SRCA Faculty Projects

2012 Summer Student Research and Clinical Assistantship Program Faculty Research Abstracts

1. Approach to non-responsive pneumonia diagnosed in the primary care office
2. Difficult patients: exploring the patient perspective
3. Virtual reality home visit- teaching home safety
4. Parental knowledge of their children's vaccination status
5. Pedometer walking program with farmers in Shawano County
6. Irrigation for chronic rhinosinusitis and fatigue in patients with Gulf War Illness
7. Patients' experience of PCMH transformation in an urban family medicine clinic
8. Using EMR Data to Evaluate Obesity Prevalence in Pregnancy
9. Mammograms for women in their 40s: Developing clinical guidelines from the evidence

1. Title:  Approach to non-responsive pneumonia diagnosed in the primary care office
Faculty: Dennis J. Baumgardner, MD
Location: Center for Urban Population Health (CUPH), Milwaukee, WI

Background: Community-acquired pneumonia (CAP) is frequently diagnosed and successfully treated by primary care clinicians in the office setting. There is little in the literature regarding the management of non-responsive pneumonia in this setting. Initial treatment failure occurs in 6 - 7 % of patients treated for pneumonia in the ambulatory setting. Bacterial resistance, other issues related to antibiotic choice or patient factors likely explain many cases. Non-bacterial infections and non-infectious processes result in treatment failure in some cases of presumed bacterial CAP. Delay in diagnosis of alternative etiologies may worsen outcome or lead to death. We hypothesize that apparent non-responsive CAP may often be treated with change of antibiotic, rather than consideration of other etiologies.

Proposed Methods: We propose to construct a scenario-based on-line survey of primary care clinicians to be distributed through the Wisconsin Research and Education Network (WREN) Survey Group. Participants will be presented with a scenario of a healthy, non-allergic adult non-smoker with extensive in-state travel and recreation, an indoor job and no ill contacts. The scenario patient will have mild temperature elevation, no distress, common CAP symptoms and localized lung findings. The participant is then taken down one of two branches of the scenario depending on whether or not a chest X-ray is ordered, and indicates diagnostic tests and medications actually used if/when managing such a case. The scenario patient is then presented as having returned without response, and the cycle repeats.

Student Role: Role of the SSRCA student will include background reading and literature review; survey preparation (using evidenced-based guidelines for work-up and treatment), and/or organization of data and statistical analysis (with D. Baumgardner); and preparation of charts and graphs and abstract and manuscript writing.

2. FULL Difficult patients: exploring the patient perspective
Faculty: Jennifer Edgoose, MD, MPH
Location: Northeast Clinic, 3209 Dryden Drive, Madison, WI

Background: The Faculty Mentor has a particular interest in "difficult" patients and has a project underway that introduces a tool to assist clinical learners in improving their own experience with patients they identify as "difficult." While the former study encourages the learner clinician to explore their own unique biases and feelings in relation to the social context and agenda of their patient, this proposed study explores more directly the perspective of the patient. Studies show there are certain characteristics that are typical of "difficult" patients which include unmet expectations; less satisfaction with patient care; and higher use of health services. Should we not, therefore, ask these patients directly what needs and hopes they have for a more successful encounter?

Proposed Methods: During that often frustrating period in the waiting room, a questionnaire be offered to established adult patients checking into the Northeast Clinic. The patients may answer in writing if they choose to or may be interviewed formally by the medical student. I propose the following questions:

1. What would most improve your visit to the clinic?
2. What do you want your medical provider to know about you?
3. How would you describe yourself?
   1. An easy patient
   2. A typical patient
   3. A complicated patient
   4. A difficult patient
   5. None of the above.  Please explain:

Providers will determine which patients they consider "difficult" which will be linked to the coded anonymous surveys. We will then analyze whether any qualitative differences arise in the answers to these questions between patients identified as "difficult" and those not-difficult patients.

3. Title: Virtual reality home visit- teaching home safety
Faculty: Irene Hamrick, MD
Location: Madison, WI

Background: We have developed a virtual reality home visit, similar to a video game, to make health care providers and patients more aware of home safety. Falls are the leading cause of death of older adults and accidents in the home are the most common place. Our goal is to teach about hazards in the home and make home visits more comprehensive, uniform and testable. With the click of a mouse or keyboard arrow keys the player moves through the 3-D virtual reality home to identify hazards. The computer keeps track of the hazards identified and gives feedback at the end of the "walk through".

