Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial

Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis

OBJECTIVES

To quantify the influence of physicians' experiences of adverse events in patients with atrial fibrillation who were taking warfarin.

DESIGN

Population based, matched pair before and after analysis.

SETTING

Database study in Ontario, Canada.

PARTICIPANTS

The physicians of patients with atrial fibrillation admitted to hospital for adverse events (major haemorrhage while taking warfarin and thromboembolic strokes while not taking warfarin). Pairs of other patients with atrial fibrillation treated by the same physicians were selected.

MAIN OUTCOME MEASURES

Odds of receiving warfarin by matched pairs of a given physician's patients (one treated after and one treated before the event) were compared, with adjustment for stroke and bleeding risk factors that might also influence warfarin use. The odds of prescriptions for angiotensin converting enzyme (ACE) inhibitor before and after the event was assessed as a neutral control.

RESULTS

For the 530 physicians who had a patient with an adverse bleeding event (exposure) and who treated other patients with atrial fibrillation during the 90 days before and the 90 days after the exposure, the odds of prescribing warfarin was 21% lower for patients after the exposure (adjusted odds ratio 0.79, 95% confidence interval 0.62 to 1.00). Greater reductions in warfarin prescribing were found in analyses with patients for whom more time had elapsed between the physician's exposure and the patient's treatment. There were no significant changes in warfarin prescribing after a physician had a patient who had a stroke while not on warfarin or in the prescribing of ACE inhibitors by physicians who had patients with either bleeding events or strokes.

CONCLUSIONS

A physician's experience with bleeding events associated with warfarin can influence prescribing warfarin. Adverse events that are possibly associated with underuse of warfarin may not affect subsequent prescribing.

Profiling providers on use of adjuvant chemotherapy by combining cancer registry and medical record data

PURPOSE

Treatment information collected by cancer registries can be used to monitor the provision of guideline-recommended chemotherapy to colorectal cancer patients. Incomplete information may bias comparisons of these rates. We developed statistical methods that combine data from a registry and physicians' records to assess hospital quality.

DATA

From California Cancer Registry data, we selected all patients (n=12,594) newly diagnosed with stage III colon cancer or stage II or III rectal cancer from 428 hospitals during the years 1994 to 1998. To assess rates and predictors of underreporting of chemotherapy, we surveyed physicians treating 1449 of these patients from 98 hospitals during the years 1996 to 1997.

METHODS

Using Bayesian statistical models, we imputed unobserved treatments. We studied the impact of underreporting on provider profiling by comparing rankings, estimates, and credible intervals based only on registry data to those incorporating physician survey data.

RESULTS

Analyses that account for incompleteness of reporting yielded wider credible intervals for provider profiles than those that ignored such incompleteness. Among the 109 (25%) hospitals in the highest quartile of chemotherapy rates according to the registry data, 16 were not so classified when incomplete reporting was taken into account. With the more comprehensive model, 12 hospitals could be identified that ranked in the top quartile with probability>0.90.

CONCLUSION

Estimates of adjusted hospital chemotherapy rates based solely on cancer registry data overstate the precision of assessments of hospital quality. Using additional information from a physician survey and applying rigorous statistical models, better inferences can be drawn about provider quality.

A blended knowledge translation initiative to improve colorectal cancer staging [ISRCTN56824239]

BACKGROUND

A significant gap has been documented between best practice and the actual practice of surgery. Our group identified that colorectal cancer staging in Ontario was suboptimal and subsequently developed a knowledge translation strategy using the principles of social marketing and the influence of expert and local opinion leaders for colorectal cancer.

METHODS/DESIGN

Opinion leaders were identified using the Hiss methodology. Hospitals in Ontario were cluster-randomized to one of two intervention arms. Both groups were exposed to a formal continuing medical education session given by the expert opinion leader for colorectal cancer. In the treatment group the local Opinion Leader for colorectal cancer was detailed by the expert opinion leader for colorectal cancer and received a toolkit. Forty-two centres agreed to have the expert opinion leader for colorectal cancer come and give a formal continuing medical education session that lasted between 50 minutes and 4 hours. No centres refused the intervention. These sessions were generally well attended by most surgeons, pathologists and other health care professionals at each centre. In addition all but one of the local opinion leaders for colorectal cancer met with the expert opinion leader for colorectal cancer for the academic detailing session that lasted between 15 and 30 minutes.

DISCUSSION

We have enacted a unique study that has attempted to induce practice change among surgeons and pathologists using an adapted social marketing model that utilized the influence of both expert and local opinion leaders for colorectal cancer in a large geographic area with diverse practice settings.

Which Factors Are Associated with the Application of Reperfusion Therapy in ST-Elevation Acute Coronary Syndromes?

BACKGROUND/AIMS

A large proportion of patients with a ST-elevation acute coronary syndrome do not receive reperfusion therapy. In order to contribute to a better understanding of the clinical decision making process, we analyzed which factors are associated with the application of reperfusion therapy.

METHODS

From the Euro Heart Survey of Acute Coronary Syndromes I, 4,260 patients with ST-elevation acute coronary syndrome were selected for the current analysis, of which 1,539 (36%) patients received fibrinolysis and 904 (21%) primary percutaneous coronary intervention (PCI). The analysis contained 32 variables on demographics, medical history, admission parameters and reperfusion therapy.

RESULTS

A short pre-hospital delay, arrival in a hospital with PCI facilities, severe ST-elevation, and participation in a clinical trial were the strongest predictors for receiving reperfusion therapy. Primary PCI was more likely to be performed than fibrinolysis in patients with a long pre-hospital delay, arriving in a hospital with PCI facilities, not participating in a clinical trial, and with at least one previous PCI.

CONCLUSION

Hospital facilities and culture, pre-hospital delay and infarction size play a major role in management decisions regarding reperfusion therapy in ST-elevation acute coronary syndrome. This analysis indicates which factors require special attention when implementing and reviewing the reperfusion guidelines.

Implementing Research Findings into Practice Using Clinical Opinion Leaders: Barriers and Lessons Learned

BACKGROUND

An opinion leader-driven intervention to improve practice guideline-based medication management for patients with schizophrenia was tested at four Department of Veterans Affairs health care facilities. The concept of using opinion leaders as disseminators of research evidence and internal agents of change has been widely reported.

PROJECT OVERVIEW

Each intervention site received an intensive, multicomponent intervention during the course of one year. The project's process evaluation included ongoing brief surveys of physicians' attitudes and behaviors, logs of reports from opinion leader conference calls, and interviews with the opinion leaders toward the end of the implementation period.

