Multicomponent Pharmacist Intervention Did Not Reduce Clinically Important Medication Errors for Ambulatory Patients Initiating Direct Oral Anticoagulants

BACKGROUND

Anticoagulants including direct oral anticoagulants (DOACs) are among the highest-risk medications in the United States. We postulated that routine consultation and follow-up from a clinical pharmacist would reduce clinically important medication errors (CIMEs) among patients beginning or resuming a DOAC in the ambulatory care setting.

OBJECTIVE

To evaluate the effectiveness of a multicomponent intervention for reducing CIMEs.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Ambulatory patients initiating a DOAC or resuming one after a complication.

INTERVENTION

Pharmacist evaluation and monitoring based on the implementation of a recently published checklist. Key elements included evaluation of the appropriateness of DOAC, need for DOAC affordability assistance, three pharmacist-initiated telephone consultations, access to a DOAC hotline, documented hand-off to the patient's continuity provider, and monitoring of follow-up laboratory tests.

CONTROL

Coupons and assistance to increase the affordability of DOACs.

MAIN MEASURE

Anticoagulant-related CIMEs (Anticoagulant-CIMEs) and non-anticoagulant-related CIMEs over 90 days from DOAC initiation; CIMEs identified through masked assessment process including two physician adjudication of events presented by a pharmacist distinct from intervention pharmacist who reviewed participant electronic medical records and interview data.

ANALYSIS

Incidence and incidence rate ratio (IRR) of CIMEs (intervention vs. control) using multivariable Poisson regression modeling.

KEY RESULTS

A total of 561 patients (281 intervention and 280 control patients) contributed 479 anticoagulant-CIMEs including 31 preventable and ameliorable ADEs and 448 significant anticoagulant medication errors without subsequent documented ADEs (0.95 per 100 person-days). Failure to perform required blood tests and concurrent, inappropriate usage of a DOAC with aspirin or NSAIDs were the most common anticoagulant-related CIMEs despite pharmacist documentation systematically identifying these issues when present. There was no reduction in anticoagulant-related CIMEs among intervention patients (IRR 1.17; 95% CI 0.98-1.42) or non-anticoagulant-related CIMEs (IRR 1.05; 95% CI 0.80-1.37).

CONCLUSION

A multi-component intervention in which clinical pharmacists implemented an evidence-based DOAC Checklist did not reduce CIMEs.

NIH TRIAL NUMBER

NCT04068727.

Strategies to Improve Enrollment and Participation in Pulmonary Rehabilitation Following a Hospitalization for COPD: RESULTS OF A NATIONAL SURVEY

PURPOSE

Pulmonary rehabilitation (PR) improves outcomes for patients with chronic obstructive pulmonary disease (COPD); however, very few patients attend. We sought to describe strategies used to promote participation in PR after a hospitalization for COPD.

METHODS

A random sample of 323 United States based PR programs was surveyed. Using a positive deviance approach, a 39-item survey was developed based on interviews with clinicians at hospitals demonstrating high rates of participation in PR. Items focused on strategies used to promote participation as well as relevant contextual factors.

RESULTS

Responses were received from 209 programs (65%), of which 88% (n = 184) were hospital-based outpatient facilities. Most (91%, n = 190) programs described enrolling patients continuously, and 80% (n = 167) reported a wait time from referral to the initial PR visit of <4 wk. Organization-level strategies to increase referral to PR included active surveillance (48%, n = 100) and COPD-focused staff (49%, n = 102). Provider-level strategies included clinician education (45%, n = 94), provider outreach (43%, n = 89), order sets (45%, n = 93), and automated referrals (23%, n = 48). Patient-level strategies included bedside education (53%, n = 111), flyers (49%, n = 103), motivational interviewing (33%, n = 69), financial counseling (64%, n = 134), and transportation assistance (35%, n = 73). Fewer than one-quarter (18%, n = 38) of PR programs reported using both bedside education and automatic referral, and 42% (n = 88) programs did not use either strategy.

CONCLUSIONS

This study describes current practices in the United States, and highlights opportunities for improvement at the organization, provider, and patient level. Future research needs to demonstrate the effectiveness of these strategies, alone or in combination.

Supervised preoperative walking on increasing early postoperative stamina and mobility in older adults with frailty traits: A pilot and feasibility study

Background and Aims

Frail older adults are more than twice as likely to experience postoperative complications. Preoperative exercise may better prepare these patients through improved stamina and mobility experienced in the days following surgery. We measured the impact of a walking intervention using an activity tracker and coaching on postoperative stamina, and mobility in older adults with frailty traits.

Methods

We included patients aged 60+ and scoring 4+ on the Edmonton Frailty Scale. We then randomized patients to intervention versus control stratified by anticipated hospital stay (1 night vs. 2+ night) and baseline stamina (i.e., 6-min walk distance [6MWD]). Intervention patients received an activity tracker and linked smart phone. An athletic trainer (AT) prescribed a daily step count goal and titrated this up after checking in with patients during weekly telephone calls. Controls received general walking recommendations. We then measured postoperative 6MWD 1-3 days after surgery. We also assessed postoperative mobility by measuring steps walked the day after surgery using a thigh-worn monitor. Because many patients could not walk postoperatively, we compared intervention-control difference in both 6MWD and steps using Wilcoxon rank testing and Tobit and ordinal logistic regression adjusting for several patient characteristics.

