Impact of Kidney Failure Risk Prediction Clinical Decision Support on Monitoring and Referral in Primary Care Management of CKD: A Randomized Pragmatic Clinical Trial.

Rationale & Objective: To design and implement clinical decision support incorporating a validated risk prediction estimate of kidney failure in primary care clinics and to evaluate the impact on stage-appropriate monitoring and referral. Study Design: Block-randomized, pragmatic clinical trial. Setting & Participants: Ten primary care clinics in the greater Boston area. Patients with stage 3-5 chronic kidney disease (CKD) were included. Patients were randomized within each primary care physician panel through a block randomization approach. The trial occurred between December 4, 2015, and December 3, 2016. Intervention: Point-of-care noninterruptive clinical decision support that delivered the 5-year kidney failure risk equation as well as recommendations for stage-appropriate monitoring and referral to nephrology. Outcomes: The primary outcome was as follows: Urine and serum laboratory monitoring test findings measured at one timepoint 6 months after the initial primary care visit and analyzed only in patients who had not undergone the recommended monitoring test in the preceding 12 months. The secondary outcome was nephrology referral in patients with a calculated kidney failure risk equation value of >10% measured at one timepoint 6 months after the initial primary care visit. Results: The clinical decision support application requested and processed 569,533 Continuity of Care Documents during the study period. Of these, 41,842 (7.3%) documents led to a diagnosis of stage 3, 4, or 5 CKD by the clinical decision support application. A total of 5,590 patients with stage 3, 4, or 5 CKD were randomized and included in the study. The link to the clinical decision support application was clicked 122 times by 57 primary care physicians. There was no association between the clinical decision support intervention and the primary outcome. There was a small but statistically significant difference in nephrology referral, with a higher rate of referral in the control arm. Limitations: Contamination within provider and clinic may have attenuated the impact of the intervention and may have biased the result toward null. Conclusions: The noninterruptive design of the clinical decision support was selected to prevent cognitive overload; however, the design led to a very low rate of use and ultimately did not improve stage-appropriate monitoring. Funding: Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award K23DK097187. Trial Registration: ClinicalTrials.gov Identifier: NCT02990897.

Controlled Study of Decision-Making Algorithms for Kidney Replacement Therapy Initiation in Acute Kidney Injury.

BACKGROUND AND OBJECTIVES: AKI requiring KRT is associated with high mortality and utilization. We evaluated the use of an AKI Standardized Clinical Assessment and Management Plan (SCAMP) on patient outcomes, including mortality, hospital length of stay, and intensive care unit length of stay. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a 12-month controlled study in the intensive care units of a large academic tertiary medical center. We alternated use of the AKI-SCAMP with use of a "sham" control form in 4- to 6-week blocks. The primary outcome was risk of inpatient mortality. Prespecified secondary outcomes included 30- and 60-day mortality, hospital length of stay, and intensive care unit length of stay. Generalized estimating equations were used to estimate the effect of the AKI-SCAMP on mortality and length of stay. RESULTS: There were 122 patients in the AKI-SCAMP group and 102 patients in the control group. There was no significant difference in inpatient mortality associated with AKI-SCAMP use (41% versus 47% control). AKI-SCAMP use was associated with significantly reduced intensive care unit length of stay (mean, 8; 95% confidence interval, 8 to 9 days versus mean, 12; 95% confidence interval, 10 to 13 days; P<0.001) and hospital length of stay (mean, 25; 95% confidence interval, 22 to 29 days versus mean, 30; 95% confidence interval, 27 to 34 days; P=0.02). Patients in the AKI-SCAMP group were less likely to receive KRT in the context of physician-perceived treatment futility than those in the control group (2% versus 7%; P=0.003). CONCLUSIONS: Use of the AKI-SCAMP tool for AKI KRT was not significantly associated with inpatient mortality, but was associated with reduced intensive care unit length of stay, hospital length of stay, and use of KRT in cases of physician-perceived treatment futility. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: Acute Kidney Injury Standardized Clinical Assessment and Management Plan for Renal Replacement Initiation, NCT03368183. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_07_CJN02060221.mp3.

Engaging Patients in the Use of Real-Time Electronic Clinical Data to Improve the Safety and Reliability of Their Own Care.

