models where primary care clinicians play a principle role in leadership and care delivery

Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study

Purpose: To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting. Methods: This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. the program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. the network administration and an external consultant provided performance feedback and benchmarking within the network. the primary outcome was compliance with the resuscitation bundle. the secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness. Results: the proportion of patients who received all the required items for the resuscitation bundle improved from 13 % [95 % confidence interval (CI) 8-18 %] at baseline to 62 % (95 % CI 54-69 %) in the last trimester (p < 0.001). Hospital mortality decreased from 55 % (95 % CI 48-62 %) to 26 % (95 % CI 19-32 %, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95 % CI 0.56-0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95 % CI 23.9-35.4) to 17.5 (95 % CI 14.3-21.1) thousand US dollars from baseline to the last 3 months (mean difference -11,815; 95 % CI -18,604 to -5,338). the mean QALY increased from 2.63 (95 % CI 2.15-3.14) to 4.06 (95 % CI 3.58-4.57). for each QALY, the full compliance saves US$5,383. Conclusions: A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. the intervention was cost-effective and associated with a reduction in mortality.Hosp Paulistano, Unidade Terapia Intens, BR-01321001 São Paulo, BrazilUniv São Paulo, Unidade Terapia Intens, Hosp Clin, Disciplina Emergencias Clin, BR-05403000 São Paulo, BrazilLatin Amer Sepsis Inst, BR-04039002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Disciplina Anestesiol, BR-04024900 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Disciplina Anestesiol, BR-04024900 São Paulo, BrazilWeb of Scienc