Results

We randomized 104 eligible patients; 80 patients remained for final analysis. There was no difference in intervention versus control postoperative 6MWD (median 72 vs. 74 m Wilcoxon p = 0.54) or postoperative steps taken (median 128 vs. 51 steps Wilcoxon p = 0.76). Analysis adjusting for patient characteristics was consistent with these findings.

Conclusion

Our intervention consisting of goal setting with an activity tracker and telephonic coaching by an AT did not appear to improve stamina or mobility measured in the days after surgery. Small sample size limited our ability to examine this impact in subsets defined by surgical specialty or baseline stamina.

SUPPORT-AF IV: Supporting use of AC through provider prompting about oral anticoagulation therapy for AF clinical trial study protocol

Background

Six million Americans suffer from atrial fibrillation (AF), a heart rhythm abnormality that significantly increases the risk of stroke. AF is responsible for 15% of ischemic strokes, which lead to permanent disability in 60% of cases and death in up to 20%. Anticoagulation (AC) is the mainstay for stroke prevention in patients with AF. Despite guidelines recommending AC for patients, up to half of eligible patients are not on AC. Clinical decision support tools in the electronic health record (EHR) can help bridge the disparity in AC prescription for patients with AF.

Objective

To enhance and assess the effectiveness of our previous rule-based alert on AC initiation and persistence in a diverse patient population from UMass-Memorial Medical Center and University of Florida at Jacksonville.

Methods/Results

Using the EHR, we will track AC initiation and persistence. We will interview both patients and providers to determine a measure of satisfaction with AC management. We will track digital crumbs to better understand the alert’s mechanism of effect and further add enhancements. These enhancements will be used to refine the alert and aid in developing an implementation toolkit to facilitate use of the alert at other health systems.

Conclusion

If the number of AC starts, the likelihood of persisting on AC, and the frequency alert use are found to be higher among intervention vs control providers, we believe such findings will confirm our hypothesis on the effectiveness of our alert.

Facility Characteristics Associated With Intensity of Care of Nursing Home Residents With Advanced Dementia

Profound variations in care intensity of nursing home (NH) residents with advanced dementia exist for NHs within and across hospital referral regions (HRRs). Little is known about how these levels of influence relate. Nationwide 2016-2017 Minimum DataSet was used to categorize NHs and HRRs into 4 levels of care intensity based on hospital transfer and tube-feeding rates among residents with advanced dementia: low intensity NH in low intensity HRR; high intensity NH in low intensity HRR; low intensity NH in high intensity HRR; and high intensity NH in high intensity HRR. We used multinomial logistic regression to identify NH characteristics associated with belonging to each of 4-levels of intensity as compared to low intensity NH in low intensity HRRs (reference). We found high intensity NHs in high intensity HRRs were more likely to be in an urbanized area, not have an dementia unit, have an NP/PA on staff, have a higher proportion of residents who were male, age <65, of Black race, and had pressure ulcers, and relatively fewer days on hospice. Whereas in low intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high intensity NH. These findings suggest potentially modifiable factors within high intensity HRRs that could be targeted to reduce burdensome care, including having a dementia unit, palliative care training for NP/PAs, or increased use of hospice care. This study underscores the critical need to better understand the role race plays in the intensity of care of NH residents with dementia.

Usability and Perceived Usefulness of the AFib 2gether Mobile App in a Clinical Setting: Single-Arm Intervention Study

Background

Although the American Heart Association and other professional societies have recommended shared decision-making as a way for patients with atrial fibrillation (AF) or atrial flutter to make informed decisions about using anticoagulation (AC), the best method for facilitating shared decision-making remains uncertain.

Objective

The aim of this study is to assess the AFib 2gether mobile app for usability, perceived usefulness, and the extent and nature of shared decision-making that occurred for clinical encounters between patients with AF and their cardiology providers in which the app was used.

Methods

We identified patients visiting a cardiology provider between October 2019 and May 2020. We measured usability from patients and providers using the Mobile App Rating Scale. From the 8 items of the Mobile App Rating Scale, we reported the average score (out of 5) for domains of functionality, esthetics, and overall quality. We administered a 3-item questionnaire to patients relating to their perceived usefulness of the app and a separate 3-item questionnaire to providers to measure their perceived usefulness of the app. We performed a chart review to track the occurrence of AC within 6 months of the index visit. We also audio recorded a subset of the encounters to identify evidence of shared decision-making.

Results

We facilitated shared decision-making visits for 37 patients visiting 13 providers. In terms of usability, patients’ average ratings of functionality, esthetics, and overall quality were 4.51 (SD 0.61), 4.26 (SD 0.51), and 4.24 (SD 0.89), respectively. In terms of usefulness, 41% (15/37) of patients agreed that the app improved their knowledge regarding AC, and 62% (23/37) agreed that the app helped clarify to their provider their preferences regarding AC. Among providers, 79% (27/34) agreed that the app helped clarify their patients’ preferences, 82% (28/34) agreed that the app saved them time, and 59% (20/34) agreed that the app helped their patients make decisions about AC. In addition, 32% (12/37) of patients started AC after their shared decision-making visits. We audio recorded 25 encounters. Of these, 84% (21/25) included the mention of AC for AF, 44% (11/25) included the discussion of multiple options for AC, 72% (18/25) included a provider recommendation for AC, and 48% (12/25) included the evidence of patient involvement in the discussion.

Conclusions

Patients and providers rated the app with high usability and perceived usefulness. Moreover, one-third of the patients began AC, and approximately 50% (12/25) of the encounters showed evidence of patient involvement in decision-making. In the future, we plan to study the effect of the app on a larger sample and with a controlled study design.