BARRIERS OR ISSUES AND POTENTIAL SOLUTIONS

Several barriers or problematic issues surfaced: (1) physicians do not always agree on who is an opinion leader; some sites may have no opinion leader; (2) some sites had poorly developed formal and informal social networks among physicians; (3) a focus on physicians only as agents of change; and (4) how much directive should be given to the opinion leaders concerning how to influence attitudes and behaviors?

DISCUSSION

Four major problematic issues encountered during the project offer potential solutions for addressing them.

The role of the Veterans Affairs Medical Centers in patient care, surgical education, research and faculty development

Veterans Administration (VA) medical centers have had a long history of providing medical care to those who have served their country. Over time, the VA has evolved into a facility that has had a major role in graduate medical education. In surgery, this had provided experience in the medical and surgical management of complex surgical disease involving the head and neck, chest, and gastrointestinal tract, and in the fields of surgical oncology, peripheral vascular disease, and the subspecialties of urology, orthopedics, and neurosurgery. The VA provides a venue for the attending physician and resident to work in concert to allow the resident to shoulder increasing accountability in decision-making and delivery of care in the outpatient arena, the operating room, and the intensive care unit. Medical students assigned to a VA hospital are afforded a great opportunity to be exposed to preoperative planning, discussions leading to informed consent for surgery, the actual operation, and postoperative care. Numerous opportunities at the VA are available for novice and experienced medical faculty members to develop and/or enhance skills and abilities in patient care, medical education, and research. In addition, the VA offers unique opportunities for academic physicians and other healthcare professionals to administer its many programs, thereby developing leadership skills and experience in the process. The VA is uniquely situated to design and conduct multicenter clinical trials. The most important aspect of this is the infrastructure provided by the VA Cooperative Studies Program. Of the four missions of the Department of Veterans Affairs, research and education is essential to provide quality, state of the art clinical care to the veteran. The National Surgical Quality Improvement Program (NSQIP) is an example of how outcomes based research can favorably impact on patient outcome. Looking across the horizon of information solutions available to surgeons, the options are limited. This is not the case for the Department of Veterans Affairs. With the congressionally mandated charge for the VA to compare its quality to private clinicians, the advent of the "Surgery Package" became possible. The VA will continue its leadership position in the healthcare arena if it can successfully address the challenges facing it.

Barriers to General Practitioner Participation in a Clinical Trial Initiated by Pharmacists

Objective:

The purpose of this study was to determine general practitioners' (GPs) reasons for not entering patients into a randomized trial that compared outpatient anticoagulation management by community pharmacists with that of physicians.

Methods:

An anonymous survey was mailed to all GPs who were invited to participate in the anticoagulation study ( n = 118).

Results:

Completed surveys were received from 78/110 (71%) of GPs who had declined to participate in the anticoagulation study. Of those who had consented to participate, 8/8 completed surveys were received. The top-ranked reasons for not entering patients were “pharmacist should accept legal liability” (40%), “concern about other health care professionals taking over physician responsibilities” (33%), and “concern about responsibility for my patients” (29%). Other frequently cited barriers included concern about pharmacists' ability to manage warfarin patients, general issues related to control over patient care decisions, and lack of time. The top-ranked reason for agreeing to participate was the belief that “research advances the profession” (87%). Shortly after this survey, a statement published by the College of Physicians and Surgeons of BC reinforced physicians' concern about legal liability and recommended that physicians avoid referring patients to community pharmacy—based anticoagulation programs.

Conclusion:

Pharmacists who plan to conduct research in the community setting should thoroughly investigate potential barriers to GP involvement in patient recruitment, because of the difficulty in anticipating the most crucial issues. Local physicians may not support pharmacy-based anticoagulation programs, whether or not they are implemented as part of a clinical trial.

Using a framework for spread: The case of patient access in the Veterans Health Administration

BACKGROUND

Experience indicates that an effective operational system will spread much more slowly than, for example, a new antinausea drug. The Veterans Health Administration (VHA) used a Framework for Spread to spread improvements in access to more than 1800 outpatient clinics between April 2001 and December 2003. The framework identifies strategies and methods for planning and guiding the spread of new ideas or new operational systems, including the responsibilities of leadership, packaging the new ideas, communication, strengthening the social system, measurement and feedback, and knowledge management. APPLYING THE FRAMEWORK FOR SPREAD: Following a collaborative for reducing waiting times for patients without the large-scale addition of resources, each of the participating 22 Veterans Integrated Service Networks (VISNs) used the framework to expand improvements in access to care to six additional targeted clinics (for example, primary care, eye care, cardiology).

RESULTS

During the VHAs spread initiative, waiting time for a primary care appointment decreased from 60.4 days at the end of fiscal year (FY) 2000 to 28.4 at the end of FY 2002. Results were sustained. Waiting time was <25 days at the end of FY 2004.

DISCUSSION

The Framework for Spread suggests areas that organizations should consider when developing and executing a strategy for a spread initiative. Further study is needed to determine the specific activities that should be emphasized to accelerate spread.

Do popular students smoke? The association between popularity and smoking among middle school students

BACKGROUND

Several studies have shown an association between popularity and behavior, indicating that popular people tend to reflect the norms of their group. Among adolescents, it has been hypothesized that popular students are more likely to smoke, especially in schools with high smoking prevalence.

METHODS

Data were collected on friendship patterns and smoking from 1,486 sixth and seventh graders in 16 middle schools in southern California. Susceptibility to smoke was measured as not stating a commitment not to smoke in the future, and smoking as ever taken a puff or smoked a whole cigarette. We measured popularity as the number of times a student was chosen as a friend. Multivariate logistic regression was used to correlate popularity with susceptibility to smoke and smoking at follow-up controlling for baseline outcomes, demographic characteristics, and clustering within schools.

RESULTS

Popularity was associated with increased susceptibility to smoke (Adjusted Odds Ratio [AOR] = 5.64, p < .001) and smoking (AOR = 5.09, p < .05) over the 1-year interval between surveys. Although the association was strongest for non-White boys, we did not find evidence of interactions between popularity and gender or ethnicity.

CONCLUSIONS

Popular middle school students were more likely to become smokers compared to their less popular peers. Although there seems some difference in the association by gender and ethnicity, the evidence does not suggest subgroup effects in this population. Implications for the study of adolescent smoking and prevention programming are discussed.

Evaluation and outcomes of women with a breast lump and a normal mammogram result

BACKGROUND

Many women experience a breast lump. Clinical guidelines suggest that a normal mammogram result alone is not adequate to exclude a diagnosis of cancer.

OBJECTIVE

To examine the characteristics of women with a breast lump and a normal mammogram that were associated with receiving further evaluation, and to examine cancer outcomes.

