Advisory Committee on Training in Primary Care Medicine and Dentistry

MINUTES OF MEETING, FEBRUARY 10-11, 2005

(Approved on May 5, 2005)

Advisory Committee Members Present
Eugene C. Rich, MD, Chair
David P. Asprey, PhD, PA-C, Vice Chair
Man Wai Ng, DDS, MPH, Vice Chair
Tammy L. Born, DO, Member
Rodolfo 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
Michelle Hauser, PA-C, Member
Bonnie Head, MD, Member
Warren A. Heffron, MD, Member
Christopher M. Howard, MD, Member
Matilde M. Irigoyen, MD, Member
Rubens P. Pamies, MD, Member
Joseph L. Price, PhD, Member
Gregory Strayhorn, MD, PhD, Member
Raymond J. Tseng, Member
Craig D. Whiting, DO, FACFP, Member

Others Present
Elizabeth M. Duke, Administrator, HRSA
Kerry Paige Nesseler, RN, MS, Associate Administrator for Health Professions
Tanya Pagán Raggio, MD, MPH, FAAP, Director of Division of Medicine and Dentistry and Executive Secretary of the Advisory Committee
Jerilyn K. Glass, MD, PhD, Deputy Executive Secretary of the Advisory Committee
O’Neal A. Walker, PhD, Chief, Dental and Special Projects Branch, Division of Medicine and Dentistry

Thursday, February 10, 2005

The Advisory Committee on Training in Primary Care Medicine and Dentistry (Advisory Committee) convened at 8:30 a.m. in the Plaza Ballroom of the DoubleTree Hotel, 1750 Rockville Pike, Rockville, Maryland 20852.  Eugene C. Rich, Chair, opened the meeting and introduced Elizabeth M. Duke, Administrator of HRSA.

In her welcoming remarks, Dr. Duke stressed the importance of programs being able to demonstrate results.  She said the Agency is committed to maintaining the safety net and supporting direct involvement in the healthcare of America.  With an investment of over six billion dollars in general health professions training, challenges remain in outputs being consistent with priorities.  Only about 20 percent of graduates from HRSA-supported grant programs take jobs working with the underserved.  Dr. Duke foresees the Agency reaching its goal of 1200 new community health centers by 2006 and stated that funding will be requested for 40 new sites in high-poverty counties.  She said that about half the professionals in the National Health Service Corps (NHSC) take jobs in health centers, and 55 percent of the Corps who entered practice in underserved areas are providing service there 15 years later.  Of the 30,000 professionals needed for the health center expansion, 11,000 will be clinicians.  Dr. Duke described the Agency’s commitment to partnerships with regional commissions, oral and mental health services in primary care, improved use of technology in HRSA’s programs, and its hospital preparedness program. 

Dr. Rich introduced Tanya Pagán Raggio, MD, MPH, FAAP, Director, Division of Medicine and Dentistry and Executive Secretary of the Advisory Committee.  Dr. Raggio said that to date the Primary Care Medical Education Branch had received 250 grant applications, and she outlined the schedule of grant reviews.  She said that the Title VII, section 747 grant guidance for the first time this year included support for interdisciplinary collaborations between family practice medicine and oral health programs.  This fiscal year, 40 of the grants were in dental areas and of those, 20 were new applications.  With regard to the Advisory Committee’s fifth report, Dr. Raggio pointed out that the authorizing legislation for Title VII, section 747 states that special consideration be given to “projects which prepare practitioners to care for underserved populations...”  This statement is consistent with the Advisory Committee’s often expressed suggestion that medically underserved communities should not be defined by geography alone.  That concern has been taken to the Bureau of Health Professions. 

The minutes of the October 21-22, 2004 meeting were approved by the Advisory Committee.

Man Wai Ng, DDS, MPH, Co-Chair of the Fifth Report Writing Group, provided an update of the group’s meeting on December 3, 2004.  The group concluded that the report should focus on primary care and primary care education and training outcomes, but also make linkages to workforce- and healthcare-related outcomes using an evidence-based approach.  The report should discuss the relationship of Title VII, section 747 programs to other programs in the Bureau, including the NHSC and community health centers, and should present the pipeline model for primary care health professions training.  There was discussion of societal, demographic, and market forces that contribute to the supply, distribution, and diversity of primary care providers.  The group suggested that the report be clearer on outputs and outcomes, and the background more policy relevant.  Dr. Ng stated that the presentation given by P. Preston Reynolds, MD, PhD, Chief, Primary Care Medical Education Branch, on the legislative history of Title VII, section 747 gave a good perspective on the intent of these programs, and these historical materials should be included in the report’s background and section on outcomes.

Eric Moore, contract writer for the fifth report, briefly described the approach his team used to develop the near- and long-term outcomes and logic model. 