Trial Registration

ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270

International Registered Report Identifier (IRRID)

RR2-21986

Implementation of Patient Engagement Tools in Electronic Health Records to Enhance Patient-Centered Communication: Protocol for Feasibility Evaluation and Preliminary Results

Background

Patient–physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient–physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters.

Objective

In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient–physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters.

Methods

We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit “patient important issue” questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient–staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes.

Results

The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient–clinician communication, particularly during the COVID-19 pandemic.

Conclusions

EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians’ work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians.

Trial Registration

ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512

International Registered Report Identifier (IRRID)

DERR1-10.2196/30431

Usability, Perceived Usefulness, and Shared Decision-Making Features of the AFib 2gether Mobile App: Protocol for a Single-Arm Intervention Study

BACKGROUND

The Centers for Disease Control and Prevention has estimated that atrial fibrillation (AF) affects between 2.7 million and 6.1 million people in the United States. Those who have AF tend to have a much higher stroke risk than others. Although most individuals with AF benefit from anticoagulation (AC) therapy, a significant majority are hesitant to start it. To add, providers often struggle in helping patients negotiate the decision to start AC therapy. To assist in the communication between patients and providers regarding preferences and knowledge about AC therapy, different strategies are being used to try and solve this problem. In this research study, we will have patients and providers utilize the AFib 2gether app with hopes that it will create a platform for shared decision making regarding the prevention of stroke in patients with AF receiving AC therapy.

OBJECTIVE

The aim of our study is to measure several outcomes related to encounters between patients and their cardiology providers where AFib 2gether is used. These outcomes include usability and perceived usefulness of the app from the perspective of patients and providers. In addition, we will assess the extent and nature of shared decision making.

METHODS

Eligible patients and providers will evaluate the AFib 2gether mobile app for usability and perceived usefulness in facilitating shared decision making regarding understanding the patient's risk of stroke and whether or not to start AC therapy. Both patients and providers will review the app and complete multiple questionnaires about the usability and perceived usefulness of the mobile app in a clinical setting. We will also audio-record a subset of encounters to assess for evidence of shared decision making.

RESULTS

Enrollment in the AFib 2gether shared decision-making study is still ongoing for both patients and providers. The first participant enrolled on November 22, 2019. Analysis and publishing of results are expected to be completed in spring 2021.

CONCLUSIONS

The AFib 2gether app emerged from a desire to increase the ability of patients and providers to engage in shared decision making around understanding the risk of stroke and AC therapy. We anticipate that the AFib 2gether mobile app will facilitate patient discussion with their cardiologist and other providers. Additionally, we hope the study will help us identify barriers that providers face when placing patients on AC therapy. We aim to demonstrate the usability and perceived usefulness of the app with a future goal of testing the value of our approach in a larger sample of patients and providers at multiple medical centers across the country.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21986.

Assessing Anticoagulation Management and Shared Decision-Making Documentation From Providers Participating in the SUPPORT-AF II Study

BACKGROUND

A previously tested intervention featured educational outreach with modified academic detailing (AD) to increase anticoagulation use in patients with atrial fibrillation. Currently, this study compares providers receiving and not receiving AD in terms of inclusion of AD educational topics and shared decision-making elements in documentation.

METHODS

Physicians reviewed themes discussed with providers during AD and evaluated charts for evidence of shared decision-making. Frequencies of documentation of individual items for providers receiving AD versus non-AD providers were compared. To understand baseline documentation practices of AD providers, encounters of AD providers before their AD participation were randomly selected.

RESULTS

There were 113 eligible encounters in the four months after AD-36 from AD providers and 77 from non-AD providers. Thirty-five encounters were identified from AD providers before participating in the intervention. Providers infrequently documented many reviewed items (% documenting): anticoagulation mentioned (44%), multiple options for anticoagulation (5%), CHA2DS2-VASc score (11%), bleeding risk factors (2%). Compared with non-AD providers, AD providers had statistically significant higher percentages for the following items: mention of anticoagulation (64% versus 35%), stroke risk (11% versus 0%), anticoagulation benefits (8% versus 0%), and patient involvement (17% versus 0%). There was no improvement, however, for AD providers compared with baseline documentation percentages.

DISCUSSION

Providers infrequently documented important items in anticoagulation management and shared decision-making. AD participation did not improve documentation. Improving adoption of AD educational items may require more prolonged interaction with providers. Improving shared decision-making may require an intervention more focused on it and its documentation.

A TRIAL TO IMPROVE MEDICATION SAFETY IN OLDER ADULTS: RECRUITMENT CHALLENGES HAVE GENERALIZABILITY IMPLICATIONS

For older adults, the transition from hospital to home is a high-risk period for adverse drug events, functional decline, and hospital readmission. Randomized trials of interventions to improve this transition must recruit potential subjects immediately after hospital discharge, when people are recovering and tired. Within a randomized trial assessing the impact of a pharmacist home visit to provide medication assistance immediately post-discharge, we determined whether individuals who enrolled were comparable to those who were invited but did not enroll, and described reasons for not enrolling. Individuals ≥50 years of age discharged from the hospital and prescribed a high-risk medication were eligible. We attempted to recruit individuals by phone within 3 days of discharge, and recorded reasons for not enrolling. Of 3,606 eligible individuals reached, 3,147 (87%) declined, 361 (10%) were enrolled, and 98 (3%) were initially recruited but did not complete a consent form. Individuals ≥80 years of age (odds ratio 0.45, CI 0.25, 0.78) and those with an assigned visiting nurse (odds ratio 0.64, CI 0.48, 0.85) were least likely to enroll. Among those who provided a reason for declining (2,473) the most common reason given was the belief they did not need medication assistance (22%). An additional 332 (13%) declined because they were receiving visiting nurse services. Recruiting older adults recently discharged from the hospital is difficult and may under-enroll the oldest individuals, limiting the ability to generalize findings across older patient populations. Researchers planning RCTs among newly discharged older adults may need creative approaches to overcome resistance.