OBJECTIVES: There is considerable evidence that providing patients with access to their health information is beneficial, but there is limited evidence regarding the effect of providing real-time patient safety-related information on health outcomes. The aim of this study was to evaluate the association between use of an electronic patient safety dashboard (Safety Advisor) and health outcomes. METHODS: The Safety Advisor was implemented in 6 adult medicine units at one hospital in the United States. Study participants were asked to use the Safety Advisor, which provides real-time patient safety-related information through a Web-based portal. The primary outcome was the association between the application usage and health outcomes (readmission rate and mortality rate) per 3 different usage groups, and the secondary outcome was the association of Patient Activation Measure (PAM) scores with use. RESULTS: One hundred eighty-one participants were included for the data analysis. Approximately 90% of users accessed the application during the first 4 days of enrollment: 51.6% of users only accessed it on 1 day, whereas 5.8% used it more than 3 days. Patients who used the application more had lower 30-day readmission rates (P = 0.01) compared with the lower-usage group. The PAM scores for users of Safety Advisor (71.8) were higher than the nonpatient portal users (60.8, P < 0.0001). CONCLUSIONS: We found an association between the use of Safety Advisor and health outcomes. Differences in PAM scores between groups were statistically significant. A larger-scale randomized control trial is warranted to evaluate the impact on patient outcomes among a high-risk patient population.

Evaluation of a Patient-Centered Fall-Prevention Tool Kit to Reduce Falls and Injuries: A Nonrandomized Controlled Trial.

Importance: Falls represent a leading cause of preventable injury in hospitals and a frequently reported serious adverse event. Hospitalization is associated with an increased risk for falls and serious injuries including hip fractures, subdural hematomas, or even death. Multifactorial strategies have been shown to reduce falls in acute care hospitals, but evidence for fall-related injury prevention in hospitals is lacking. Objective: To assess whether a fall-prevention tool kit that engages patients and families in the fall-prevention process throughout hospitalization is associated with reduced falls and injurious falls. Design, Setting, and Participants: This nonrandomized controlled trial using stepped wedge design was conducted between November 1, 2015, and October 31, 2018, in 14 medical units within 3 academic medical centers in Boston and New York City. All adult inpatients hospitalized in participating units were included in the analysis. Interventions: A nurse-led fall-prevention tool kit linking evidence-based preventive interventions to patient-specific fall risk factors and designed to integrate continuous patient and family engagement in the fall-prevention process. Main Outcomes and Measures: The primary outcome was the rate of patient falls per 1000 patient-days in targeted units during the study period. The secondary outcome was the rate of falls with injury per 1000 patient-days. Results: During the interrupted time series, 37 231 patients were evaluated, including 17 948 before the intervention (mean [SD] age, 60.56 [18.30] years; 9723 [54.17%] women) and 19 283 after the intervention (mean [SD] age, 60.92 [18.10] years; 10 325 [53.54%] women). There was an overall adjusted 15% reduction in falls after implementation of the fall-prevention tool kit compared with before implementation (2.92 vs 2.49 falls per 1000 patient-days [95% CI, 2.06-3.00 falls per 1000 patient-days]; adjusted rate ratio 0.85; 95% CI, 0.75-0.96; P = .01) and an adjusted 34% reduction in injurious falls (0.73 vs 0.48 injurious falls per 1000 patient-days [95% CI, 0.34-0.70 injurious falls per 1000 patient-days]; adjusted rate ratio, 0.66; 95% CI, 0.53-0.88; P = .003). Conclusions and Relevance: In this nonrandomized controlled trial, implementation of a fall-prevention tool kit was associated with a significant reduction in falls and related injuries. A patient-care team partnership appears to be beneficial for prevention of falls and fall-related injuries. Trial Registration: ClinicalTrials.gov Identifier: NCT02969343.

Screening for Adverse Drug Events: a Randomized Trial of Automated Calls Coupled with Phone-Based Pharmacist Counseling.

