Quality Improvement Initiative for Aspirin Screening and Prescription Rates for Preeclampsia Prevention in an Outpatient Obstetric Clinic.

OBJECTIVE: Hypertensive disorders of pregnancy (HDP) impact 10% of pregnancies in the United States and cause adverse maternal and neonatal outcomes such as prematurity and low birth weight. Aspirin administration to at-risk individuals during pregnancy can reduce risk of HDP. STUDY DESIGN: Define-Measure-Assess-Improve-Control methodology was utilized to improve aspirin screening in an outpatient obstetric clinic. Retrospective cohort analysis compared outcome metrics pre- and postimplementation by using logistic regression models, adjusting for race and insurance. Key informant interviews and process mapping identified barriers to aspirin screening. A multidisciplinary team implemented low-cost strategies such as provider education, additional screening by ancillary staff, automated electronic reminders, and standardized patient counseling. RESULTS: Over 6 months, the screening rate improved from 62.5 to 92.0% (adjusted odds ratio [aOR] = 6.89, 95% confidence interval [CI]: 3.30-14.43). The prescription rate for patients correctly identified to be eligible for aspirin improved from 66.7 to 82.4% (aOR = 1.96, 95% CI: 0.88-4.35). CONCLUSION: Comprehensive, tailored quality improvement efforts can significantly increase aspirin screening and prescription, which may decrease maternal and neonatal morbidity due to HDP. KEY POINTS: · Initiative improved overall and correct screening rates.. · Initiative increased provider knowledge of eligibility.. · Low-cost interventions can have high impact over short time interval..

National evaluation of multidisciplinary quality metrics for head and neck cancer.

BACKGROUND: The National Quality Forum has endorsed quality-improvement measures for multiple cancer types that are being developed into actionable tools to improve cancer care. No nationally endorsed quality metrics currently exist for head and neck cancer. METHODS: The authors identified patients with surgically treated, invasive, head and neck squamous cell carcinoma in the National Cancer Data Base from 2004 to 2014 and compared the rate of adherence to 5 different quality metrics and whether compliance with these quality metrics impacted overall survival. The metrics examined included negative surgical margins, neck dissection lymph node (LN) yield ≥ 18, appropriate adjuvant radiation, appropriate adjuvant chemoradiation, adjuvant therapy within 6 weeks, as well as overall quality. RESULTS: In total, 76,853 eligible patients were identified. There was substantial variability in patient-level adherence, which was 80% for negative surgical margins, 73.1% for neck dissection LN yield, 69% for adjuvant radiation, 42.6% for adjuvant chemoradiation, and 44.5% for adjuvant therapy within 6 weeks. Risk-adjusted Cox proportional-hazard models indicated that all metrics were associated with a reduced risk of death: negative margins (hazard ratio [HR] 0.73; 95% confidence interval [CI], 0.71-0.76), LN yield ≥ 18 (HR, 0.93; 95% CI, 0.89-0.96), adjuvant radiation (HR, 0.67; 95% CI, 0.64-0.70), adjuvant chemoradiation (HR, 0.84; 95% CI, 0.79-0.88), and adjuvant therapy ≤6 weeks (HR, 0.92; 95% CI, 0.89-0.96). Patients who received high-quality care had a 19% reduced adjusted hazard of mortality (HR, 0.81; 95% CI, 0.79-0.83). CONCLUSIONS: Five head and neck cancer quality metrics were identified that have substantial variability in adherence and meaningfully impact overall survival. These metrics are appropriate candidates for national adoption. Cancer 2017;123:4372-81. © 2017 American Cancer Society.

How Reliable Is a Statewide Prescription Monitoring Program for Identifying Post-Cesarean Opioid Use?

Objective This study was aimed to estimate the percentage of women taking opioids post-cesarean who could be detected in a state prescription monitoring program (PMP) and characteristics of those not able to be detected. Study Design This observational cohort study included all women with an Illinois address who delivered via cesarean section and used opioids within 24 hours prior to discharge at a tertiary care hospital between August 21, 2017 and March 1, 2018. The Illinois PMP was queried for presence of an opioid prescription filled within the first 3 months postpartum. Sociodemographic and clinical factors associated with an undetectable PMP record were evaluated in bivariable and multivariable logistic regression analyses. Results A total of 517 women underwent a cesarean delivery during the study period, of whom 344 (66.5%) met inclusion criteria. Of these women, 169 (49%) did not have a detectable PMP record of filling any outpatient postpartum prescription opioid. On bivariable and multivariable logistic regression analysis, year of delivery (2018 vs. 2017) was significantly associated with a higher incidence of detectable postpartum prescription opioid record in the PMP with increasing relative risk of detectable records in the second year of analyses ( n = 110/244 [45%] in 2017 vs. n = 59/100 [59%] in 2018, adjusted risk ratio [aRR] = 1.32, 95% confidence interval [CI]: 1.06-1.64, p = 0.013). No other sociodemographic or clinical characteristics was significantly associated. Conclusion Nearly half of women who underwent a cesarean section and who were administered opioids 24 hours prior to discharge did not have a detectable postpartum opioid prescription in the PMP. While identification of prescription filling improved with time, many of women were not detectable in the PMP system. These data call into question the accuracy of PMPs in identifying prescription opioid filling patterns in the postpartum setting.