DESIGN

Observational cohort.

PARTICIPANTS

Women aged 35 to 70 years who participated in a population-based mammography registry and who did not have a history of breast cancer noted at the time of their mammogram that they had a breast lump, and had a "normal" (Breast Imaging Reporting and Data System 1 or 2) mammogram result (n=771).

MEASUREMENTS

Telephone survey performed 6 months after the mammogram to ascertain information about evaluation. Cancer outcomes within 12 months of the index mammogram were confirmed through linkage with a cancer registry.

RESULTS

Only 56.9% of women reported receiving an adequate evaluation for their breast lump, including a subsequent clinical breast exam, a visit to a breast specialist, an ultrasound, a biopsy, or aspiration. Latinas were less likely than white women to have received adequate evaluation, as were obese women compared with normal-weight women, and uninsured women compared with women with insurance. Among women with at least 12 months of follow-up, 1.4% were diagnosed with cancer.

CONCLUSIONS

Many women do not receive adequate evaluation for a recent breast lump. Interventions should be designed to improve the follow-up of women with this common clinical problem.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

BACKGROUND

Strategies to implement change in health professional performance have variable impact. A potential explanation is that the barriers to implementation are different in different settings and at different times. Change may be more likely if the strategies were specifically chosen to address the identified barriers.

OBJECTIVES

To assess the effectiveness of strategies tailored to address specific, identified barriers to change in professional performance.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register and pending files until end of December 2002. English language articles only were included.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that reported objectively measured professional practice or health care outcomes in which at least one group received an intervention designed (or tailored) to address prospectively identified barriers to change.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed quality. We also contacted study authors to obtain any missing information. Quantitative and qualitative analyses were undertaken.

MAIN RESULTS

We included 15 studies. For Comparison 1 (an intervention tailored to address identified barriers to change compared to no intervention or an intervention(s) not tailored to the barriers), there was no consistency in the results and the effect sizes varied both across and within studies.A meta-regression of a subset of the included studies, using a classical approach estimated a combined OR of 2.18 (95% CI: 1.09, 4.34), p = 0.026 in favour of tailored interventions. However, when a Bayesian approach was taken, meta-regression gave a combined OR of 2.27 (95% Credible Interval: 0.92, 4.75), which was not statistically significant.

AUTHORS' CONCLUSIONS

Interventions tailored to prospectively identify barriers may improve care and patient outcomes. However, from the studies included in this review, we were unable to determine whether the barriers were valid, which were the most important barriers, whether all barriers were identified and if they had been addressed by the intervention chosen. Based on the evidence presented in this review, the effectiveness of tailored interventions remains uncertain and more rigorous trials (including process evaluations) are needed. Further research needs to address explicitly the questions of identifying and addressing barriers.

A cluster randomized trial to assess the impact of opinion leader endorsed evidence summaries on improving quality of prescribing for patients with chronic cardiovascular disease: rationale and design [ISRCTN26365328]

BACKGROUND

Although much has been written about the influence of local opinion leaders on clinical practice, there have been few controlled studies of their effect, and almost none have attempted to change prescribing in the community for chronic conditions such as heart failure (HF) or ischemic heart disease (IHD). These two conditions are common and there is very good evidence about how to best prevent morbidity and mortality - and good evidence that quality of care is, in general, suboptimal. Practice audits have demonstrated that about one-half of eligible HF patients are prescribed ACE inhibitors (with fewer still reaching appropriate target doses) and less than one-third of patients with established IHD are prescribed statins (with many fewer reaching recommended cholesterol targets). It is apparent that interventions to improve quality of prescribing are urgently needed. We hypothesized that an intervention that consisted of patient-specific one-page evidence summaries, generated and then endorsed by local opinion leaders, would be able to change prescribing practices of community-based primary care physicians.

METHODS (STUDY DESIGN)

A pragmatic single-centre cluster randomized controlled trial comparing an opinion leader-based intervention to usual care for patients with HF or IHD. Randomization will be clustered at the level of the primary care physician; as the design effect is anticipated to be negligible, the unit of analysis will be the patient. Patients with HF or IHD (not receiving ACE inhibitors or statins, respectively) will be recruited from community pharmacies and allocated to intervention or usual care based on the randomization status of their primary care physician. The primary outcome is improvement in prescription of proven efficacious therapies for HF (ACE inhibitors) or IHD (statins) within 6 months of the intervention.

CONCLUSION

If the methods used in this intervention are found to improve prescribing practices, similar interventions could be designed for other chronic conditions dealt with in the outpatient setting.

Teaching and improving quality of care in a primary care internal medicine residency clinic

Purpose Learning and applying quality of care principles are essential to practice-based learning and improvement. The authors investigated the feasibility and effects of a self-directed curriculum in quality of care for residents. Method In 2001-02, 13 second-year residents at two community-based outpatient clinics in the Yale University primary care internal medicine residency program were asked to participate in a trial of a quality improvement curriculum (intervention group). Thirteen third-year residents in the same residency program served as the comparison group. The curriculum consisted of readings in quality of care, weekly self-reflection with a faculty member, completion of a commitment to change survey, and medical record audits. Study outcome measures were patient level quality of care measures for diabetes, satisfaction with the curriculum, and self-reported behavioral changes. Results In the follow-up, patients of the intervention group were significantly more likely to have received a monofilament foot examination and baseline electrocardiogram than were patients of the comparison group. When comparing the change between baseline and follow-up, patients for the second-year residents showed significantly more improvement in hemoglobin A1c and LDL cholesterol levels and Pneumovax administration than did patients of the comparison group. All residents in the intervention group were highly satisfied with the curriculum. Thirty-five of 54 residents' personal commitments to change were either partially or fully implemented six months after the curriculum. Conclusions A multifaceted curriculum in quality improvement led to modest improvements in the care of diabetic patients and meaningful changes in self-reported practice behaviors. Future research should include more focus on the microsystems of residency outpatient experiences.

A qualitative examination of primary care providers' and physician managers' uses and views of research evidence

OBJECTIVE

To examine the reasons and search strategies related to physicians' search for evidence and to compare clinician and physician manager approaches.

DESIGN

Qualitative analysis of verbatim transcripts of four focus groups in 2002. Study setting. Clinicians and managers in community practices in Southern California.

PARTICIPANTS

Pediatricians, family practitioners, and general internists (i.e. child and adult primary care providers) in non-academic practice and physician managers whose primary responsibility involved making management decisions within a moderate to large sized health care delivery system (e.g. health plan, community hospital, large group practice).