Proposed Methods: Our research is using a pre- and posttest to assess learning from the simulation. We will enroll 300 students of various disciplines, including medicine, physician assistant, nursing, physical therapy, occupational therapy, etc. In addition to demographic information, we will obtain feedback on its use to make improvements of the software. Additionally, we will take a small group of learners on house calls and make comparisons of learning between the virtual and live home visit. The student will be able to come along for the house calls and to nursing home rounds in the area. We have beta tested the questionnaire and software and have made improvements. As the student you will be able to help us further improve the questionnaire and then enroll participants to test the simulation.

4. Title: Parental knowledge of their children's vaccination status
Faculty: Paul Hunter MD, UW SMPH; Associate Medical Director, City of Milwaukee Health Department; Angela Hagy MSPH, Infectious Disease Epidemiologist, Immunization Program Manager, MHD
Location: City of Milwaukee Health Department, Milwaukee, WI

Background: Immunization rates of children in Milwaukee are lower than the rest of Wisconsin. A previous survey by the Milwaukee Health depatment showed that parents did NOT have philosophical or religious objections to having their children vaccinated. The manager of the immunization program at MHD proposed modifying the previous survey to see if low immunization rates might be in part due to parents thinking that their children are up to date on shots, when records show they still need vaccinations.

Proposed Methods: A 3rd year medical student in TRIUMPH already developed the modified survey and obtained exempt status for the study from the UW institutional review board. The SSRCA student would work with MHD staff to recruit interviewees from the waiting rooms at WIC clinics (WIC = Women, Infants, & Children supplement food program) operated by MHD. Parental responses to surveys will be compared to records of vaccinations given as listed in the Wisconsin Immunization Registry (WIR, an electronic database) and as listed in the child's medical record. It is anticipated that parents will think their children have had more vaccinations than have been recorded in the immunization registry and in the medical record. If the results are as expected, educational efforts of MHD and the Immunize Milwaukee Coalition may be directed at increasing parental knowledge about missing vaccinations, so that parents can advocate for their children to get vaccinations up-to-date during doctors' visits and at health department vaccination clinics.

5. FULL Pedometer walking program with farmers in Shawano County
Faculty: Rhonda Strebel, Executive Director, Rural Health Initiative, Shawano WI; Yuchin Fang, MD, Shawano Medical Center; Paul Hunter MD, UW SMPH
Location: Rural Health Initiative, Shawano WI

Background: Shawano County, population 42,000, is located in northeastern Wisconsin and has high prevalence of overweight adults (42% by self report). As part of its mission to improve the health and safety of Shawano County farmers, the Rural Health Initiative (RHI) has already focused on healthy eating and good nutrition habits with its farming population. A UW medical student (Alison Gold) on her 4th Year Preceptorship and the director of RHI propose to lower weight of farmers by increasing physical activity with a program using pedometers.

Proposed Methods: Farmers already affiliated with RHI will be recruited to participate in the pedometer program. The height and weight of farmers will be measured and a short pre-project questionnaire regarding views on physical activity will be administered by the student and RHI nurses in the farmers' homes. The farmers will be given a pedometer, taught how to use it and asked to continue with regular activity while recording daily steps. After 4-6 weeks the medical student would gather the data sheets of daily step counts and re-measure the farmers' heights and weights and give the same questionnaire as a post-test to establish any changes in behavior and views of physical activity. We expect minimal decreases in weight and modest increases in physical activity and positive views toward activity through the study period. If the results are as expected, this program may be expanded to additional farmers in Shawano County and elsewhere for further study, especially of whether the results are sustainable.

6. Title: Nasal Irrigation for chronic rhinosinusitis and fatigue in patients with Gulf War Illness
Faculty: David Rabago, MD
Location: UW Department of Family Medicine, Madison, WI

Overview: The student will work with David Rabago on a study testing two forms of nasal irrigation (NI) for chronic rhinosinusitis (CRS) and fatigue in patients with Gulf War Illness. The 3-year study is federally funded, submitted to the IRB (UW Ethics Board), and in the pre-enrolment phase. Enrolment is planned for the summer of 2012. Goals for the student are to work closely with the principal investigator and DFM-IT personnel to develop an online information page to facilitate subject recruitment.

Background: Gulf War Illness (GWI) has tremendous impact to quality of life. Sinus symptoms and fatigue are the first (47%) and third (41%) most common symptoms in GWI. Two forms of NI may be effective adjunctive therapy for GWI: saline NI is hypothesized to improve sinus symptoms by thinning and clearing mucus and inflammatory mediators. Xylitol NI (X-NI) has been shown to enhance antimicrobial properties of nasal mucosa.

