Research Day Winning Presentations 2015

Michigan Family Medicine Research Day XXXVIII Awardees

May 21, 2015

Award Winners


The 38th Annual Michigan Family Medicine Research Day was Thursday, May 21, 2015, at The Johnson Center at Cleary University. We invite you to follow the links to abstracts for each of this year's winning presentations.

Research Day 2015 winnersBest Oral Presentation by a Student


Best Poster by a Student


Best Oral Presentation by a Resident


Best Oral Presentation by a Faculty/Teacher


Abstracts of Winning Presentations


Best Oral Presentation by a Student


Prostate Cancer Knowledge, Information Sources, And Qualities Of Treatment Decision For Localized Prostate Cancer

Elyse Reamer, BS; Lisa Daum, BS; Julie Ruterbusch, MPH; Jinping Xu, MD, MS – Mentor: Jinping Xu, MD, MS

Program: Wayne State University

Presenter: Elyse Reamer

Background: Considerable controversy surrounds the optimal treatment options for localized prostate cancer (LPC). It was hypothesized that increased knowledge about LPC should help patients make informed decisions, increase treatment satisfaction, and decrease treatment conflict and regret. We assessed black and white LPC patients’ knowledge, information sources, treatment choice, and whether knowledge was associated with qualities of treatment decision. Methods: Self-administered mailed survey of a population-based sample in metropolitan Detroit identified through the Surveillance, Epidemiology, and End Results (SEER) registry. LPC knowledge scale and information source measures designed based on literature review and qualitative studies. Qualities of treatment decision measured using validated scales.  Results: 201 men (104 white, 97 black) with response rate of 68%; ≤ 75 years with newly diagnosed LPC. Mean age was 61(±7.6) years; 2/3 had >high school education. Overall, the mean LPC knowledge was low, 5.87 (±2.53, maximum score 11). Black men, less educated men, and men not married/partnered had lower knowledge than those of white men (5.00 vs. 6.88), more educated men (4.17 vs. 6.87), and married/partnered men (4.52 vs. 6.33), respectively (all p<0.001). Increasing number of media sources used and increasing number of healthcare providers (urologists, radiation oncologists, and PCPs) consulted were associated with increased knowledge (p=0.004 and p=0.044, respectively) after adjusting for demographics, tumor characteristics, and treatment choice. Knowledge was not associated with treatment choice, satisfaction with treatment decision, or treatment regret. However, increasing knowledge was associated with increased treatment conflict (p=0.018) after adjusting for demographics, tumor characteristics, and treatment choice. Conclusions: We found significant LPC knowledge gaps existed for both white and black men; however, the knowledge gap was greater in black men. Increased knowledge was associated with increased decisional conflict for both groups of men. Patient education on evidence-based unbiased information is needed but it may not alleviate some of the decisional conflict that men face when making a treatment decision for LPC.



Best Posters by Students


Left Lower Limb Weakness As The Initial Presentation Of Glioblastoma Multiforme: A Case Report with Literature Review

Albert Ma, BS; Jinping Xu, MD, MS – Mentor: Jinping Xu, MD, MS

Program: Wayne State University

Presenter: Albert Ma

Glioblastoma Multiforme (GBM) is the most prevalent and malignant adult primary brain neoplasm, characterized by rapid progression and ultimately poor prognosis.  The unknown etiology and initially nonspecific presentation pose a diagnostic challenge especially in the primary care setting where more common causes of overlapping neurologic deficits are seen. This case report describes a 56-year-old female patient presenting with symptoms suggestive of a lumbosacral radiculopathy visualized on initial spinal imaging. While pursuing conservative management, subsequent progression of neurologic dysfunction prompted further imaging and discovery of an underlying intracranial tumor, histologically diagnosed as GBM. Though patients most commonly present with symptoms of increased intracranial pressure, headache, and an array of focal neurologic deficits may also be seen depending on tumor size and location. Our patient never had any symptoms suggesting increased intracranial pressure during her entire course of illness. Her only presenting symptom was left lower extremity weakness, which gradually worsening with progression of involving left upper extremity. Rapid progression of these neurologic symptoms may be the only clue for clinicians to initially suspect GBM over more common explanations, including radiculopathies. The majority of patients with neurologic symptoms will not have an underlying intracranial tumor, though clinician judgment must be used to balance conservative imaging and the potential for earlier diagnosis and its survival benefit. Primary care providers thus have a unique role in the initial assessment of such patients and in subsequent follow up that requires the correlation of serial clinical exams with radiographic findings.