We Want to Know: Eliciting Hospitalized Patients' Perspectives on Breakdowns in Care

BACKGROUND

There is increasing recognition that patients have critical insights into care experiences, including breakdowns in care. Harnessing patient perspectives for hospital improvement requires an in-depth understanding of the types of breakdowns patients identify and the impact of these events.

METHODS

We interviewed a broad sample of patients during hospitalization and postdischarge to elicit patient perspectives on breakdowns in care. Through an iterative process, we developed a categorization of patient-perceived breakdowns called the Patient Experience Coding Tool.

RESULTS

Of 979 interviewees, 386 (39.4%) believed they had experienced at least one breakdown in care. The most common reported breakdowns involved information exchange (n = 158, 16.1%), medications (n = 120, 12.3%), delays in admission (n = 90, 9.2%), team communication (n = 65, 6.6%), providers' manner (n = 62, 6.3%), and discharge (n = 56, 5.7%). Of the 386 interviewees who reported a breakdown, 140 (36.3%) perceived associated harm. Patient- perceived harms included physical (eg, pain), emotional (eg, distress, worry), damage to relationship with providers, need for additional care or prolonged hospital stay, and life disruption. We found higher rates of reporting breakdowns among younger ( <60 years old) patients (45.4% vs 34.5%, 𝑃 < 0.001), those with at least some college education (46.8% vs 32.7%, 𝑃 < 0.001), and those with another person (family or friend) present during the interview or interviewed in lieu of the patient (53.4% vs 37.8%, 𝑃 = 0.002).

CONCLUSIONS

When asked directly, almost 4 out of 10 hospitalized patients reported a breakdown in their care. Patient- perceived breakdowns in care are frequently associated with perceived harm, illustrating the importance of detecting and addressing these events.

Informed Family Member Involvement to Improve the Quality of Dementia Care in Nursing Homes

OBJECTIVES

To describe the extent to which nursing homes engaged families in antipsychotic initiation decisions in the year before surveyor guidance revisions were implemented.

DESIGN

Mixed-methods study based on semistructured interviews.

SETTING

U.S. nursing homes (N = 20) from five CMS regions (III, IV, VI, VIII, IX).

PARTICIPANTS

Family members of nursing home residents (N = 41).

MEASUREMENTS

Family member responses to closed- and open-ended questions regarding involvement in resident care and antipsychotic initiation. Two researchers used a content analytical approach to code open responses to themes of family involvement in behavior management, decision-making, knowledge of risks and benefits, and informed consent.

RESULTS

Fifty-four percent of family members felt highly involved in decisions about behavior management. Forty-two percent recalled being asked how to manage resident behavior without medication, and 17% recalled receipt of information about antipsychotic risks and benefits. Sixty-six percent felt highly involved in the process of initiating antipsychotic medication; 24% reported being asked for input into the antipsychotic initiation decision and knowing before the antipsychotic was started.

CONCLUSION

Under existing federal regulations but before guidance revisions were implemented in 2013, more than 40% of families reported being involved in nonpharmacological behavior management of family members, but fewer than one in four reported being involved throughout the entire antipsychotic prescribing process. Interventions that standardize family engagement and promote adherence to existing federal regulations are needed. This discussion builds on these findings to weigh the policy options of greater enforcement of existing regulations versus enactment of new legislation to address this challenging issue.

Dissemination of Evidence-Based Antipsychotic Prescribing Guidelines to Nursing Homes: A Cluster Randomized Trial

OBJECTIVES

To evaluate the effectiveness of efforts to translate and disseminate evidence-based guidelines about atypical antipsychotic use to nursing homes (NHs).

DESIGN

Three-arm, cluster randomized trial.

SETTING

NHs.

PARTICIPANTS

NHs in the state of Connecticut.

MEASUREMENTS

Evidence-based guidelines for atypical antipsychotic prescribing were translated into a toolkit targeting NH stakeholders, and 42 NHs were recruited and randomized to one of three toolkit dissemination strategies: mailed toolkit delivery (minimal intensity); mailed toolkit delivery with quarterly audit and feedback reports about facility-level antipsychotic prescribing (moderate intensity); and in-person toolkit delivery with academic detailing, on-site behavioral management training, and quarterly audit and feedback reports (high intensity). Outcomes were evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

RESULTS

Toolkit awareness of 30% (7/23) of leadership of low-intensity NHs, 54% (19/35) of moderate-intensity NHs, and 82% (18/22) of high-intensity NHs reflected adoption and implementation of the intervention. Highest levels of use and knowledge among direct care staff were reported in high-intensity NHs. Antipsychotic prescribing levels declined during the study period, but there were no statistically significant differences between study arms or from secular trends.

CONCLUSION

RE-AIM indicators suggest some success in disseminating the toolkit and differences in reach, adoption, and implementation according to dissemination strategy but no measurable effect on antipsychotic prescribing trends. Further dissemination to external stakeholders such as psychiatry consultants and hospitals may be needed to influence antipsychotic prescribing for NH residents.