BACKGROUND: Medication adverse events are important and common yet are often not identified by clinicians. We evaluated an automated telephone surveillance system coupled with transfer to a live pharmacist to screen potentially drug-related symptoms after newly starting medications for four common primary care conditions: hypertension, diabetes, depression, and insomnia. METHODS: Cluster randomized trial with automated calls to eligible patients at 1 and 4 months after starting target drugs from intervention primary care clinics compared to propensity-matched patients from control clinics. Primary and secondary outcomes were physician documentation of any adverse effects associated with newly prescribed target medication, and whether the medication was discontinued and, if yes, whether the reason for stopping was an adverse effect. RESULTS: Of 4876 eligible intervention clinic patients who were contacted using automated calls, 776 (15.1%) responded and participated in the automated call. Based on positive symptom responses or request to speak to a pharmacist, 320 patients were transferred to the pharmacist and discussed 1021 potentially drug-related symptoms. Of these, 188 (18.5%) were assessed as probably and 479 (47.1%) as possibly related to the medication. Compared to a propensity-matched cohort of control clinic patients, intervention patients were significantly more likely to have adverse effects documented in the medical record by a physician (277 vs. 164 adverse effects, p < 0.0001, and 177 vs. 122 patients discontinued with documented adverse effects, p < 0.0001). DISCUSSION: Systematic automated telephone outreach monitoring coupled with real-time phone referral to a pharmacist identified a substantial number of previously unidentified potentially drug-related symptoms, many of which were validated as probably or possibly related to the drug by the pharmacist or their physicians. Multiple challenges were encountered using the interactive voice response (IVR) automated calling system, suggesting that other approaches may need to be considered and evaluated. TRIAL REGISTRATION: ClinicalTrials.gov : NCT02087293.

The first 30 years of the American Academy of Dermatology skin cancer screening program: 1985-2014.

BACKGROUND: The incidence of melanoma is rising faster than that of any other preventable cancer in the United States. The American Academy of Dermatology has sponsored free skin cancer education and screenings conducted by volunteer dermatologists in the United States since 1985. OBJECTIVE: We aimed to assess the American Academy of Dermatology's national skin cancer screening program from 1986 to 2014 by analyzing the risk factor profile, access to dermatologic services, and examination results. METHODS: We conducted several detailed statistical analyses of the screening population. RESULTS: From 1986 to 2014, records were available for 2,046,531 screenings, 1,963,141 (96%) of which were subjected to detailed analysis. Men comprised 38% of all participants. The number of annual screenings reached approximately 100,000 in 1990 and remained relatively stable thereafter. From 1991 to 2014 (data for 1995, 1996 and 2000 were unavailable), clinical diagnoses were rendered for 20,628 melanomas, 156,087 dysplastic nevi, 32,893 squamous cell carcinomas, and 129,848 basal cell carcinomas. Only 21% of screenees had a regular dermatologist. Those with a clinical diagnosis of skin cancer were more likely than the general screening population to be uninsured. LIMITATIONS: Inability to verify clinical diagnoses histopathologically. CONCLUSION: Our findings suggest that the SPOTme program has detected thousands of skin cancers that may have gone undetected or experienced a delay in detection.

The Impact of Alternative Payment in Chronically Ill and Older Patients in the Patient-centered Medical Home.

BACKGROUND: Patient-centered medical home (PCMH) has gained prominence as a promising model to encourage improved primary care delivery. There is a paucity of studies that evaluate the impact of payment models in the PCMH. OBJECTIVES: We sought to examine whether coupling coordinated, team-based care transformation plan with a novel reimbursement model affects outcomes related to expenditures and utilization. RESEARCH DESIGN: Interrupted time-series model with a difference-in-differences approach to assess differences between intervention and control groups, across time periods attributable to PCMH transformation and/or payment change. RESULTS: Although results were modest and mixed overall, PCMH with payment reform is associated with a reduction of $1.04 (P=0.0347) per member per month (PMPM) in pharmacy expenditures. Patients with hypertension, hyperlipidemia, diabetes, and coronary atherosclerosis enrolled in PCMH without payment reform experienced reductions in emergency department visits of 2.16 (P<0.0001), 2.42 (P<0.0001), 3.98 (P<0.0001), and 3.61 (P<0.0001) per 1000 per month. Modest increases in inpatient admission were seen among these patients in PCMH either with or without payment reform. Patients 65 and older enrolled in PMCH without payment reform experienced reductions in pharmacy expenditures $2.35 (P=0.0077) PMPM with a parallel reduction in pharmacy standardized cost of $2.81 (P=0.0174) PMPM indicative of a reduction in the intensity of drug utilization. CONCLUSIONS: We conclude that PCMH implementation coupled with an innovative payment arrangement generated mixed results with modest improvements with respect to pharmacy expenditures, but no overall financial improvement. However, we did see improvement within specific groups, especially older patients and those with chronic conditions.