Health Coaching In Primary Care: A Pilot Study

Jeffrey M. Mann; Zora Djuric, PhD; Michelle Segar*, PhD; Jessica McKenna, BS; Amy Locke, MD – Mentor: Zora Djuric, PhD

Program: University of Michigan Department of Family Medicine and *Women’s Studies Program

Presenter: Jeffrey Mann

Background: Health coaching is a method by which individuals can obtain support for achieving and maintaining healthy lifestyles. There is limited research on integration of health coaching within a primary care setting. In health coaching, the coach partners with the patient, helping them discover their own strengths, challenges, and solutions. Health coaching has the potential to maximize patient health in a cost-effective way.  Methods: The aim of this ongoing study is to determine whether a medical assistant could be trained as a health coach to assist primary care providers to promote healthier lifestyles in their patients. The focus areas addressed were improvement in diet, physical activity, and sleep habits. Our hypothesis was that health coaching can be done by existing medical support staff to facilitate healthy lifestyles in a primary care setting. The 12-week program consists of in person, phone and portal visits with the coach. Results: Thus far, 39 subjects have enrolled, and 16 have finished the program. All the subjects except for one were overweight or obese, and mean BMI was 33.8 kg/m2. Most of the participants were female (82%) and college graduates (82%). Fruit and vegetable intakes, as well as physical activity, were below that recommended by the USDA. Of the 16 subjects who completed the study, 15 indicated a desire to work on improving physical activity, 12 on improving diet and 6 on improving sleep. After 12 weeks, encouraging trends were noted in body weight, physical activity and autonomous motivation for changes in diet, physical activity and sleep. All the subjects who completed 12 weeks of the study, except one, strongly or mostly liked the health coaching and intended to keep following the lifestyle changes encouraged by the coaching. All but one of the study completers also indicated that all family medicine practices should offer health coaching. Discussion: These results show that a medical assistant can be trained to conduct health coaching, and that health coaching is feasible and well-accepted within the context of a primary care practice.



Best Oral Presentations by Residents


Impact Of United States Preventative Services Task Force Guideline Recommendations For Hepatitis C Screening On Primary Care Physicians’ Ordering

Hetal Choxi, MD; Melissa Plegue, MA; Pamela Rockwell, DO; Mack Ruffin MD, MPH – Mentors: Pamela Rockwell, DO; Mack Ruffin MD, MPH