Kerry Paige Nesseler, RN, MS, Associate Administrator for Health Professions, was invited by Dr. Rich to give remarks.  She reported that the Bureau has collected logic models and performance measures from all 40 of its programs.  The performance data will be aggregated in the context of Bureau goals and linked to 12 health status outcomes, using National data sets.  The purpose is to say:  because we are health care providers, because we are primary care, because of the professional training that we receive, when we go out to serve, we are the ones that make the difference in the healthcare of America.  The logic models will be discussed at the Bureau’s All-Grantee Meeting June 1-3, 2005.  Captain Nesseler said the plan is to pilot test actual measures and develop data-collection tools.  She described the ready-responder program which has sent healthcare providers for Florida hurricane relief and for tsunami relief.

The Advisory Committee started work on its fifth report with a discussion of suggested changes to the objectives for Title VII, section 747 programs.  After working in three workgroups, the members reconvened in plenary session following lunch.

Charles H. Griffith III, MD, MSPH, reported from the group that addressed the constituent perspective and reviewed near-term outcomes related to faculty, curricula, and learners.  The members said it was important to measure new topics and new approaches to topics in “innovative” curricula as well as the cost of curriculum implementation.  One might compare time spent on various primary care topics, number of programs that implement primary care curricula, and number that respond to emerging healthcare needs.  The members were less convinced about measures of career choice.  They believed institutions should be accountable for learners’ knowledge, skills, attitudes, and behaviors, while acknowledging the difficulty of demonstrating progress in the short time of a grant.  It may be feasible to use instruments that have already been developed.  In the discussion that followed it was mentioned that Dr. Maxine Papadakis, a former member of the Advisory Committee, has published work on how to measure the behavior of professionalism. 

Matilde M. Irigoyen, MD, reported from the group on the stakeholder perspective.  The members recommended use of the phrase “improve the quality of the training” in the first objective.  Potential measures could be the number of people trained and their knowledge, skills, and attitudes.  As far as workforce capacity, they emphasized an examination of the increase in number of primary care faculty, their increased leadership in academia and research, as well as increased linkages to community faculty, community health centers, and underserved populations.  For example, measures could be the number of faculty at community health centers and the number participating in continuing education.  There was some discussion about measuring the productivity and effectiveness of the primary care workforce by the number of patients that programs serve or by a decrease in emergency room visits.  They stated the importance of improving the quality of primary care; measuring a decrease in health disparities; and addressing disadvantaged, high-risk, and special needs populations.  They added an objective to increase the workforce’s capability to respond to emerging health issues in the community.

Dr. Rich observed that many near-term outcomes are not so near-term, prompting the need at some point to discuss how to coordinate near- and long-term outcomes.  Increasing the primary care workforce serving underserved populations may be a long-term outcome.  In the near-term one might count the number of people going into the NHSC, training experiences in underserved areas, and intent to serve the underserved.  Warren A. Heffron, MD, and Dr. Ng suggested that the number of students who went from primary care residencies to faculty positions should be measured.  Joseph L. Price, PhD, suggested that programs demonstrate the achievement of competencies set forth by the Accreditation Council for Graduate Medical Education (ACGME).

Alan K. David, MD, reported from the group on long-term outcomes.  On workforce capacity, the members suggested that output was not the number of people in the field but those who actually do the training in primary care.  Candidate measures should include the number of primary care departments or divisions, assuming their growth has been due to Title VII, section 747 funding, the number of required primary care clerkships, and the number of primary care faculty in leadership positions.  The change in workforce competence as a result of a particular curriculum given priority with Title VII, section 747 funding should be measured.  Perhaps it could be shown that the increase in the number of primary care providers is keeping pace with the increase in the whole workforce and the population.  Other measures might be satisfaction of delivering care to underserved populations and retention rate of people who had received Title VII, section 747 training and entered the NHSC.  Surveys are available that assess how many people today can identify a primary care provider, allowing a comparison to studies done in the past.  These surveys can be tailored to specific primary care disciplines and specific populations.  One might look at the number of underrepresented minorities entering primary care programs, going into urban and rural settings or serving underserved populations, and completing faculty development programs. 

In the discussion that followed, Sanford J. Fenton, DDS, MDS, said that the average age of a dental faculty member is ten years older than the average age of a dental practitioner.  He said that success of Title VII, section 747 might be measured by a decrease in interval size between the ages.  Dr. Irigoyen said the report should highlight the curricular output of these programs and how the curricula are implemented, disseminated, and thus, change the face of education.  During a break,  Dr. Irigoyen and Dr. David developed a common list of stakeholder objectives.  After resuming, Mr. Moore reviewed the criteria for how the recommended measures were identified.  All agreed that the report should give a rationale for the recommendations.   

Three workgroups were formed, each given the same sets of constituent and stakeholder objectives.  They were asked to determine candidate measures for each proposed outcome and then develop recommended measures.  Dr. Rich suggested that each group should come up with 8-10 recommended measures.  He envisioned a chart of all the candidate measures from which a smaller subset of measures are selected as the ones to be recommended in the report. 

The Advisory Committee resumed in plenary session after the workgroup sessions.  Dr. Rich asked staff to make copies of all the tables of objectives, recommended measures, and candidate measures for examination in the morning.  Mr. Moore and his team were to meet with the Writing Group chairs, the executive committee, and several staff at a breakfast meeting in the morning to determine how best to utilize the time remaining in the meeting.  Dr. Rich thanked the members of the Advisory Committee and staff.