Patient-centered prescribing of medications for comorbid illness in older adults with advanced cancer: A qualitative study

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Background: Polypharmacy is common, burdensome, and potentially harmful in older adults with advanced cancer. According to the IOM, prescribing and coordination of chronic disease medication for these patients is suboptimal. We conducted a qualitative study with patients, caregivers, nurses, and physicians to better understand these issues. Methods: We used semi-structured interviews to explore participants’ views on medication management, care coordination, and communication for advanced cancer patients enrolled in 3 hospice agencies in New England. Eligible hospice patients were aged ≥ 65 yrs, had a diagnosis of cancer, and prescribed ≥5 medications. Family caregivers participated at the patient’s discretion. We also interviewed nurses and physicians to obtain an interdisciplinary perspective on medication coordination and communication. We used content analysis to identify emerging themes. Eighteen (18) patients (mean age 80 yrs [SD 10], 42% female) and 8 caregivers (mean age 63 yrs [SD 16.6], 88% female) were included, along with 10 nurses and 7 physicians from hospice, outpatient oncology and primary care settings. Results: Emerging themes revealed that patients and families were receptive to comprehensive medication reviews upon transition to hospice that assess the ongoing use of longstanding medications for comorbid illness. Effective framing for discussions included a focus on reducing harmful and non-essential medications; a less effective approach emphasized time to benefit (i.e. whether a medication is indicated for active symptom management vs prevention). Hospice nurses reported physician reluctance to discontinue medications, lack of physician confidence in their medication assessments, and lack of prescribing guidelines as barriers to optimizing prescribing. Conclusions: Patients enrolled in hospice for cancer and their families are willing to reassess the ongoing use of chronic medications for comorbid illness; information about medication harms and their impact on quality of life is considered particularly useful. Barriers to optimal prescribing include physician reluctance to discontinue medications and mistrust between providers.

Dissemination, implementation, and quality improvement research within the HMO Cancer Research Network

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Background: The HMO Cancer Research Network, funded by the National Cancer Institute, provides infrastructure support to facilitate cancer research in non-profit integrated healthcare delivery systems. A key CRN goal to improve quality and outcomes through research and research-based methods for accelerating implementation of innovations in cancer care. Methods: The CRN is led by a Steering Committee and an Executive Committee. CRN Scientific Working Groups support activity within distinct areas; the CRN Communication and Dissemination Scientific Working Group (C&D SWG) supports the design, conduct and reporting of research on (1) communication and decision makin in cancer care and (2) dissemination and implementation of cancer research findings and best practices. C&D SWG activities include monthly calls presenting C&D research resources, project ideas and funding opportunities; individual consultation and technical assistance to support CRN researchers developing funding applications and conducting research in relevant areas; and mentorship for CRN Scholars. General CRN resources to facilitate research to improve cancer care quality include a multi-institution Virtual Data Warehouse with accompanying query tools to facilitate preparatory-to-research and collaborative research studies and specific cancer-related data items; funding for Developmental and Pilot Studies; and an Outreach and External Collaborations Core to facilitate research collaborations among (a) CRN institution-based scientists, (b) scientists at other institutions, and (c) clinical and operations partners. Results: The CRN C&D SWG continues to stimulate increased awareness and interest in conducting dissemination and implementation studies and quality improvement research in cancer care, and to support the development of new project ideas and funding applications and the successful completion and publication of such studies. Conclusions: CRN activities facilitate innovative multi-site, multi-disciplinary cancer studies in the integrated delivery system setting, and motivate continued evolution of CRN institutions as the nation's premier learning health care systems. Supported by U24 CA171524.

Predictors of very low adherence with medications for osteoporosis: towards development of a clinical prediction rule

We developed a clinical prediction rule score to predict medication non-adherence for women prescribed osteoporosis treatment. When combined into a summative score, 62% with seven or more points on the score demonstrated very low adherence. This compares with 17% subjects with fewer than seven points (c-statistic = 0.74).

INTRODUCTION

Medication non-adherence is extremely common for osteoporosis; however, no clear methods exist for identifying patients at risk of this behavior. We developed a clinical prediction rule to predict medication non-adherence for women prescribed osteoporosis treatment.

METHODS

Women undergoing bone mineral density testing and fulfilling WHO criteria for osteoporosis were invited to complete a questionnaire and then followed for 1 year. Adjusted logistic regression models were examined to identify variables associated with very low adherence (medication possession ratio <20%). The weighted variables, based on the logistic regression, were summed, and the score was compared with the proportion of subjects with very low adherence.

RESULTS

One hundred forty two women participated in the questionnaire and were prescribed an osteoporosis medication. After 1 year, 36% (n = 50) had very low adherence. Variables associated with very low adherence included prior non-adherence with chronic medications, agreement that side effects are concerning, agreement that she is taking too many medications, lack of agreement that osteoporosis is a worry, lack of agreement that a fracture will cause disability, lack of agreement that medications help her stay active, and frequent use of alcohol. When combined into a summative score, 36 of the 58 subjects (62%) with seven or more points on the score demonstrated very low adherence. This compares with 14 of the 84 (17%) subjects with fewer than seven points (c-statistic = 0.74).

CONCLUSION

We developed a brief clinical prediction rule that was able to discriminate between women likely (and unlikely) to experience very low adherence with osteoporosis medications.

Using standardized patients to assess professionalism: a generalizability study

BACKGROUND

Assessment of professionalism in undergraduate medical education is challenging. One approach that has not been well studied in this context is performance-based examinations.

PURPOSE

This study sought to investigate the reliability of standardized patients' scores of students' professionalism in performance-based examinations.