Program: University of Michigan Department of Family Medicine

Presenter: Hetal Choxi, MD

Background: On June 2013, the US Preventative Services Task Force (USPSTF) released new guidelines that all asymptomatic patients born between the years of 1945 and 1965 should undergo and one time screening for Hepatitis C. The goal of this study was to investigate what the impact of the new USPSTF recommendations was for clinical practice in a large academic center on primary care physicians. Methods: Electronic data was extracted from patient charts that were born between 1945 and 1965 and were seen in a primary care clinic at the University of Michigan for at least one office visit between June 1, 2012 and May 31, 2014. 42,959 qualified patients were seen during the study time period. 8,399 were excluded (180 had HCV diagnosis prior to 6/1/2012, 7940 had resulted HCV tests prior to the start of the study period, 279 patients had missing or invalid age data). Final sample: 34,560 patients. This study investigated the likelihood of a patient having HCV screening ordered prior to and after USPSTF guideline release; compared screening rates between the departments of family medicine and internal medicine; and looked at patient demographics and visit characteristics which may increase the likelihood of screening. Results: The odds of getting a Hepatitis C screening lab ordered after the USPSTF guidelines publication was 1.45 times higher than prior to guideline publication. However, while the odds of ordering is higher in period 2 compared to period 1, in both time periods screening was ordered very rarely. No significant difference was found between HCV screening rates of patients seen in family medicine offices vs. internal medicine offices. Black and Asian patients were more likely to get a HCV screening compared with white patients, males were more likely to get a screening ordered than females, and if a patient had an HME visit during the study period, then they were also more likely to get a screening ordered. Conclusions: Our study found that there was an increased probability that a patient who met the age criteria for Hepatitis C screening after the publication the USPSTF guidelines was screened for HCV. However, overall screening was still very low and a significant number of patients who should have been screened were not. These results suggest that considerable physician and patient outreach is still needed in order to ensure that the baby boomer population is appropriately screened for HCV. 



Partnering Primary Care Physicians And School-Based Health Centers In An Expanded Patient Centered Medical Home Model

Anna R. Laurie, MD; Margaret Riley, MD – Mentor: Margaret Riley, MD

Program: University of Michigan Department of Family Medicine

Presenter: Anna R. Laurie, MD

Background: The Patient Centered Medical Home (PCMH) model of care provides a framework in which to facilitate partnerships between patients, families, and physicians in order to provide comprehensive primary care. School-Based Health Centers (SBHCs) were originally introduced as a “safety net” to improve health care provided to underserved adolescents, and have been shown to improve health outcomes while addressing a number of barriers to accessing health care. Although there is controversy surrounding whether SBHCs can serve as an independent PCMH, collaborative efforts between primary care offices and SBHCs have been emerging. This project examines whether an expanded PCMH model, in which Primary Care Physicians (PCPs) are partnered with SBHCs, improves adolescent preventive medical care, specifically with regard to asthma measures. Methods: In this Quality Improvement project, Family Medicine PCPs at the University of Michigan Ypsilanti Health Center (YHC) partnered with an affiliated network of six area SBHCs within the Regional Alliance of Healthy Schools (RAHS). The Electronic Health Record (EHR) shared between YHC and RAHS clinics was utilized to identify patients, ages 11-19, seen at either YHC alone (non-shared patients) or at YHC and RAHS clinics (shared patients) within the past year. A subset of those patients with a diagnosis of asthma were then identified to compare rates of asthma preventive measures completed by non-shared versus shared patients. These comparisons were made at the beginning and middle of the current school year. Interventions to increase awareness and communication between patients, YHC, and RAHS were also performed throughout the project. Results: Asthma preventive measures included spirometry and influenza vaccine for all patients with asthma, as well as Asthma Action Plans (AAPs) for those with persistent asthma. Both at baseline and at the midpoint of the school year, shared patients had higher rates of spirometry and AAPs as compared to non-shared patients, although the difference did not reach statistical significance. Conclusions: Overall, patients served by our expanded PCMH model (shared between YHC and RAHS) had better rates of asthma preventive care compared to those only seen at YHC. An additional end-point comparison is planned for the end of the school year, and future directions include targeting further preventive care measures while continuing to increase the visibility of the expanded PCMH model to patients and physicians.