MAIN OUTCOME MEASURES

Themes related to clinician and manager reasons for using evidence and approach to selecting among evidence sources.

RESULTS

Clinicians and managers differed substantially in their reasons for using evidence. Whereas clinicians consistently invoked clinical intuition as a guide to most routine clinical decisions, managers articulated both motivation and interest in using medical research to guide decision-making, most commonly prompted by cost. Both clinicians and managers rated trustworthiness as a paramount consideration in arbitrating between evidence sources, because neither group evinced comfort with the complexity of primary literature. Both groups expressed a preference for tested, convenient, and respected evidence sources such as expert colleagues and professional societies.

CONCLUSIONS

Because clinicians invoke intuition in confronting the challenges of daily practice, evidence-based medicine interventions that target managers are likely to have larger effects on health outcomes than those that target primary care providers and individual patient treatment. Ensuring trustworthiness of evidence is of the utmost importance. Because both groups express discomfort with the format of primary evidence sources, strategies should probably not rely on individual appraisal.

Electronic health record systems: the vehicle for implementing performance measures

Advances in information technology and recent national directives have the potential to support dramatic improvements in health care. Two key components are the implementation of functional electronic health record systems and widely accepted, evidence-based clinical performance measures for physicians. Midwest Heart Specialists, a 55-physician cardiovascular group at 14 locations in northern Illinois, has utilized an outpatient electronic health record system since 1997. Since 2003, the group has integrated cardiovascular measurement sets developed by the American Medical Association-convened Physician Consortium for Performance Improvement into its electronic health record system. With this integration, the group was able to capture data needed for internal quality assessment and improvement as part of routine outpatient care without the need for additional resources. Critical disease-management data for decision support are available continuously, resulting in improvements in health care. The reporting of these standardized data could be the foundation to support quality-based reimbursement strategies and physician office-based disease-management strategies.

National Prescribing Service: creating an implementation arm for national medicines policy

Medicines make an essential contribution to the health of the community, but rapidly rising drug budgets have caused governments to seek ways of ensuring this expenditure results in value for money. The National Prescribing Service was established against this background to implement a quality use of medicines service as part of the National Medicines Policy. A range of programmes that attempt to use evidence-based strategies to deliver evidence-based messages have been established. These use multifaceted interventions, such as newsletters, prescriber feedback, clinical audit and educational visiting, that are provided both centrally, through the national office, and locally, through Divisions of General Practice. The work is underpinned by an evaluation strategy that incorporates strong qualitative elements as well as an emphasis on time-series analyses for changes in drug utilization. Some 80% of Australian general practitioners have voluntarily participated in activities such as educational visiting and clinical audit within the National Prescribing Service programmes. New programmes for the community and consumers will be coordinated with the work that has become well established within general practice.

Influence of the randomized trials, AFFIRM and RACE, on the management of atrial fibrillation in two University Medical Centers

The results of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) and the Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation (RACE) study were presented in March 2002. These large studies showed no benefit of a rhythm-control strategy over a rate-control strategy in managing atrial fibrillation (AF). Cardioversion and atrioventricular junctional ablation are forms of rhythm control and rate control, respectively. The numbers of cardioversions and atrioventricular junctional ablations performed at the University of Virginia and the Medical College of Virginia during the 52 months before AFFIRM and RACE results were released and the 21 months afterward were compared. From January 1998 to March 2002, monthly averages of 31 +/- 8 elective cardioversions and 6 +/- 3 atrioventricular junctional ablations were performed; from April 2002 to December 2003, the monthly averages were 21 +/- 6 cardioversions (p = 0.001) and 9 +/- 3 ablations (p = 0.001). AF management changed at these institutions shortly after the RACE and AFFIRM results were released.

From adversary to partner: have quality improvement organizations made the transition?

OBJECTIVE

To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement.

DATA SOURCE

Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002.

STUDY DESIGN

We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness.

PRINCIPLE FINDINGS

More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one-quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators.

CONCLUSIONS

Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians.

Quality Improvement Efforts and Hospital Performance

BACKGROUND

Hospitals are under increasing pressure to measure and improve quality of care, and substantial resources are being directed at a variety of quality improvement strategies; however, the evidence base supporting these strategies is limited.

OBJECTIVE

We sought to identify quality improvement efforts that were associated with hospitals' beta-blocker prescription rates after acute myocardial infarction (AMI).

RESEARCH DESIGN

This was a cross-sectional study using data from a telephone survey of quality management directors at participating hospitals linked with patient-level data from the National Registry of Myocardial Infarction (NRMI) during the study period, October 1997 to September 1999.

SUBJECTS

A total of 60,363 patients discharged with a confirmed AMI from 234 US hospitals were included.

MEASURES

Hospital performance based on beta-blocker rates characterized as the top 20%, lower 20%, and middle 40% of hospitals; reported quality improvement efforts, including system interventions, physician leadership, administrative support for quality improvement efforts, and data feedback; hospital teaching status, AMI volume, geographic location, and ownership type.

RESULTS

The mean hospital-specific beta-blocker rate was 60.2%; however, the variation in beta-blocker use across hospitals was marked (range, 19.4-89.3%, standard deviation, 12.7% points), and quality improvement efforts used varied greatly. None of the quality improvement efforts distinguished higher from medium performers; the higher and the medium performers together were distinguished from the lower performers in organizational support for quality improvement efforts (fully adjusted odds ratio [OR] 1.89, 95% confidence interval [CI] 1.17-3.06) and physician leadership (fully adjusted OR 9.88, 95% CI 2.64-37.02). Among the specific quality improvement interventions, only standing orders were associated with having higher/medium versus lower performance, and their effect had borderline significance (fully adjusted OR 2.26, 95% CI 0.97-5.30, P = 0.07).

CONCLUSIONS

Our findings highlight the organizational environment, specifically the absence of administrative support or physician leadership for quality improvement, as an important correlate of poor beta-blocker rates after AMI. Future studies are needed to isolate hospital quality improvement efforts that are associated with superior performance.

Assessing Outcomes in Advanced Practice Nursing Practice

Advanced practice nurses (APNs) impact both patient care and healthcare systems on a daily basis. Tracking and documenting the outcomes of APN practice have become essential, due partly to the emphasis on outcomes that has become a component of the majority of healthcare initiatives. This article outlines important aspects related to assessing outcomes and discusses the use of quality indicators to demonstrate outcomes of APN practice. Examples from clinical practice are provided in order to demonstrate that assessing the outcomes of APN practice can be incorporated into daily practice as part of ongoing initiatives. In delineating the outcomes of APN care, the value of APNs can be formally acknowledged.