The Benefits and Challenges of an Interfaced Electronic Health Record and Laboratory Information System: Effects on Laboratory Processes.

CONTEXT: - A recent government regulation incentivizes implementation of an electronic health record (EHR) with computerized order entry and structured results display. Many institutions have also chosen to interface their EHR with their laboratory information system (LIS). OBJECTIVE: - To determine the impact of an interfaced EHR-LIS on laboratory processes. DESIGN: - We analyzed several different processes before and after implementation of an interfaced EHR-LIS: the turnaround time, the number of stat specimens received, venipunctures per patient per day, preanalytic errors in phlebotomy, the number of add-on tests using a new electronic process, and the number of wrong test codes ordered. Data were gathered through the LIS and/or EHR. RESULTS: - The turnaround time for potassium and hematocrit decreased significantly (P = .047 and P = .004, respectively). The number of stat orders also decreased significantly, from 40% to 7% for potassium and hematocrit, respectively (P < .001 for both). Even though the average number of inpatient venipunctures per day increased from 1.38 to 1.62 (P < .001), the average number of preanalytic errors per month decreased from 2.24 to 0.16 per 1000 specimens (P < .001). Overall there was a 16% increase in add-on tests. The number of wrong test codes ordered was high and it was challenging for providers to correctly order some common tests. CONCLUSIONS: - An interfaced EHR-LIS significantly improved within-laboratory turnaround time and decreased stat requests and preanalytic phlebotomy errors. Despite increasing the number of add-on requests, an electronic add-on process increased efficiency and improved provider satisfaction. Laboratories implementing an interfaced EHR-LIS should be cautious of its effects on test ordering and patient venipunctures per day.

National trends in hospitalizations for sickle cell disease in the United States following the FDA approval of hydroxyurea, 1998-2008.

BACKGROUND: Patients with sickle cell disease (SCD) can suffer frequent hospital admissions for painful vasoocclusive crises. Hydroxyurea was approved by the FDA in 1998 to decrease the morbidity of SCD, but nationwide hospitalizations for SCD in the United States since 1998 have not been evaluated. We hypothesized that the availability of hydroxyurea for SCD would be associated with a decrease in hospitalizations for SCD over time. OBJECTIVE: To assess trends in hospitalization and length-of-stay in hospital for SCD in the United States, 1998 through 2008. RESEARCH DESIGN: Retrospective cohort study of SCD-related hospital discharges in the Nationwide Inpatient Sample of US hospital discharges. SUBJECTS: All discharges in the Nationwide Inpatient Sample associated with a principal diagnosis of SCD in blacks, 1998 through 2008. MEASURES: Trends in hospitalization rates and average length-of-stay in hospital for SCD. RESULTS: We found 216 (95% confidence interval, 173.3-258.7) SCD-related hospitalizations per 100,000 US blacks in 1998 and 178.4 (95% confidence interval, 144.2-212.5) in 2008, but no consistent yearly decrease, 1998 through 2008 (P=0.30). Conversely, the length-of-stay in hospital in 1998 was 5.38 days and in 2008 was 5.18 days, an absolute change of 0.2 days and a downward trend that was statistically significant. CONCLUSIONS: Between 1998 and 2008, there was not a steady decrease in hospitalization rates for the population of SCD in the United States. On the contrary, there was a decline in length-of-stay in hospital over this time. Hydroxyurea underuse is well documented. Efforts to increase hydroxyurea use may help to reduce hospitalization rates.

Distal anastomotic vein adjunct usage in infrainguinal prosthetic bypasses.