METHODS

Twenty students were observed on 4 simulated cases involving professional challenges; 9 raters evaluated each encounter on 21 professionalism items. Correlational and multivariate generalizability (G) analyses were conducted.

RESULTS

G coefficients were .75, .53, and .68 for physicians, standardized patients (SPs), and lay raters, respectively. Composite G coefficient for all raters reached acceptable level of .86. Results indicated SP raters were more variable than other rater types in severity with which they rated students, although rank ordering of students was consistent among SPs.

CONCLUSIONS

SPs' ratings were less reliable and consistent than physician or lay ratings, although the SPs rank ordered students more consistently than the other rater types.

Comparing drug effectiveness at health plans: the ethics of cluster randomized trials

"Cluster randomized trials," in which groups of patients are randomly assigned to different therapeutic interventions, provide a powerful way of evaluating drugs. CRTs have not been widely used, in good part because of concerns about whether patients must give informed consent to participate in them. A better understanding of how CRTs fit into clinical practice resolves the concerns.

How patients perceive a doctor's caring attitude

OBJECTIVE

Caring is closely associated with reduced malpractice litigation, adherence to treatment and even symptom relief. Caring also is included in pay for performance formulas as well as widely utilized for quality improvement purposes. Our objective in this prospective qualitative study was to define caring behaviors associated with three challenging encounters: discussing the transition from curative to palliative care, delivering bad news (cancer), and discussing a medical error (misplaced test result). The purpose was to lay the groundwork for the creation of a 'patient-centered' caring attitude checklist that could help the healthcare provider understand and ultimately enhance the patient's experience of care.

METHODS

Groups of randomly selected lay people, henceforth referred to as patients: (1) engaged in 'think aloud' exercises to help create a 15-item caring behavior checklist; (2) used the checklist to rate videotapes of simulated challenging encounters conducted by twenty primary care physicians (total of 600 ratings sets); and (3) participated in 12 separate 1.5 h focus groups discussing the caring (and non-caring) behaviors exhibited in videotapes of the highest and lowest rated encounters.

RESULTS

Thirteen behaviors emerged as focal for describing a doctor's caring attitude but with disagreement as to whether specific examples of these behaviors were 'caring' or 'uncaring.' For example, although the concept of empathic inquiry was considered important by most patients, the physician question, "Is there someone you can call or talk with" (about a cancer diagnosis) was interpreted by one patient as 'very caring' while another was 'impressed with how uncaring' the statement appeared.

CONCLUSION

At the conceptual level there is a set of behaviors that represent caring, however, the manifestation of these behaviors is 'in the eye of the beholder.' The most important element of caring may not be the set of behaviors but a set of underlying abilities that include taking the patient's perspective and reflecting on the patient's responses.

PRACTICE IMPLICATIONS

Medical education must focus on the underlying abilities of caring.

Older patients' perceptions of medication importance and worth: an exploratory pilot study

BACKGROUND

Cost-related medication non-adherence may be influenced by patients' perceived importance of their medications.

OBJECTIVES

This exploratory pilot study addresses three related but distinct questions: Do patients perceive different levels of importance among their medications? What factors influence perceptions of medication importance? Is perceived importance associated with perceived worth of medications, and does expense impact on that association?

METHODS

Study participants included individuals aged >or=60 years who were taking three or more prescription drugs. Semi-structured, in-person interviews were conducted to measure how patients rated their medications in terms of importance, expense and worth. Factors that influenced medication importance were identified using qualitative analysis. Ordinal logistic regression analyses were employed to examine the association between perceived importance and perceived worth of medications, and the impact of expense on that association.

RESULTS

For 143 prescription drugs reported by 20 participants, the weighted mean rating of medication importance was 8.2 (SD 1.04) on a scale from 0 (not important at all) to 10 (most important). Patients considered 38% of these medications to be expensive. The weighted mean rating of worth was 8.4 (SD 1.46) on a scale from 0 (not worth it at all) to 10 (most worth). Three major factors influenced medication importance: drug-related (characteristics, indications, effects and alternatives); patient-related (knowledge, attitudes and health); and external (the media, healthcare and family caregivers, and peers). Regression analyses showed an association between perceived importance and perceived worth for inexpensive medications (odds ratio [OR] 2.23; p = 0.002) and an even greater association between perceived importance and perceived worth for expensive medications (OR 4.29; p < 0.001).

DISCUSSION

This study provides preliminary evidence that elderly patients perceive different levels of importance for their medications based on factors beyond clinical efficacy. Their perception of importance influences how they perceive their medications' worth, especially for medications of high costs. Understanding how patients perceive medication importance may help in the development of interventions to reduce cost-related non-adherence.

Evaluation of missing data in an assessment of professional behaviors

BACKGROUND

The National Board of Medical Examiners is currently developing the Assessment of Professional Behaviors, a multisource feedback (MSF) tool intended for formative use with medical students and residents. This study investigated whether missing responses on this tool can be considered random; evidence that missing values are not random would suggest response bias, a significant threat to score validity.

METHOD

Correlational analyses of pilot data (N = 2,149) investigated whether missing values were systematically related to global evaluations of observees.

RESULTS

The percentage of missing items was correlated with global evaluations of observees; observers answered more items for preferred observees compared with nonpreferred observees.

CONCLUSIONS

Missing responses on this MSF tool seem to be nonrandom and are instead systematically related to global perceptions of observees. Further research is needed to determine whether modifications to the items, the instructions, or other components of the assessment process can reduce this effect.