Specific Aims-Hypotheses: The specific aims of this 3-arm randomized controlled trial (n=75) are to determine whether routine care plus S-NI, or X-NI, compared to routine care alone, result in improved health-related quality of life, are cost-effective and decrease proinflammatory bias in subjects with GWI with CRS and fatigue.

Proposed Methods: The student will work closely with the PI-Study team to develop an online webpage to facilitate subject recruitment. IT experience is helpful but not necessary. S/he will gain content expertise in NI and in "clinical trialsmanship". S/he may participate as desired in the conduct of several other projects in varying stages of completion. The PI works well with students; prior summer students have had successful experiences leading to peer-reviewed publications and abstract presentations.

7. FULL Patients' experience of PCMH transformation in an urban family medicine clinic
Faculty: Kirsten Rindfleisch, MD; Beth Potter, MD
Location: Wingra Family Medical Center, Madison, WI

Background: Wingra Family Medical Center is one of the UW Department of Family Medicine's residency clinic sites. Located in south Madison, the clinic serves an economically and ethnically diverse patient population, including a large number of uninsured patients. Wingra is currently in the early phase of planning for application for NCQA recognition as a Patient-Centered Medical Home (PCMH). In the last one to two years, a tremendous amount of scholarly work has been published in the medical literature addressing the PCMH model, including early outcomes from a national demonstration project. Every national conference in our discipline includes multiple lectures and workshops offering guidance for clinics embarking on this effort. PCMH is quite clearly the hottest topic in academic primary care. It is therefore surprising that almost nothing has been written addressing the experience of patients during this process of transformation.

Proposed Methods: We propose to study our patients' experience, beginning in this early planning phase, and continuing through the submission of our NCQA application. The research will likely include a combination of written and telephone surveys, meetings with our patient advisory panel, and dedicated focus groups.

8. FULL Using EMR Data to Evaluate Obesity Prevalence in Pregnancy
Faculty: Brian Arndt, MD
Location: Verona Family Medical Center, Verona, WI

Background: Given the potential health risks of obesity during pregnancy to both mother and infant, it is important to determine the prevalence of obesity during pregnancy, identify current efforts to manage it, and track the efforts to determine what, if any, additional interventions are needed. The project will examine the prevalence of obesity among pregnant women, maternal weight gain during pregnancy, and the clinical management of obesity during pregnancy.

Proposed Methods: Methods: Electronic medical record (EMR) data from the University of Wisconsin Medical Record Public Health Information Exchange (UW-PHINEX) database (a data exchange between the University of Wisconsin Department of Family Medicine (DFM) and Wisconsin State Division of Public Health) will be used to determine: 1) the prevalence of obesity among pregnant women by identifying the maternal BMIs at the start of all pregnancy episodes in the database, 2) differences in weight gain patterns during the course of pregnancy among women of different pre-pregnancy BMI classes, and 3) frequency of weight-management counseling provided during prenatal care.

Anticipated Student Roles: The student will: 1) conduct a literature review and gain an understanding of risks associated with maternal obesity during pregnancy, guidelines for recommended weight gain during pregnancy, and appropriate management of obesity during pregnancy, 2) review the UW-PHINEX EMR database to identify, clean, and analyze variables of interest in assessing prevalence of maternal obesity during pregnancy, weight gain trends during pregnancy, and clinical management of obesity during pregnancy, and 3) follow the prenatal care of DFM patients gaining direct experience in the clinical management of obesity during pregnancy.

9. FULL Mammograms for women in their 40s: Developing clinical guidelines from the evidence
Faculty: Sarina Schrager, MD, MS
Location: Northeast Family Medical Center, Madison, WI

Background: Breast cancer is very common in women. In the US, over 40,000 women die each year from this disease. Although breast cancer is more common in women as they get older, between 1 and 2% of women will get breast cancer in their 40s. Mammograms are a good screening tool for breast cancer in women over the age of 50. More controversy exists about screening women in their 40s. The USPSTF recommended that women not start screening mammograms until 50; a recommendation that provoked a lot of controversy. Subsequently, recommendations on screening mammograms among women in their 40s have varied widely.

Proposed Methods: This project aims to gather all of the different recommendations, evaluate the original evidence, and develop a clear clinical guideline for primary care clinicians to use in practice. The final paper will help practicing clinicians counsel their forty year old women effectively about the risk of developing breast cancer and the value of a screening mammogram.