Practitioners As Experts: The Influence of Practicing Oncologists “in-the-Field” on Evidence-Based Guideline Development

Purpose

Panels of experts are used to develop clinical practice guidelines (CPGs) intended to be used by practitioners “in-the-field.” Therefore, oncologists’ participation in CPG development is an important strategy to promote CPG adoption. The purpose of this study was to evaluate the contributions of oncologists in-the-field to evidence-based CPG development using data from Ontario’s cancer system.

Methods

CPG development in Ontario includes surveys of oncologists’ opinions, using a structured questionnaire, about draft recommendations that were developed from rigorous systematic reviews of evidence prepared by expert panels. Two research assistants reviewed background documents to trace the changes in CPG recommendations from draft to final stage to determine the contribution of oncologists’ input to final recommendations. Changes to recommendations were categorized as either substantive (content or tone) or minor (ideas clarification or edits).

Results

From 2000 to 2003, 43 CPGs were developed. There were 87 changes to draft recommendations for 31 CPGs, of which 40 changes to 19 CPGs could be attributed to survey input from practicing oncologists. Of the 40 changes, 28 (70%) were judged to be substantive.

Conclusion

Despite a rigorous evidence-based process for CPG development, practicing oncologists contribute substantially to the final recommendations approved by the expert panel. It is hypothesized that the responsiveness of expert panels to input from oncologists in-the-field will facilitate adoption of CPGs.

Evidence-based outcome data after hernia surgery: A possible role for the National Surgical Quality Improvement Program

Since its inception in 1994, the National Surgical Quality Improvement Program (NSQIP) has been used to compare the performance of all Veterans Administration (VA) hospitals offering major surgical procedures. The program's outcome data are used to identify areas of both excellent and poor performance. The data can also be used to focus on specific procedures, especially high frequency operations such as inguinal herniorrhaphy. Following several successful feasibility studies, the NSQIP has been adopted by the American College of Surgeons (ACS) and is being offered nationwide in the non-VA sector. Given the profound decrease in operative mortality and morbidity seen within the VA, it seems realistic to expect similar improvements in global-and procedure specific-surgical outcomes within the non-VA sector.

How to Design Computerized Alerts to Ensure Safe Prescribing Practices

BACKGROUND

Medication errors and preventable adverse drug events are common, and about half of medication errors occur during medication ordering. This study was designed to develop and evaluate medication safety alerts and processes for educating prescribers about the alerts.

METHODS

At Kaiser Permanente Northwest, a group-model health maintenance organization where prescribers have used computerized order entry since 1996, qualitative interviews were conducted with 20 primary care prescribers.

RESULTS

Prescribers considered alerts helpful for providing prescribing and preventive health information. More than half the interviewees stated that it would be unwise to let clinicians control or avoid safety alerts. Common frustrations were (1) being delayed by the alert, (2) having difficulty interpreting the alert, and (3) receiving the same alert repeatedly. Most prescribers preferred small-group educational sessions tied to existing meetings and having local physicians conduct education sessions.

DISCUSSION

The findings were used to design a strategy for introducing and promoting the interventions, modifying the alert text and tools, and focusing the education on how clinicians could use the alerts effectively.

Physician-perceived barriers to adopting a critical pathway for unity-acquired pneumonia

BACKGROUND

A proven efficacious and evidence-based critical pathway for community-acquired pneumonia (CAP) was implemented in six hospitals across a health service region (Edmonton, Canada). After one year (November 2000-November 2001), the pathway had reduced average length of stay by 1 day (from 10.8 to 9.8 days, p < .001). However, great variation was observed in physician adherence to the pathway.

METHODS

Physician-perceived barriers to adoption of the CAP pathway were identified through in-depth interviews. Data saturation was reached after 10 physicians, representing a convenience sample of those willing to participate, were interviewed.

RESULTS

Self-reported adherence to the CAP pathway was 75% (range 50%-100%). Qualitative analysis of the interview data indicated that comments could be grouped into five themes: (1) limited applicability, (2) lack of flexibility to accommodate atypical clinical presentations, (3) perception of insufficient evidence to support recommendations, (4) local organizational barriers, and (5) need for local adaptation. For example, one physician remarked that his community hospital had insufficient staff to support collection of lab samples for all patients.

DISCUSSION

Interventions to increase pathway adoption and further improve quality of CAP care should address the identified barriers. For example, local audit and feedback of outcomes data to persuade physicians of the benefits of CAP pathways will need to be instituted.

Improved adherence to practice guidelines yields better outcome in high-risk patients with acute coronary syndrome without ST elevation: findings from nationwide FINACS studies

OBJECTIVES

Treatment options for acute coronary syndrome (ACS) without ST elevation have evolved rapidly during the recent years, but the successful implementation of practice guidelines incorporating new treatments into practice has been challenging. In this study, we evaluate whether targeted educational intervention could improve adherence to treatment guidelines of ACS without ST elevation.

DESIGN, SETTING AND SUBJECTS

A previous study, FINACS I, evaluated the treatment and outcome of 501 consecutive non-ST elevation ACS patients that were referred in early 2001 to nine hospitals, covering nearly half of the Finnish population. That study revealed poor adherence to ESC guidelines, so targeted educational intervention on optimal practice was arranged before the second study (FINACS II), which was performed in the same hospitals using the same protocol as FINACS I. FINACS II, undertaken in early 2003, evaluated 540 consecutive patients. Interventions. Targeted educational programmes on optimal practice.

MAIN OUTCOME MEASURES

The use of evidence-based therapies in non-ST elevation ACS patients. In-hospital event-free (death, new myocardial infarction, refractory angina, readmission with unstable angina and transient cerebral ischaemia/stroke) survival, and event-free survival at 6 months.

RESULTS

Baseline characteristics and risk markers were similar in both studies, and no significant changes in resources were seen. In 2003, the in-hospital use of statins, ACE-inhibitors, clopidogrel and glycoprotein (GP) IIb/IIIa receptor antagonists increased significantly, and in-hospital angiography was performed more often, especially in high-risk patients (59% vs. 45%, P < 0.05); waiting time also shortened (4.2 +/- 5.5 vs. 5.8 +/- 4.7 days, P < 0.01). Overall no significant change was seen in the frequency of death either in-hospital (2% vs. 4%, P = NS) or at 6 months (7% vs. 10%, P = NS) in FINACS II. However, the survival of high-risk patients improved both in-hospital (95% vs. 90%, P = 0.05) and at 6 months (89% vs. 78%, P = 0.05).