Reliability and validity of checklists and global ratings by standardized students, trained raters, and faculty raters in an objective structured teaching environment

BACKGROUND

Objective structured teaching exercises (OSTEs) are relatively new in medical education, with few studies that have reported reliability and validity.

PURPOSE

To systematically examine the impact of OSTE design decisions, including number of cases, choice of raters, and type of scoring systems used.

METHODS

We examined the impact of number of cases and raters using generalizability theory. We also compared scores from standardized students (SS), faculty raters (FR) and trained graduate student raters (TR), and examined the relation between behavior checklist ratings and global perception scores.

RESULTS

Generalizability (g) coefficients for checklist scores were higher for SSs than TRs. The g estimates based on SSs' global scores were higher than g estimates for FRs. SSs' checklist scores were higher than TRs' checklist scores, and SSs' global evaluations were higher than FRs' and TRs' global scores. TRs' relative to SSs' global perceptions correlated more highly with checklist scores.

CONCLUSIONS

SSs provide more generalizable checklist scores than TRs. Generalizability estimates for global scores from SSs and FRs were comparable. SSs are lenient raters compared to TRs and FRs.

Validation of a New Measure of Concept of a Good Death

BACKGROUND

The concept of a good death is central to end-of-life care research. Despite its importance and the high interest in the topic, there are few measures currently available for use in clinical research.

PURPOSE

The present work describes the development and testing of a set of items intended to measure the importance of several components posited to be critical to the concept of a good death. It is intended for use with health care providers and lay people in the context of end-of-life care research and education.

POPULATION

Four cohorts (n = 596) were recruited to participate, representing two helping profession disciplines, nonhelping professionals, and a range of ages, specifically: (1) undergraduate medical students; (2) master's degree students in nursing; (3) graduate students from the life sciences; and (4) practicing hospice nurses.

METHODS

Participants completed self-report questionnaires at baseline and retest. Psychometric analyses included item frequency distributions, factor analysis, alpha reliability, intraclass correlation, and measures of association.

RESULTS

The new Concept of a Good Death measure demonstrated good item frequency distributions, acceptable internal consistency reliability, and test-retest stability. Its factor structure revealed that three distinct domains are measured, reflecting the psychosocial/spiritual, physical, and clinical aspects of a good death. An examination of patterns of correlations showed differential associations with death anxiety, spiritual beliefs and practices, anxious mood, and sociodemographic characteristics.

CONCLUSIONS

The new Concept of a Good Death instrument appears to measure three distinct factors which people consider important to a Good Death. Ratings of the importance of these factors are reliable and valid. The instrument has the advantage of being a brief, self-report index for use in end-of-life care research.

Development and implementation of an objective structured teaching exercise (OSTE) to evaluate improvement in feedback skills following a faculty development workshop

BACKGROUND

Faculty development programs focusing on teaching have become widespread.

PURPOSE

Despite the popularity of such programs, evidence as to their effectiveness is limited. This article reports on the development of an objective structured teaching exercise (OSTE) and its pilot implementation in an evaluation of a faculty development program module. A written test intended to measure feedback skills was also developed and pilot tested.

METHODS

A separate-sample, pretest-posttest design was used to pilot test both instruments.

RESULTS

The results showed some evidence of significant differences between groups tested preworkshop and postworkshop. Higher scores were observed for the posttest group compared to the pretest group only for OSTE items focusing on prioritizing and limiting the amount of feedback given at one time and on action planning.

CONCLUSIONS

Results suggest that an OSTE may be sensitive to changes in preceptor skill level for skills that are relatively easy to incorporate immediately into practice. Lack of differences in other skill areas may be due to lack of sensitivity of the measure or to need for practice and reflection before changes in performance on other feedback skills are evident.

The impact of a brief interclerkship about substance abuse on medical students' skills

PURPOSE

To examine the immediate and delayed impact of an intensive one- or two-day interclerkship on substance abuse (SA) for third-year medical students. The program is a response to the problem of inadequacy of substance abuse education in the standard curriculum.

METHOD

Each year since 1997-98 all third-year students at the University of Massachusetts Medical School have participated in a one- or two-day SA interclerkship to enhance their knowledge and competence with SA assessment and brief intervention. Students' knowledge, attitudes, and confidence were assessed immediately before and after the interclerkship. In addition, during 1998-99, each student's clinical skills in SA assessment and intervention were evaluated at the completion of the student's six-week psychiatry clerkship using objective standardized clinical examinations (OSCEs) with two simulated patients, one with and one without active SA issues. Students who took the psychiatry clerkship in the first half of the year had not yet participated in the interclerkship. Students' pooled performances before and after the interclerkship were compared.

RESULTS

Students' attitudes toward and knowledge about SA disorders and their confidence about SA assessment and intervention all showed significant positive changes immediately after the interclerkship. The OSCE performance data demonstrated a significant sustained improvement in clinical skills in SA assessment and intervention as measured up to six months following the interclerkship.

CONCLUSION

These data suggest that brief intensive training in SA during the clinical years of medical school can have a positive and lasting impact on students' clinical performances.

Using differences between perceptions of importance and competence to identify teaching needs of primary care preceptors

BACKGROUND

An important goal of a comprehensive faculty development plan is to improve teaching. This is especially important for clinical preceptors.

PURPOSE

This study used a novel approach to assessing the teaching needs of preceptors, an essential and often neglected first step in faculty development. Measurement focused on discrepancies between importance and current performance related to a rich variety of teaching behaviors. This study also considered differences in perceived teaching needs among primary care specialties.