The Assessment of Continuity of Care as a Requisite Family Medicine Resident Competency That Can Be Measured Using The Usual Provider Continuity Index

Jose Manuel, MD; Rey Anthony Garibay, MD; Francisco Terrazas, MD – Mentors: Scott Plensdorf, MD; Mohamed Mansour, MD

Program: Michigan State University – McLaren Medical Center

Presenters: Jose Manuel, MD; Rey Anthony Garibay, MD

Background: The Usual Provider Continuity index (UPC) is a statistical tool that is used to measure interpersonal continuity.  Prior studies have described the favorable effect of an increase in mean UPC on patient outcomes, but no studies have looked at its potential utility in evaluating a resident’s learning  experience.  We propose the use of the UPC as a tool to evaluate the learning experience of residents in primary care residency programs.  Methods: We conducted a descriptive quantitative data analysis of the UPC at McLaren-Flint Family Medicine Residency Ambulatory Health Center.  We obtained the total number of visits per month from July 1, 2014 to December 31, 2014 from Family Medicine residents whom have been with the program for a minimum of two years, and divided these visits into three categories: Primary Care Physician (PCP) Continuity visits, non-PCP Continuity visits and acute care visits. We determined the mean UPC for each resident as well as the overall mean UPC for the residents included in the study.  Results:  A total of 6 providers were included in our quantitative data analysis.  The total number of patients seen during the 6-month study period was 1689. There was no increasing trend noted in UPC index throughout the duration of the study period from July 1 2014 to December 31 2014.  The range of UPC index varies among the 6 residents.  The lowest value obtained was 27.3% and the highest was 45.3%. The average percentile total continuity visits of all the residents is 31.2 % and if excluding the number of acute care visits it averages to 37%.  Conclusion: The mean Usual Provider Continuity Index (UPC) provides valuable information when extremes in the UPC are identified, allowing a residency program to make necessary interventions to balance the types of office visits that a resident is exposed to.  However, its utility is currently limited by the lack of a standard mean UPC among primary care residency programs, thus no recommendations can be made if the mean UPC index value falls in the mid range of the spectrum.



Management Of Concussions In Adolescent Athletes Amongst Michigan Family Physicians

Noshir Y. Amaria,DO, ATC, CSCS – Mentors: Randolph Pearson, MD, FAAFP, FACSM; Julie Phillips, MD, MPH

Program: Sparrow/MSU Family Medicine Residency

Presenter: Noshir Y. Amaria, DO, ATC, CSCS

Background: The use of a graduated return to play protocol (RTP) after concussion was outlined in the “Consensus Statement on Concussion in Sport” at the 3rd International Conference on Concussion in Sport (Zurich, 2008). This was again outlined in the most recent consensus statement (4th International Conference on Concussion in Sport - Zurich, 2012). While there are many guidelines on concussion management after the event itself, there remains only one objective RTP protocol for use when assessing a patient for return to sports participation. The purpose of this study was to evaluate if physicians are using this particular update to concussions guidelines, and whether they were using the graduated RTP per the 2012 consensus statement guidelines. Another purpose was to ask who the clinician depends on to objectively measure and implement this protocol. Methods: A 15-question survey was sent to a random sampling of 1085 board certified family medicine (with and without CAQ in sports medicine) physicians in Michigan, with a 34% (n = 365) response rate. Physicians were asked to provide demographic information of age, years in practice, type of practice, and practice geographical population. Results: Results concluded that of the 356 survey respondents, 30% stated they use the concussion guidelines per the 2012 consensus statement (Zurich – 2012). 44% of physicians surveyed stated they were unsure of what concussion management guidelines they use. 46% of all physicians stated they utilize a 6-step RTP (per the 2012 consensus statement). When asking who do physicians count on to reliably administer/monitor the progression of a 6-step RTP as part of their concussion management, physicians reported using any combination of the patient, the high school certified athletic trainer (majority), the parent/guardian or coach. Conclusion: A statistically significant correlation was shown between confidence in managing adolescent athletes with concussion and number of concussions managed. Overall, the study confirmed the need for clarification of differences within concussion management guidelines, as well as clarification of objective use of a 6-step return to play protocol.