CONCLUSION

In patients with non-ST elevation ACS-targeted educational interventions appeared to be associated with improved adherence to practical guidelines, which yielded a better outcome in high-risk ACS patients.

Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure

PURPOSE

To assess the effects of an intervention involving dissemination of treatment recommendations to primary care physicians treating outpatients with acute myocardial infarction or heart failure.

METHODS

The study comprised 509 patients with myocardial infarction and 323 patients with heart failure who were discharged from hospital. The primary care physicians caring for these patients were assigned randomly to either the intervention or control group; the intervention group was mailed practice guidelines immediately after patient discharge, and patients were cited by name. During a 6-month assessment period, the records of primary care physicians (and cardiologists, if any) were reviewed to assess mean conformance with the guidelines, using seven measures of care for myocardial infarction and eight measures of care for heart failure.

RESULTS

After adjusting for demographic and clinical characteristics of patients, and the number of eligible measures per patient, we observed no effect of the intervention on care of patients with myocardial infarction (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.81 to 1.17) or heart failure (OR = 1.25; 95% CI: 0.96 to 1.59). However, there was a higher likelihood of conformance with measures for patients with infarction (OR = 1.56; 95% CI: 1.29 to 1.87) or heart failure (OR = 1.71; 95% CI: 1.29 to 2.23) who had also been seen by a cardiologist during the 6-month assessment period.

CONCLUSION

Mailing treatment recommendations did not improve the quality of care of recently discharged patients with myocardial infarction or heart failure. However, efforts to include cardiologists in the care of these patients might be worthwhile.

Improving prescribing of antihypertensive and cholesterol-lowering drugs: a method for identifying and addressing barriers to change

BACKGROUND

We describe a simple approach we used to identify barriers and tailor an intervention to improve pharmacological management of hypertension and hypercholesterolaemia. We also report the results of a post hoc exercise and survey we carried out to evaluate our approach for identifying barriers and tailoring interventions.

METHODS

We used structured reflection, searched for other relevant trials, surveyed general practitioners and talked with physicians during pilot testing of the intervention. The post hoc exercise was carried out as focus groups of international researchers in the field of quality improvement in health care. The post hoc survey was done by telephone interviews with physicians allocated to the experimental group of a randomised trial of our multifaceted intervention.

RESULTS

A wide range of barriers was identified and several interventions were suggested through structured reflection. The survey led to some adjustments. Studying other trials and pilot testing did not lead to changes in the design of the intervention. Neither the post hoc focus groups nor the post hoc survey revealed important barriers or interventions that we had not considered or included in our tailored intervention.

CONCLUSIONS

A simple approach to identifying barriers to change appears to have been adequate and efficient. However, we do not know for certain what we would have gained by using more comprehensive methods and we do not know whether the resulting intervention would have been more effective if we had used other methods. The effectiveness of our multifaceted intervention is under evaluation in a randomised controlled trial.

Improving care in patients with acute coronary syndromes: the Erlanger quality improvement initiative

Quality improvement (QI) in emergency department (ED) patients with acute coronary syndromes (ACS) is a complex and dynamic phenomenon. ED physicians are faced with the challenge of multitasking a variety of patient complaints. This chaotic environment frequently hampers the ED physician's ability to properly evaluate and treat chest pain patients. Just as an airplane pilot would never take off without performing the comprehensive preflight operational checklist, the ED physician should have a standardized protocol for the evaluation and treatment of chest pain patients. In this report, we describe Erlanger Medical Center's 10-year QI initiative in developing a successful chest pain protocol for the rapid evaluation and treatment of patients with suspected ACS. Our initiative resulted from a collaborative effort among emergency physicians, cardiologists, nuclear radiologists, nursing staff, and administration. The systematic step-wise approach we utilized at our institution consisted of identification of the problem, development of standardized protocols, hospital-based QI initiatives, and continuation of QI efforts through national initiatives. Through this "building of bridges" among physicians, nursing, and administration, we hope that other institutions will modify our protocols to assist them in the development of their own successful QI program for improving the evaluation, treatment, and disposition of patients with suspected ACS.

A Cognitive Aid for Cardiac Arrest: You Can’t Use It if You Don’t Know About It

BACKGROUND

A cognitive aid developed by the Department of Veterans Affairs (VA) and distributed to all VA facilities provides caregivers with information to minimize omission of critical steps when diagnosing and treating cardiac arrest. In 2002, caregivers were surveyed about the usefulness of the cognitive aid and the success of its dissemination throughout the VA.

METHODS

Fifty randomly selected VA hospitals were sent a letter to alert them of the upcoming survey. Twenty surveys were sent to each of the selected hospitals with instructions to distribute the survey to specific caregiver types.

RESULTS

Nine (18%) of the VA hospitals had not used the cognitive aid tool because of dissemination problems. Of the 565 caregivers responding to the survey, 59% (332) were aware of the cognitive aid. Of these 332, 96% agreed that putting the cognitive aid on code carts is a good idea. There were 234 respondents who were both aware of the cognitive aid and had been involved in at least one code within the past 30 days. Of these 234, some 29 (12%) used the aid during a code, 28 of whom agreed that the cognitive aid was helpful during the code.

DISCUSSION

Both new and experienced caregivers find the cognitive aid helpful when responding to "code" situations. However, cognitive aids cannot be helpful if theintended users are unaware of their availability. Dissemination and awareness of the aids can be problematic in large health care systems.

Towards more effective use of decision support in clinical practice: what the guidelines for guidelines don’t tell you

The Brisbane Cardiac Consortium Clinical Support Systems Program used multiple strategies in optimising quality of care of patients with either of two cardiac conditions. One of these strategies was the development and active implementation of decision support systems centred on evidence-based, locally agreed clinical practice guidelines. Our experience in undertaking this task highlighted numerous operational challenges for which solutions were difficult to extract from existing published literature. In the present article we provide a methodology grounded in both theory and real-world experience that may assist others in developing and implementing systems of guideline-based decision support.

Multihospital system membership and patient treatments, expenditures, and outcomes

OBJECTIVE

To determine the relationship between hospital membership in systems and the treatments, expenditures, and outcomes of patients.

DATA SOURCES

The Medicare Provider Analysis and Review dataset, for data on Medicare patients admitted to general medical-surgical hospitals between 1985 and 1998 with a diagnosis of acute myocardial infarction (AMI); the American Hospital Association Annual Survey, for data on hospitals.

STUDY DESIGN

A multivariate regression analysis. An observation is a fee-for-service Medicare AMI patient admitted to a study hospital. Dependent variables include patient transfers, catheterizations, angioplasties or bypass surgeries, 90-day mortality, and Medicare expenditures. Independent variables include system participation, other admission hospital and patient traits, and hospital and year fixed effects. The five-part system definition incorporates the size and location of the index admission hospital and the size and distance of its partners.