OBJECTIVE: Single-segment saphenous vein remains the optimal conduit for infrainguinal revascularization. In its absence, prosthetic conduit may be used. Existing data regarding the significance of anastomotic distal vein adjunct (DVA) usage with prosthetic grafts are based on small series. METHODS: This is a retrospective cohort analysis derived from the regional Vascular Study Group of New England as well as the Brigham and Women's hospital database. A total of 1018 infrainguinal prosthetic bypass grafts were captured in the dataset from 73 surgeons at 15 participating institutions. Propensity scoring and 3:1 matching was performed to create similar exposure groups for analysis. Outcome measures of interest included: primary patency, freedom from major adverse limb events (MALEs), and amputation free survival at 1 year as a function of vein patch utilization. Time to event data were compared with the log-rank test; multivariable Cox proportional hazard models were used to evaluate the adjusted association between vein cuff usage and the primary end points. DVA was defined as a vein patch, cuff, or boot in any configuration. RESULTS: Of the 1018 bypass operations, 94 (9.2%) had a DVA whereas 924 (90.8%) did not (no DVA). After propensity score matching, 88 DVAs (25%) and 264 no DVAs (75%) were analyzed. On univariate analysis of the matched cohort, the DVA and no DVA groups were similar in terms of mean age (70.0 vs 69.0; P = .55), male sex (58.0% vs 58.3%; P > .99), and preoperative characteristics such as living at home (93.2% vs 94.3%; P = .79) and independent ambulatory status (72.7% vs 75.7%; P = .64). The DVA and no DVA groups had similar rates of major comorbidities such as hypertension chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, and dialysis dependence (P > .05 for all). Likewise, they had similar rates of distal origin grafts (13.6% vs 12.5%; P = .85), critical limb ischemia indications (P = .53), and prior arterial bypass (58% vs 47%; P = .08). The DVA group had a higher rate of completion angiogram performed (55.7% vs 37.5%; P =.002) and were more likely to be discharged on coumadin (53.4% vs 37.1%; P =.01). By multivariable analysis, use of a distal DVA was protective against MALEs (hazard ratio, 0.36; 95% confidence interval, 0.14-0.90; P = .03). CONCLUSIONS: This contemporary multi-institutional propensity-matched study demonstrates that patients that receive distal anastomotic vein adjuncts as part of infrainguinal prosthetic bypass operations in general have more extreme comorbidities and more technically challenging operations based on level of target vessel and prior bypass attempts. After propensity-matched analysis, the use of a DVA may protect against MALEs in prosthetic bypass surgery and should be considered when feasible.

Predictors of medication adherence postdischarge: the impact of patient age, insurance status, and prior adherence.

BACKGROUND: Optimizing postdischarge medication adherence is a target for avoiding adverse events. Nevertheless, few studies have focused on predictors of postdischarge medication adherence. METHODS: The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study used counseling and follow-up to improve postdischarge medication safety. In this secondary data analysis, we analyzed predictors of self-reported medication adherence after discharge. Based on an interview at 30-days postdischarge, an adherence score was calculated as the mean adherence in the previous week of all regularly scheduled medications. Multivariable linear regression was used to determine the independent predictors of postdischarge adherence. RESULTS: The mean age of the 646 included patients was 61.2 years, and they were prescribed an average of 8 daily medications. The mean postdischarge adherence score was 95% (standard deviation [SD] = 10.2%). For every 10-year increase in age, there was a 1% absolute increase in postdischarge adherence (95% confidence interval [CI] 0.4% to 2.0%). Compared to patients with private insurance, patients with Medicaid were 4.5% less adherent (95% CI -7.6% to -1.4%). For every 1-point increase in baseline medication adherence score, as measured by the 4-item Morisky score, there was a 1.6% absolute increase in postdischarge medication adherence (95% CI 0.8% to 2.4%). Surprisingly, health literacy was not an independent predictor of postdischarge adherence. CONCLUSIONS: In patients hospitalized for cardiovascular disease, predictors of lower medication adherence postdischarge included younger age, Medicaid insurance, and baseline nonadherence. These factors can help predict patients who may benefit from further interventions.

Cardiovascular disease and risk in primary care settings in the United States.