There was no public comment.  The meeting adjourned at 4:49 p.m.

Friday, February 11, 2005

The workgroups from the previous day gave their reports.  Dr. Griffith reported that in addition to outcome measures related to teaching, those of particular interest to the Office of Management and Budget (OMB) and those that highlight the uniqueness of these programs should be considered.  Tina L. Cheng, MD, MPH, added that the methods of measurement should be mixed, some qualitative and some quantitative, some gathered from the grantees and some from a sub-sample of grantees.  Dr. Ng suggested that any list of measures should include the people who will do the measurement.   

Dr. Irigoyen reported that measures of workforce capacity could be the number in leadership roles and their scholarly output.  The use of the Institute of Medicine’s performance measures may have a role in measuring quality of care.  Partnerships with community-based sites are important.  Some felt that instead of a measure of increase or a percentage, just the number of disadvantaged, underrepresented minorities should be used.  Gregory Strayhorn, MD, PhD, however, felt that some level of comparison was needed.  Dr. Rich said he could imagine the body of the report having a section that discusses methodology to which Mr. Moore responded that methodology is just one task associated with translating these measures into actual output.

Dr. David reported from the group that developed candidate measures for long-term outcomes, defined them in terms of what we train people to do, and suggested additional ones.  Dr. Strayhorn said that the Advisory Committee might recommend the kinds of methodologies and analyses that need to be done by the Agency.  There was discussion about measuring the degree to which Title VII, section 747 curricula have incorporated Healthy People 2010 objectives.  Ultimately, there needs to be a long-term evaluative mechanism with an eye to the larger National context for these programs.  Such a topic could be the focus of a sixth report.

Mr. Moore said that he needed guidance from the group on the report’s storyline, purpose statement for Title VII, section 747 objectives and outcomes, report length, additional citations, and additional content.  He suggested having a set of report objectives which explain what we want the report to do.  He gave as examples: to educate stakeholders about methodology, to convey a compelling case for the recommendations, to clarify the value proposition of Title VII, section 747, and to advocate the program.  Dr. David pointed out some inconsistencies in the text of the current draft.  Regarding the tone of the report, Michael W. Donohoo, DDS, suggested the report strongly state its puzzlement over OMB’s conclusion that these programs are ineffective.  Dr. Griffith said that the report should describe all the successes of Title VII, section 747 as a unique Federal vehicle, then discuss the reason for the program getting an unsatisfactory rating–namely, a fundamental misunderstanding as to the purpose of these programs.  Dr. Strayhorn suggested that the report state that Title VII, section 747 programs have the curricula that train people for the ever increasing number of community health centers across the country.         

Three new workgroups were formed, met, and reported back to the full Advisory Committee.  Dr. Asprey gave the report from the group developed a purpose statement based on the  new set of eight objectives for Title VII, section 747.  The following statement of purpose was approved by the Advisory Committee:  “to educate and train physicians, pediatric and general dentists, and physician assistants to enhance the quality capacity, and diversity of the Nation’s primary care workforce, giving special consideration to the healthcare needs of underserved populations and other high risk groups.”

A second group determined that the logic model needs further refinement.  A third group did some consolidation, added specification to the recommended measures, but was not able to get to the task of developing a prose version of the recommendations.  Mr. Moore, a member of the third group, will pull that material together.  Dr. Rich said that at some point language will have to be developed that lays out the rationale behind the selection of each recommended measure.  He felt, too, that more literature was needed related to the various proposed measures.  The Writing Group will meet in early April with the goal of having a draft of the fifth report ready for the May meeting.  In the interim, four subgroups will do the following:  1) develop the rationale for the selection of the recommended measures; 2) develop a prose version of report recommendations; 3) refine the charts, graphs, and logic model; and 4) select references on measurement issues related to educational programs. 

The Advisory Committee discussed possible topics for a sixth report.  One idea was to use the measures recommended in the fifth report to systematically evaluate Title VII, section 747 programs over the past decade.  Other topics were the role of Title VII, section 747 in 1) improving health-related quality of life for neurologically and cognitively impaired individuals, 2) promoting partnerships, education, and advocacy within the local community in order to improve health outcomes, 3) promoting recruitment and retention of primary care clinicians to serve underserved populations, 4) promoting healthy lifestyles and preventive care as a way to improve quality of life and reduce healthcare costs, 5) preparing health professionals to care for aging baby boomers, and 6) preparing health professionals to equitably apply genetic advances in primary care.  Other ideas were to review the evidence and make the argument that enhancing primary care improves the quality and cost-effectiveness of the Nation’s health.  A report might deal with the synergism created as Title VII, section 747 training programs impact other infrastructure that exists to provide healthcare services in this country; such a discussion would point out the void that would be created if these programs did not exist.  A report might elaborate opportunities for interdisciplinary collaboration and education.  Several topics could conceivably be addressed within one report.

There was no public comment.  The meeting adjourned at 12:35 p.m.