PRINCIPAL FINDINGS

While the effects of multihospital system membership on patients are in general limited, patients initially admitted to small rural system hospitals that have big partners within 100 miles experience lower mortality rates than patients initially admitted to independent hospitals. Regression results show that to the extent system hospital patients experience differences in treatments and outcomes relative to patients of independent hospitals, these differences remain even after controlling for the admission hospital's capacity to provide cardiac services.

CONCLUSIONS

Multihospital system participation may affect AMI patient treatment and outcomes through factors other than cardiac service offerings. Additional investigation into the nature of these factors is warranted.

Factors that impact the transfer and retention of best practices for reducing error in hospitals

Recent research and theory in organizational learning literature advances seven propositions that illuminate the nature and complexities of transferring and retaining best practices for reducing error and increasing patient safety in U.S. and Canadian hospitals.

Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings

OBJECTIVES

To evaluate the feasibility of the San Diego Attention-Deficit/Hyperactivity Disorder Project (SANDAP) protocol, a pediatric community-initiated quality improvement effort to foster implementation of the American Academy of Pediatrics (AAP) attention-deficit/hyperactivity disorder (ADHD) diagnostic guidelines, and to identify any additional barriers to providing evidence-based ADHD evaluative care.

METHODS

Seven research-naïve primary care offices in the San Diego area were recruited to participate. Offices were trained in the SANDAP protocol, which included 1) physician education, 2) a standardized assessment packet for parents and teachers, 3) an ADHD coordinator to assist in collection and collation of the assessment packet components, 4) educational materials for clinicians, parents, and teachers, in the form of handouts and a website, and 5) flowcharts delineating local paths for referral to medical subspecialists, mental health practitioners, and school-based professionals. The assessment packet included the parent and teacher versions of the Vanderbilt ADHD Diagnostic Rating Scales. In this study, we chose a conservative interpretation of the AAP ADHD guidelines for diagnosing ADHD, requiring that a child met criteria for ADHD on both the parent and teacher rating scales. A mixed-method analytic strategy was used to address feasibility and barriers, including quantitative surveys with parents and teachers and qualitative debriefing sessions conducted an average of 3 times per year with pediatricians and office staff members.

RESULTS

Between December 2000 and April 2003, 159 children were consecutively enrolled for evaluation of school and/or behavioral problems. Clinically, only 44% of the children met criteria for ADHD on both the parent and teacher scales, and 73.5% of those children were categorized as having the combined subtype. More than 40% of the subjects demonstrated discrepant results on the Vanderbilt scales, with only the parent or teacher endorsing sufficient symptoms to meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Other mental health and learning problems were common in the sample; 58.5% of subjects met screening criteria for oppositional defiant disorder/conduct disorder, 32.7% met screening criteria for anxiety/depression, and approximately one-third had an active individualized education program in place or had received an individualized education program in the past. On evaluation, the SANDAP protocol was acceptable and feasible for all stakeholders. However, additional barriers to implementing the AAP ADHD guidelines were identified, including 1) limited information in the guidelines regarding the use of specific ADHD rating scales, the evaluation and treatment of children with discrepant and/or negative results, and the indications for psychologic evaluation of learning problems, 2) families' need for education regarding ADHD and support, 3) characteristics of physical health and mental health plans that limited care for children with ADHD, and 4) limited knowledge and use of potential community resources.

CONCLUSIONS

Our results indicate that children presenting for evaluation of possible ADHD in primary care offices have complex clinical characteristics. Providers need mechanisms for implementing the ADHD diagnostic guidelines that address the physician education and delivery system design aspects of care that were developed in the SANDAP protocol. Additional barriers were also identified. Careful attention to these factors will be necessary to ensure the sustained provision of quality care for children with ADHD in primary care settings.

The Relationship Among Physicians’ Specialty, Perceptions of the Risks and Benefits of Adjuvant Tamoxifen Therapy, and Its Recommendation in Older Patients With Breast Cancer

OBJECTIVES

The objectives of this study were to determine whether tamoxifen recommendation differs by physician specialty, to determine whether perception affects tamoxifen recommendation, and to investigate the association between the physician's specialty and the perception of risks and benefits of tamoxifen.

METHODS

We enrolled a cohort of geographically diverse women aged 65 and older with stage I through IIIa breast cancer in a prospective cohort study. We recruited their surgeons and, when applicable, their medical oncologists to provide patient-specific information about their perceptions of the risks and benefits of tamoxifen and whether they recommended tamoxifen. Each physician also completed a questionnaire regarding his or her demographic and practice characteristics. Patient data were collected through medical record review and a patient interview 3 months after definitive breast cancer surgery.

RESULTS

We collected physician treatment recommendation forms for 585 women. Oncologists were 2.5 times more likely to recommend tamoxifen, compared with surgeons, after adjusting for patient and tumor characteristics (95% confidence interval, 1.5-4.2). For both specialties, their perceptions of the risks and benefits of tamoxifen were strong predictors of tamoxifen recommendation. However, there were differences in perception by physician specialty. Distant metastases and tolerance of tamoxifen side effects were more important to oncologists, whereas local recurrence and risk of cataracts were more important to surgeons.

CONCLUSION

Physicians' perceptions of the risks and benefits of tamoxifen therapy for older women are important in their decision-making process.

From knowledge to practice in chronic cardiovascular disease: a long and winding road

Although clinical practices evolve over time, the translation of specific research evidence into clinical practice is unpredictable, inconsistent, and complex. In this paper, we use examples from chronic cardiovascular conditions to: 1). highlight two types of care gaps; 2). describe the most common potential barriers to the application of evidence into clinical care; and 3). outline which of the strategies for translating evidence into clinical care have been shown to be ineffective, which strategies have been shown to be effective and to describe some untested approaches that hold promise.

Quality of care for acute myocardial infarction in rural and urban US hospitals

CONTEXT

Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care.

PURPOSE

To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers.

METHODS

This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality.

FINDINGS

Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]).

CONCLUSIONS

Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.

Impracticability of informed consent in the Registry of the Canadian Stroke Network

BACKGROUND

Government legislators and research ethics boards in some jurisdictions require all patients to give written informed consent before enrollment in clinical registries. However, the effect of such a requirement on the use of clinical registries and the extent to which registry data can be generalized remain uncertain.

METHODS

We examined the effectiveness of a comprehensive attempt to obtain informed consent between June 2001 and December 2002 on the overall participation rate and the characteristics of participating patients in the Registry of the Canadian Stroke Network, a prospective registry based at 20 major stroke centers across Canada.