Primary care site may play an important role in cardiovascular disease prevalence; however, the distribution of risk factors and outcomes across care sites is not known. In this study, a cross-sectional analysis of 21,778 adult participants from the National Health and Nutrition Examination Survey (NHANES; 1999 to 2008) using multivariate logistic regression was conducted to assess the relation between site of usual care and disease prevalence. Patients' self-reported histories of several chronic conditions (hypertension, diabetes, and hypercholesterolemia), awareness of chronic conditions, and associated cardiovascular events (angina, coronary heart disease, cardiovascular disease, myocardial infarction, and stroke) were examined. After adjustment for demographic and health care utilization characteristics, there were no significant differences in the prevalence of diabetes or hypercholesterolemia among patients receiving usual care at private doctors' offices, hospital outpatient clinics, community-based clinics, and emergency rooms (ER). However, participants without usual sources of care and those receiving usual care at ERs had significantly lower awareness of their chronic conditions than participants at other sites. The odds of having a history of each of the adverse cardiovascular events ranged from 2.21 to 4.18 times higher for patients receiving usual care at ERs relative to private doctors' offices. In conclusion, participants who report using ERs as their usual sites of care are disproportionately more likely to have histories of poor cardiovascular outcomes and are more likely to be unaware of having hypertension or hypercholesterolemia. As health care reform takes place and millions more begin seeking care, it is imperative to ensure access to longitudinal care sites designed for continuous disease management.

Factors influencing alert acceptance: a novel approach for predicting the success of clinical decision support.

BACKGROUND: Clinical decision support systems can prevent knowledge-based prescription errors and improve patient outcomes. The clinical effectiveness of these systems, however, is substantially limited by poor user acceptance of presented warnings. To enhance alert acceptance it may be useful to quantify the impact of potential modulators of acceptance. METHODS: We built a logistic regression model to predict alert acceptance of drug-drug interaction (DDI) alerts in three different settings. Ten variables from the clinical and human factors literature were evaluated as potential modulators of provider alert acceptance. ORs were calculated for the impact of knowledge quality, alert display, textual information, prioritization, setting, patient age, dose-dependent toxicity, alert frequency, alert level, and required acknowledgment on acceptance of the DDI alert. RESULTS: 50,788 DDI alerts were analyzed. Providers accepted only 1.4% of non-interruptive alerts. For interruptive alerts, user acceptance positively correlated with frequency of the alert (OR 1.30, 95% CI 1.23 to 1.38), quality of display (4.75, 3.87 to 5.84), and alert level (1.74, 1.63 to 1.86). Alert acceptance was higher in inpatients (2.63, 2.32 to 2.97) and for drugs with dose-dependent toxicity (1.13, 1.07 to 1.21). The textual information influenced the mode of reaction and providers were more likely to modify the prescription if the message contained detailed advice on how to manage the DDI. CONCLUSION: We evaluated potential modulators of alert acceptance by assessing content and human factors issues, and quantified the impact of a number of specific factors which influence alert acceptance. This information may help improve clinical decision support systems design.

Patient predictors of colposcopy comprehension of consent among English- and Spanish-speaking women.

PURPOSE: patients with limited English proficiency may be at increased risk for diminished understanding of clinical procedures. This study sought to assess patient predictors of comprehension of colposcopy information during informed consent and to assess differences in understanding between English and Spanish speakers. METHODS: between June and August 2007, English- and Spanish-speaking colposcopy patients at two Boston hospitals were surveyed to assess their understanding of the purpose, risks, benefits, alternatives, and nature of colposcopy. Patient demographic information was collected. FINDINGS: there were 183 women who consented to participate in the study. We obtained complete data on 111 English speakers and 38 Spanish speakers. English speakers were more likely to have a higher education, greater household income, and private insurance. Subjects correctly answered an average of 7.91 ± 2.16 (72%) of 11 colposcopy survey questions. English speakers answered more questions correctly than Spanish speakers (8.50 ± 1.92 [77%] vs 6.21 ± 1.93 [56%]; p < .001). Using linear regression to adjust for confounding variables, we found that language was not significantly associated with greater understanding (p = .46). Rather, education was the most significant predictor of colposcopy knowledge (p < .001). CONCLUSION: many colposcopy patients did not understand the procedure well enough to give informed consent. The observed differences in colposcopy comprehension based on language were a proxy for differences in education. Education, not language, predicted subjects' understanding of colposcopy. These results demonstrate the need for greater attention to patients' educational background to ensure adequate understanding of clinical information.