Health Insurance And Unintended Pregnancy In Latina Women

Katherine Lemler, MD; Mikel Llanes, MD; Melissa Plegue, MA; Daniel J. Kruger, PhD; Adreanne Waller, MPH; Charo Ledón; Tammy Chang, MD, MPH, MS – Mentor: Tammy Chang, MD, MPH, MS

Program: University of Michigan Department of Family Medicine 

Presenter: Katherine Lemler, MD

Background: Nearly half of US pregnancies are unintended. Women with low incomes, lower levels of education, Hispanic race, or other barriers to healthcare access have higher rates of unintended pregnancy than the general population. Methods: Encuesta Buenos Vecinos (“Good Neighbors Survey”) is a community-based participatory research project designed to characterize important health risks among Latinos in Washtenaw County, MI; it represents the largest and most comprehensive health census of Latinos in the county. Nearly five hundred Latino men and women were surveyed via either a paper or online survey. Latina women respondents to the Encuesta Buenos Vecinos survey under the age of 50 were included in the sample. The survey was administered to respondents between September and December 2013, and elicits data regarding socio-demographic characteristics, intentions regarding future pregnancy, and use of any contraceptive method. Respondents of child-bearing age who reported no intention to become pregnant in the next 12 months AND no contraception use were defined as “at risk” for unintended pregnancy. Descriptive statistics were used to determine the characteristics of the sample. Multivariate logistic regression was used to determine the association between risk for unintended pregnancy and insurance status, controlling for confounders including age, education, English speaking ability, number of non-adult children, and marital status. Results: Among 259 female respondents, 33% were age 18-29, 42% were age 30-44, and 25% were over 45 years old. Most respondents (39%) had at least some college education, whereas 35% had only a high school degree, and 28% had less than a high school degree. The majority of respondents were married (63%), have at least one child (56%), and earn less than $25K a year (64%). 119 women were coded as 'at risk' for unwanted pregnancies. 81 women were coded as 'not at risk' for unwanted pregnancy: these were either actively trying to become pregnant or taking some action to prevent it. 59 respondents were beyond childbearing years, and 22 did not respond to the question; these were coded as missing. There was not a significant relationship between risk for unwanted pregnancy and health insurance status (p-value=0.762).  Conclusions: 52% of Latina respondents in this sample are at risk for unintended pregnancy. There was no relationship between risk for unintended pregnancy and insurance status. Level of education and lower English speaking ability are associated with higher risk of unintended pregnancy irrespective of insurance status.



Rhabdomyolysis In Collegiate Swimmers: A Case Series

John Otremba, PharmD, MD; Jill Sadoski, MD; Katharine Lounsberry, MD; Matthew Clifford, MD – Mentor: John Porcerelli, PhD

Program: Wayne State University School of Medicine

Presenters: Katharine Lounsberry, MD

This case series involves male and female competitive NCAA Division II swimmers who initially presented to the Emergency Department with complaints of myalgia, muscle stiffness, decreased range of motion at the elbow, and cola colored urine three days following an intense strength training workout.  Three days prior to their presentation in the ED, all of the athletes had participated in a challenging circuit training workout that was different than previous strength training sessions.  This work out occurred after the team had been training together for a few weeks, but was new to the athletes.  The initial blood work in the ED revealed extreme elevation of creatine kinase (CK) levels ranging from 4,326 to >20,000 U/L and myoglobin levels ranging between 109 to 2583 ng/mL. All six athletes were administered intravenous normal saline at 250ml/hr, and their CK, myoglobin, urinalysis (UA), electrolytes, liver function, and renal function were monitored daily. These values improved daily and there were no signs of renal failure or compartment syndrome throughout hospital stay. All athletes were followed in the outpatient office and recovered completely from rhabdomyolysis.  This case demonstrate the need for well supervised workouts even in well trained athletes.  Coaches, trainers, and treating physicians need to be aware of the potential dangerous consequences.  