RESULTS

The overall participation rate (i.e., the consent rate among all potential participants) was 39.3 percent of 4285 eligible patients during phase 1 of the project (June 2001 through February 2002) and 50.6 percent of 2823 eligible patients during phase 2 (June 2002 through December 2002), despite the presence of neurologic research nurse coordinators at each site. Many patients died or left the hospital before they could be approached for consent. Major selection biases were found; the in-hospital mortality rate was much lower among patients who were enrolled (6.9 percent) than among those who were not enrolled (21.7 percent) (relative risk of in-hospital death, 3.13; 95 percent confidence interval, 2.65 to 3.70; P<0.001). We estimate that approximately 500,000 dollars (Canadian dollars) was spent on consent-related issues during the first two years of the registry.

CONCLUSIONS

Obtaining written informed consent for participation in a stroke registry led to important selection biases, such that registry patients were not representative of the typical patient with stroke at each center. These findings highlight the need for legislation on privacy and policies permitting waivers of informed consent for minimal-risk observational research.

Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly

PURPOSE

To determine if inpatient or outpatient geriatric evaluation and management, as compared with usual care, reduces adverse drug reactions and suboptimal prescribing in frail elderly patients.

METHODS

The study employed a randomized 2 x 2 factorial controlled design. Subjects were patients in 11 Veterans Affairs (VA) hospitals who were > or =65 years old and met criteria for frailty (n = 834). Inpatient geriatric unit and outpatient geriatric clinic teams evaluated and managed patients according to published guidelines and VA standards. Patients were followed for 12 months. Blinded physician-pharmacist pairs rated adverse drug reactions for causality (using Naranjo's algorithm) and seriousness. Suboptimal prescribing measures included unnecessary and inappropriate drug use (Medication Appropriateness Index), inappropriate drug use (Beers criteria), and underuse.

RESULTS

For serious adverse drug reactions, there were no inpatient geriatric unit effects during the inpatient or outpatient follow-up periods. Outpatient geriatric clinic care resulted in a 35% reduction in the risk of a serious adverse drug reaction compared with usual care (adjusted relative risk = 0.65; 95% confidence interval: 0.45 to 0.93). Inpatient geriatric unit care reduced unnecessary and inappropriate drug use and underuse significantly during the inpatient period (P <0.05). Outpatient geriatric clinic care reduced the number of conditions with omitted drugs significantly during the outpatient period (P <0.05).

CONCLUSION

Compared with usual care, outpatient geriatric evaluation and management reduces serious adverse drug reactions, and inpatient and outpatient geriatric evaluation and management reduces suboptimal prescribing, in frail elderly patients.

Implementing evidence-based practice: evaluation of an opinion leader strategy to improve breast-feeding rates

OBJECTIVE

The objective was to evaluate the effectiveness of opinion leaders in raising breast-feeding rates.

STUDY DESIGN

A randomized controlled trial of an opinion leader strategy in 18 hospitals in Central New York State compared mothers' intention to breast-feed during baseline and study years. Multivariate logistic regression with a mixed model analyzed the effects on breast-feeding exclusively and on breast- and formula-feeding combined.

RESULTS

Obstetric clinicians had a high degree of knowledge about breast-feeding benefits and of perceived responsibility to recommend breast-feeding. Obstetricians, family practitioners, and midwives agreed on the person identified as the opinion leader, in each case an obstetrician who was chief of obstetrics or obstetrics-gynecology. Breast-feeding rates in hospitals with the opinion leader intervention did not differ significantly from those in control-group hospitals during the study year.

CONCLUSION

The opinion leader strategy in this case did not improve breast-feeding rates during the study year. Opinion leader strategies may make assumptions about clinician control that are not justified in situations such as breast-feeding.

Implementing effective ventilator practice at the bedside

PURPOSE OF REVIEW

New data on the efficacy of low tidal volume ventilation for acute lung injury, noninvasive ventilation for chronic obstructive pulmonary disease exacerbation, weaning from mechanical ventilation, and prevention of ventilator-associated pneumonia provide, for perhaps the first time in respiratory care, compelling evidence for clinicians to change practice. However, experience from every other field in medicine suggests that there will be significant barriers to changing clinical practice at the bedside. Studies on implementation of effective practice in medicine shows that a multifaceted, team-oriented approach incorporating reminders, efficient use of non-physician personnel, protocols, and education is required to change clinical practice. Limited data on current practice of mechanical ventilation suggest that it deviates from recommended practice. Unfortunately, there are no studies exploring community-based implementation of mechanical ventilation guidelines and only a few studies to inform clinicians as to why ventilator practice may be difficult to change. As the evidence base grows for effective critical care practice, so does the responsibility to translate practices that improve outcome from research journals to patients' bedsides. Strategies for doing this are presented in the review.

Acute pain treatment for older adults hospitalized with hip fracture: current nursing practices and perceived barriers

This article examines acute pain management practices for patients 65 years of age and older who were hospitalized during 1999 for hip fracture. Data were collected from the medical records of patients (N = 709) admitted to 12 hospitals in the Midwest and from questionnaires on pain practices completed by nurses (N = 172) caring for these patients. The major variables examined were (1). pharmacological and nonpharmacological treatments for acute pain in hospitalized elders, (2). nurses' perceived stage of adoption for avoiding meperidine use and for administering analgesics around-the-clock, and (3). nurses' perceived barriers to optimal treatment of acute pain in elders. Acetaminophen was the most frequently administered analgesic, but administered doses were far less than the maximum daily recommended dose. More than one third (39%) of the nurses reported that they always avoided the use of meperidine, and over half reporting avoiding its use sometimes. However, the majority of patients (56.8%) received at least one dose of meperidine, even though evidence suggests that other analgesic agents are more appropriate for treatment of acute pain in elders. Only 27% of patients received patient-controlled analgesia, and only 22.3% of patients received around-the-clock administration during the first 24 hours after admission of analgesics that had been ordered on a prn basis. The majority of nurses were aware that around-the-clock administration of analgesics was preferable, but only 33.7% were persuaded (believed) that this method should be used. Intramuscular injection was used for 52.2% of patients, even though this route is not recommended for older adults. The most frequently used nonpharmacological intervention was repositioning, followed by use of pressure relief devices and cold application. Nurses reported difficulty contacting physicians and difficulty communicating with them about type and/or dose of analgesics as the greatest barriers to pain management. Findings from this multi-site study show that active and focused "translation" interventions are needed to promote adoption of evidence-based acute pain management practices by health care providers.