METHOD

Twenty-six clerkship directors from 13 participating medical schools in the Northeast United States invited randomly selected family medicine, internal medicine, and pediatric preceptors to complete a teaching needs survey. One hundred five preceptors responded.

RESULT

Findings revealed that preceptors most need to develop general teaching skills that will help them save time such as selecting appropriate teaching behaviors, assessing learners' needs and providing appropriate feedback, and helping learners learn independently. On the other hand, preceptors expressed less need to improve teaching related to cost containment, disease prevention, clinical decision making, office management, and using computers to aid teaching. Family practice preceptors rated their current teaching performance significantly higher than pediatric preceptors despite no differences in previous faculty development experience.

CONCLUSION

Faculty development for preceptors should focus on general teaching skills relative to teaching skills tied to specific medical areas. Novel approaches to teaching while practicing medicine that increase efficiency should be explored. Faculty developers should consider differences in confidence among preceptors from different specialties.

Muscular dystrophy due to dysferlin deficiency in Libyan Jews. Clinical and genetic features

The cluster in Jews of Libyan origin of limb-girdle muscular dystrophy type 2B due to a dysferlin 1624delG mutation is described. The carrier frequency of this mutation is calculated to be approximately 10% in this population, in which the disease prevalence is at least 1 per 1300 adults. Twenty-nine patients from 12 families were all homozygous for the same mutation. However, clinical features were heterogeneous even within the same family: in half of the patients onset was in the distal muscles of the legs, which is similar to Miyoshi myopathy, while in others onset was in the proximal musculature, which is similar to other forms of limb-girdle dystrophies. Age at onset varied from 12 to 28 years (mean 20.3 +/- 5.5 years). One patient was presymptomatic at age 28 years. Progression was slow regardless of age of onset, patients remaining ambulatory until at least 33 years. Five patients described subacute, painful enlarged calves as an early, unusual feature. The variable features in this ethnic cluster contribute to the definition of the clinical spectrum of dysferlinopathies in general. The cause of the observed heterogeneity remains unclear.

Cancer control knowledge, attitudes, and perceived skills among medical students

BACKGROUND

The Cancer Prevention and Control Education (CPACE) program aims to strengthen and coordinate curriculum offerings in cancer prevention and control for medical, graduate nursing and public health students.

METHODS

Students were surveyed on cancer-related knowledge and confidence as part of needs assessment and evaluation efforts. The students completed self-administered surveys (response rate 78%). Descriptive and stratified analysis and ANOVA were conducted.

RESULTS

Knowledge and confidence generally increased with each successive class year, but confidence varied markedly across specific counseling scenarios and by gender. While the students overall reported greater confidence in performing an examination than in interpreting the results, confidence varied significantly across specific types of examinations.

CONCLUSIONS

Understanding of basic information about common cancers was disappointing. Confidence to perform and interpret examinations could be higher, especially for opposite-gender screening examinations. Implications of the findings for CPACE curriculum development are discussed.

The effect of a domestic violence interclerkship on the knowledge, attitudes, and skills of third-year medical students

PURPOSE

To determine whether participation in an intensive domestic violence interclerkship (DVI) improved the knowledge, attitudes, and skills of two successive cohorts of students at the University of Massachusetts Medical School.

METHOD

The authors measured the knowledge, attitudes, and skills pertaining to domestic violence of third-year students in the classes of 1997 and 1998 using a validated written examination administered before, immediately after, and six months after participation in a 3.5-day or two-day DVI, respectively; they compared the scores using paired t-tests. Nine months after the DVI, the students' domestic violence screening skills were measured by a performance-based assessment (OSCE); using unpaired t-tests, the authors compared the OSCE scores with those of a previous third-year class that had not participated in a DVI. Immediately after the OSCE, the students reported their levels of confidence in domestic violence screening and their satisfaction with the domestic violence curriculum; using chi-square analysis, those self-reports were compared with those of the class with no DVI.

RESULTS

The students who participated in the DVIs immediately and significantly improved their knowledge, attitudes, and skills (p < .001), and fully or partially sustained those improvements six months later (p < .001). Nine months after the DVI, the students performed domestic violence screening more effectively (p < .001), expressed greater comfort with domestic violence screening (p < .001), and felt better-prepared by the curriculum to address domestic violence issues (p < .001) than did the students with no DVI.

CONCLUSION

Participation in a short, focused DVI curriculum produced sustainable improvements in knowledge, attitudes, and skills that were successfully applied by third-year medical students to effective domestic violence screening. Interclerkships are an effective way to fit into the clinical curriculum those subjects that transcend the traditional biomedical domain and intersect all areas of medical practice.

The standardized family: an innovation in primary care education at the University of Massachusetts

In 1995 as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative, the University of Massachusetts (UMass) Medical School developed the "standardized family" as a new model for teaching the essential elements of primary care in a core curriculum format outside of the clinical setting. Using this model, a hypothetical family unit (the "McQ Family") serves as the focus for case-based clinical problem solving. This paper describes the standardized family model and provides two years of evaluation outcomes such as curriculum assessments, student performance outcomes, and correlation with external measures of clinical performance to support the effectiveness of this educational model. It discusses the transferability of the standardized family model from UMass Medical School to Pennsylvania State University College of Medicine and uses Pennsylvania State's adaptation (the "Hershey-Penn Family") to illustrate how the standardized family can be customized to integrate a core curriculum into a three-year longitudinal primary care program. The authors suggest that the standardized family model has the potential to meet a broad range of primary care teaching needs at other institutions.