Trends in quality of care and barriers to improvement in the Indian Health Service.

BACKGROUND: Although Native Americans experience substantial disparities in health outcomes, little information is available regarding healthcare delivery for this population. OBJECTIVE: To analyze trends in ambulatory quality of care and physician reports of barriers to quality improvement within the Indian Health Service (IHS). DESIGN: Longitudinal analysis of clinical performance from 2002 to 2006 within the IHS, and a physician survey in 2007. PARTICIPANTS: Adult patients cared for within the IHS and 740 federally employed physicians within the IHS. MAIN MEASURES: Clinical performance for 12 measures of ambulatory care within the IHS; as well as physician reports of ability to access needed health services and use of quality improvement strategies. We examined the correlation between physician reports of access to mammography and clinical performance of breast cancer screening. A similar correlation was analyzed for diabetic retinopathy screening. KEY RESULTS: Clinical performance significantly improved for 10 of the 12 measures from 2002 to 2006, including adult immunizations, cholesterol testing, and measures of blood pressure and cholesterol control for diabetes and cardiovascular disease. Breast cancer screening rates decreased (44% to 40%, p = 0.002), while screening rates for diabetic retinopathy remained constant (51%). Fewer than half of responding primary care physicians reported adequate access to high-quality specialists (29%), non-emergency hospital admission (37%), high-quality imaging services (32%), and high-quality outpatient mental health services (16%). Breast cancer screening rates were higher at sites with higher rates of physicians reporting routine access to mammography compared to sites with lower rates of physicians reporting such access (46% vs. 35%, ρ = 0.27, p = 0.04). Most physicians reported using patient registries and decision support tools to improve patient care. CONCLUSIONS: Quality of care has improved within the IHS for many services, however performance in specific areas may be limited by access to essential resources.

Treatment interruptions among patients with tuberculosis in Russian TB hospitals.

OBJECTIVE: To evaluate risk factors for in-patient treatment interruptions (TIs) in Russian tuberculosis (TB) hospitals. METHODS: The regional case-based registers for all TB patients registered in the main regional TB hospitals were analyzed for the period 1993-2002. Multivariable analysis of risk factors for TIs was performed using logistic regression. The prediction rule was developed based on the final multivariable model coefficients obtained from analysis of the largest (Lipetsk) database. RESULTS: During the study period, 18-50% of new cases and 36-56% of retreatment cases had interrupted in-patient treatment. In multivariate analysis, independent predictors of treatment interruption included: male gender (odds ratios (ORs) 1.5-2.3), age group 25-50 years (ORs 1.5-1.7), alcohol abuse (ORs 1.8-4.0), imprisonment history (ORs 1.3-2.5), unemployment (ORs 1.1-2.8), being a retreatment case (ORs 1.3-2.5), and having severe forms of TB (1.4-4.0); factors protective from interruption included urban residence (ORs 0.7-0.9) and having concomitant diseases (ORs 0.6-0.8). Based on the Lipeck model, new TB cases from the four regions were divided into low, high, and very high risk groups. Proportions of TI were approximately 20-35% in the low risk group, approximately 60-75% in the high risk group, and approximately 75-85% in the very high risk group (except Orel). CONCLUSIONS: We have described the independent predictors of patient TI, and a predictive rule for the in-patient TB treatment phase interruptions has been developed. Treatment interruption is a significant obstacle in the success of the National Tuberculosis Control Program in Russia. Interventions targeted at the high risk groups should be implemented in order to prevent in-patient treatment interruption.

Disparities in adherence to hypertensive care in urban ambulatory settings.