Diabetes And Its Association To Adenomatous Polyps And Colorectal Cancer

Nik Gjurashaj, MD; Johnathon Justice, MD; Brittany Okpagu, MD; Allison Simms, DO; Maliha Nafees, MD; Mike Eldirani, MD; Wajeeh Muhammad, MD; Priya Murthy, MD – Mentors: Katarzyna Budzynska, MD; Lois Lamerato, PhD; Della A. Rees, PhD; Susan Schooley, MD

Program: Wayne State University School of Medicine/ Henry Ford Hospital 

Presenter: Nik Gjurashaj, MD; Wajeeh Muhammad, MD; Allison Simms, DO.

Background: Colorectal cancer (CRC) is the third leading cause of cancer death and third most commonly diagnosed cancer in the USA. Established risk factors include age, male gender, African American ethnicity, colorectal polyps, diet, obesity, lack of activity, and diabetes mellitus (DM). The aim was to better understand the incidence of CRC and adenomatous polyps in diabetic patients as compared to non-diabetic patients within Henry Ford Health System. Methods: Population included from retrospective cohort of adult patients with colonoscopy, continuously HAP enrolled from 2003 to 2012. From that, 1800 adults were randomly selected, reviewing pathology reports and determining DM status. Regression analysis computed associations between diabetes, diabetes type, diabetes control and colorectal cancer/adenomatous polyp. Results: There were 11,933 patients in the cohort, 55% were female, 81% were between ages 50 and 64, 49% white, followed by 30% African American, and 18% Hispanic. Eighty four percent of the population was overweight or obese. The subpopulation demographics were not statistically different from the population. In univariate analysis, risk of CRC/polyp was associated with age, male gender, Hispanic ethnicity, higher body mass index, diagnosis of DM, with medication for DM, and hemoglobina1c above 5.7. In univariate analyses, those with DM had 1.44 times the odds of developing colorectal cancer and polyp compared to those without (p=0.0015); but the effect was attenuated when adjusted for confounders (OR=1.27, 95% CI: 0.91; 1.78, p=0.161).  Conclusions: Our study validated risks associated with age, male gender, and BMI in relation to CRC and adenomatous polyps. However, we were not able to detect an association between DM and CRC or adenomatous polyps when controlling for other variables. BMI and hyperglycemia appear as strong risk factors, as opposed to DM, associated with CRC and adenomatous polyps. Furthermore, the Hispanic population demonstrated greater significance for CRC compared to other races.



Best Oral Presentation by a Faculty/Teacher


Post-Discharge Adverse Events Among Urban And Rural Patients Of An Urban Community Hospital:  A Prospective Cohort Study

Dennis Tsilimingras, MD, MPH

Program: Wayne State University School of Medicine

Presenter: Dennis Tsilimingras, MD, MPH

Background: There has been little research to examine post-discharge adverse events (AEs) in rural patients discharged from community hospitals. Objective: We aimed to determine the rate of post-discharge AEs, classify the types of post-discharge AEs, and identify risk factors for post-discharge AEs in urban and rural patients.  Methods: This was a prospective cohort study of patients at risk for post-discharge adverse events from December 2011 through October 2012. Six hundred and eighty-four patients who were under the care of hospitalist physicians and were being discharged home, spoke English, and could be contacted after discharge, were admitted to the medical service. Patients were stratified as urban/rural using zip code of residence. Rural patients were oversampled to ensure equal enrollment of urban and rural patients. The main outcome of the study was post-discharge AEs based on structured telephone interviews, health record review, and adjudication by two blinded, trained physicians using a previously established methodology. Results: Over 28 % of 684 patients experienced post-discharge AEs, most of which were either preventable or ameliorable. There was no difference in the incidence of post-discharge AEs in urban versus rural patients (ARR 1.04 95 % CI 0.82 -1.32 ), but post-discharge AEs were associated with hypertension, type 2 diabetes mellitus, and number of secondary discharge diagnoses only in urban patients. Conclusions: Post-discharge AEs were common in both urban and rural patients and many were preventable or ameliorable. Potentially different risk factors for AEs in urban versus rural patients suggests the need for further research into the underlying causes. Different interventions may be required in urban versus rural patients to improve patient safety during transitions in care.