Improving Diabetes Control Using Lean Six Sigma Quality Improvement in an Endocrine Clinic in a Large Accountable Care Organization.

This article describes a quality improvement project to reduce the number of patients with diabetes who have poor glycemic control in a large tertiary care endocrinology clinic. The project used the Lean Six Sigma Define-Measure-Analyze-Improve-Control process improvement methodology to develop clinic workflow processes for obtaining A1C measurements in a timely manner to facilitate interventions to improve glycemic control. The percentage of patients with poorly controlled diabetes (A1C >9.0% or missing value in the past 12 months) significantly improved from 26.4% at baseline to 16% (P <0.001), and the proportion of patients with an A1C test within 3-6 months of an appointment improved from 76 to 92%.

Social and Metabolic Characteristics Associated With Multiple DKA Admissions at a Large County Hospital.

Context: Diabetic ketoacidosis (DKA) is a preventable, deadly, and costly complication of type 1 diabetes mellitus (T1DM). Some individuals with T1DM have recurrent DKA admissions. Objective: We sought to characterize social factors that differ between patients with single vs multiple DKA admissions at an urban, safety-net hospital. Methods: We queried the electronic health records for T1DM patients admitted for DKA from 2019 to 2021. Admission laboratory values, demographic information, and detailed social histories were collected and analyzed statistically, including logistical regression. Results: A total of 243 patients were admitted for DKA, 64 of whom had multiple DKA admissions. There was no significant difference between the groups in their admission laboratory values, hospital length of stay, health-care payer status, history of homelessness, current employment, living alone, independence of activities of daily living, and barriers to discharge. T1DM patients with multiple DKA admissions had greater rates of substance use disorder (33.0% vs 60.9%; P < .001), especially with cannabis (6.7% vs 25.0%; P < .001), tobacco (26.3% vs 46.3%; P = .002), and psychoactive substance use (1.1% vs 6.3%; P = .043). Regression models of substance use showed increased risk with any substance use (odds ratio [CI] 3.17 [1.78-5.73]; P < .001) and cannabis (3.70 [1.55-8.83]; P = .003). Conclusion: We identified substance use as a possible predictor of T1DM patients at risk for multiple DKA admissions. Our findings identify a group of T1DM patients for whom interventions may help to decrease recurrence of DKA episodes within similar community hospital populations.

Extraintestinal manifestations of Edwardsiella tarda infection: a 10-year retrospective review.

Edwardsiella tarda, a member of the family Enterobacteriaceae found in aquatic environments, is an unusual cause of human disease, presenting most frequently as gastroenteritis. Extraintestinal manifestations of E. tarda infection are rare but have included meningitis, cholecystitis, endocarditis, osteomyelitis, soft tissue infections, bacteremia, and septicemia. Over a 10-year period at our institution, 10 cases of extraintestinal infection related to E. tarda were identified. The infections ranged from soft tissue infections secondary to trauma to intra-abdominal infections with abscess formation. Several of the patients had documented factors predisposing them to infection including diabetes mellitus and C1 esterase deficiency. Interestingly, two of the patients had chronic idiopathic inflammatory bowel disease, and one patient developed a respiratory tract infection related to E. tarda, a previously unreported clinical manifestion. Although the mortality rate for extraintestinal E. tarda infections has been as high as 50% in some studies, antimicrobial treatment was eventually successful in each of the 10 cases at our institution.

Mere exposure and the endowment effect on consumer decision making.

Previous researchers (e.g., J. A. Bargh, 1992, 2002) demonstrated the importance of nonconscious processes on consumer choice behavior. Using an advertisement, the authors determined the effect of two nonconscious processes--the mere exposure effect, which increases object preference by increasing consumer exposure to an object, and the endowment effect, which increases object valuation by providing consumer possession of an object--on consumer behavior. Although the mere exposure effect and endowment effect did not produce an interaction, they produced independent effects. The endowment effect increased object valuation but not object preference. The mere exposure effect increased object preference but not object valuation. Thus, at the unconscious level, an increase in object preference does not lead to an increase in object valuation, nor does an increase in object valuation lead to an increase in object preference. The authors discuss the importance of developing measures of unconscious process in advertising effectiveness.

Managing controversy through consultation: a qualitative study of communication and trust around MMR vaccination decisions.

BACKGROUND: Controversy over the measles, mumps, and rubella (MMR) vaccine has reduced uptake, raising concerns of a future disease epidemic. AIMS: To explore parents' accounts of decision making relating to the MMR vaccine controversy, identifying uptake determinants and education needs. DESIGN OF STUDY: Qualitative interviews analysed using the 'framework' approach. SETTING: Five general practices in the Leeds area, 2002-2003. METHOD: Sixty-nine interviews conducted with parents of children aged between 4 and 5 years, and 12 interviews with primary care practitioners, managers and immunisation coordinators serving participating sites. Participants were interviewed one-to-one in a place of their choice. RESULTS: The vaccination decision is primarily a function of parental assessments of the relative acceptability and likelihood of possible outcomes. For most parents the evidence of science and medicine plays little role in the decision. Although local general practitioners and health visitors are trusted information sources, the influence of primary care providers on the vaccination decision is limited by concerns over consultation legitimacy, discussion opportunity, and perceptions of financial and political partiality. Parents and practitioners identify a need for new approaches to support decisions and learning when faced with this and similar healthcare controversies. These include new collaborative approaches to information exchange designed to transform rather than supplant existing parent knowledge as part of an ongoing learning process. CONCLUSION: The study identified new ways in which parents and practitioners need to be supported in order to increase understanding of medical science and secure more informed decisions in the face of health controversy.

Analysis of soft tissue display during enjoyment smiling: part 1--Caucasians.

Esthetic considerations have become increasingly important in dental therapy. Evaluation of the soft tissue display during enjoyment smiling can provide useful information for esthetic oral rehabilitation. To date, no study has quantified the amount and frequency of soft tissue display in the area of the papilla. Photographic examination of 66 fully dentate patients with a mean age of 28.5 years was performed during enjoyment smiling. Digital processing and measurement of the tooth, gingival, and papillary display revealed that over 90% of subjects displayed papillae in the anterior teeth and first premolars during enjoyment smiling regardless of sex. The frequency of display in descending order consisted of maxillary lateral incisors (96%), central incisors (94%), canines (94%), first premolars (91%), second premolars (85%), and first molars (39%). The mean papillary display was 3.4 mm (range, 0.0 to 10.0 mm). There was no significant difference in the amount of papillary display between the sexes for anterior teeth, premolars, or first molars (P = .97, P = .79, and P = .48, respectively).