Nationally, a higher proportion of the medically underserved than of the general population suffer from hypertension. Poorer adherence to recommended therapies (including medication regimens, salt intake reduction, and regular visits with provider) has been linked to poorer blood pressure control. To identify whether differences in adherence are associated with racial/ethnic and socioeconomic characteristics, we administered a survey to 141 African American and non-Hispanic White hypertensive patients within two hospital-based clinics in an urban setting in the Northeast U.S. There were no differences in adherence to follow-up appointments or dietary recommendations between racial/ ethnic or income groups. However, there were differences between groups in adherence to medication regimens, with African Americans and lower-income groups significantly more likely to be non-adherent to medication regimens. When treating patients or implementing interventions aimed at improving adherence, special attention should be paid to African Americans and patients from low-income communities.

Cultural competency training and performance reports to improve diabetes care for black patients: a cluster randomized, controlled trial.

BACKGROUND: Increasing clinician awareness of racial disparities and improving communication may enhance diabetes care among black patients. OBJECTIVE: To evaluate the effect of cultural competency training and performance feedback for primary care clinicians on diabetes care for black patients. DESIGN: Cluster randomized, controlled trial conducted between June 2007 and May 2008. (ClinicalTrials.gov registration number: NCT00436176) SETTING: 8 ambulatory health centers in eastern Massachusetts. PARTICIPANTS: 124 primary care clinicians caring for 2699 (36%) black and 4858 (64%) white diabetic patients. INTERVENTION: INTERVENTION clinicians received cultural competency training and monthly race-stratified performance reports that highlighted racial differences in control of hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein (LDL) cholesterol levels and blood pressure. MEASUREMENTS: Clinician awareness of racial differences in diabetes care and rates of achieving clinical control targets among black patients at 12 months. RESULTS: White and black patients differed significantly in baseline rates of achieving an HbA(1c) level less than 7% (46% vs. 40%), an LDL cholesterol level less than 2.59 mmol/L (<100 mg/dL) (55% vs. 43%), and blood pressure less than 130/80 mm Hg (32% vs. 24%) (all P < 0.050). At study completion, intervention clinicians were significantly more likely than control clinicians to acknowledge the presence of racial disparities in the 8 health centers as a whole (82% vs. 59%; P = 0.003), within their local health center (70% vs. 51%; P = 0.020), and among their own patients (63% vs. 43%; P = 0.037). Black patients of clinicians in the intervention and control groups did not differ at 12 months in rates of controlling HbA(1c) level (48% vs. 45%; P = 0.24), LDL cholesterol level (48% vs. 49%; P = 0.40), or blood pressure (23% vs. 25%; P = 0.47). LIMITATION: 11% of primary care teams did not attend cultural competency training sessions. CONCLUSION: The combination of cultural competency training and race-stratified performance reports increased clinician awareness of racial disparities in diabetes care but did not improve clinical outcomes among black patients.

Hospital readmission in general medicine patients: a prediction model.

BACKGROUND: Previous studies of hospital readmission have focused on specific conditions or populations and generated complex prediction models. OBJECTIVE: To identify predictors of early hospital readmission in a diverse patient population and derive and validate a simple model for identifying patients at high readmission risk. DESIGN: Prospective observational cohort study. PATIENTS: Participants encompassed 10,946 patients discharged home from general medicine services at six academic medical centers and were randomly divided into derivation (n = 7,287) and validation (n = 3,659) cohorts. MEASUREMENTS: We identified readmissions from administrative data and 30-day post-discharge telephone follow-up. Patient-level factors were grouped into four categories: sociodemographic factors, social support, health condition, and healthcare utilization. We performed logistic regression analysis to identify significant predictors of unplanned readmission within 30 days of discharge and developed a scoring system for estimating readmission risk. RESULTS: Approximately 17.5% of patients were readmitted in each cohort. Among patients in the derivation cohort, seven factors emerged as significant predictors of early readmission: insurance status, marital status, having a regular physician, Charlson comorbidity index, SF12 physical component score, >or=1 admission(s) within the last year, and current length of stay >2 days. A cumulative risk score of >or=25 points identified 5% of patients with a readmission risk of approximately 30% in each cohort. Model discrimination was fair with a c-statistic of 0.65 and 0.61 for the derivation and validation cohorts, respectively. CONCLUSIONS: Select patient characteristics easily available shortly after admission can be used to identify a subset of patients at elevated risk of early readmission. This information may guide the efficient use of interventions to prevent readmission.