Quality of care of patients with non-small-cell lung cancer: a report of a performance improvement initiative.

BACKGROUND: Lung cancer is the leading cause of cancer deaths in the United States. In recent years, significant advancements have been made in the molecular characterization of tumors, and the availability of new agents to treat non-small-cell lung cancer has increased. Despite these achievements, optimal care of patients with this condition remains less than ideal. Although national quality measures and guideline recommendations provide the necessary framework for patient care, routine self-assessment of adherence to these measures is required for physician practice improvement. To this end, a performance improvement initiative that met national continuing medical education standards was designed. METHODS: Focusing on non-small-cell lung cancer patient care, oncologists underwent a three-step process that included a self-assessment of predetermined performance measures, the development and implementation of an actionable plan for improvement, and a second round of assessment to measure practice change. RESULTS: A total of 440 unique patient charts were reviewed by 22 practicing oncologists. Participants demonstrated high baseline performance levels of established quality measures, such as inclusion of the patient's pathology report and assessment of smoking history. Significant gains were observed in the areas of supportive care, including assessment of the patient's emotional well-being and the use of molecular markers in diagnostic and treatment decision making. CONCLUSIONS: Data from this study support the value of performance improvement initiatives to help increase physician delivery of evidence-based care to patients.

Strategies for improving outcomes in the acute management of ischemic stroke in rural emergency departments: a quality improvement initiative in the Stroke Belt.

BACKGROUND: The timely evaluation and initiation of treatment for acute ischemic stroke (AIS) is critical to optimal patient outcomes. However, clinical practice often falls short of guideline-established goals. Hospitals in rural regions of the USA, and notably those in the Stroke Belt, are particularly challenged to meet timing goals since the vast majority of primary stroke centers (PSCs) are concentrated in urban academic institutions. METHODS: Between May 2015 and May 2017, emergency department (ED) teams from 5 non-PSC hospitals in the Stroke Belt participated in a quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, repeat audit-and-feedback cycles with patient data on AIS treatment timing, personalized Continuing Medical Education/Continuing Education-certified grand rounds sessions at each participating site with expert study faculty, targeted reinforcement of best practices, and follow-up to evaluate the benefits and limitations of the intervention. RESULTS: At the start of the initiative, clinical staff from participating EDs overestimated the proportion of patients with AIS who received alteplase within the guideline-recommended 60-minute door-to-needle window at their facility. At the end of the 6-month intervention period, significantly more patients were treated with alteplase within 60 minutes of ED arrival compared to baseline across the entire sample (1.9% of patients at baseline vs. 5.2% at 6 months; P < 0.01). Similarly, there was a trend toward a decrease in the percentage of patients whose alteplase treatment was initiated more than 60 minutes after their arrival at the ED (67.3% at baseline vs. 22.2% at 6 months). CONCLUSION: Structured QI interventions that engage ED care teams to reflect on processes related to AIS diagnosis and treatment and deploy repeat audit-and-feedback cycles with real-time patient data have the potential to support an increase in the number of patients who receive alteplase within the guideline-recommended timeframe of 60 minutes from hospital arrival.

Strengthening care teams to improve adherence in cystic fibrosis: a qualitative practice assessment and quality improvement initiative.

BACKGROUND: Treatment regimens for patients with cystic fibrosis (CF) are complex, time consuming, and burdensome, and adherence to CF treatment is suboptimal. CF care teams play a critical role in supporting patients' chronic self-management skills, but there is no uniform method for assessing patients' adherence to treatment or standard interventions to help patients improve when necessary. METHODS: Between May 2015 and March 2016, care team members from 10 CF centers in the USA participated in a practice assessment and quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, personalized continuing medical education (CME)-certified Webconferences with expert study faculty, targeted reinforcement of key practice points, and follow-up online survey and telephone interviews to evaluate the benefits and limitations of the intervention. RESULTS: Responses to the baseline practice assessment survey were received from 50 multidisciplinary care team members representing 10 CF centers. Primary barriers to adherence-related aspects of care in their clinics were motivating patients and caregivers to improve adherence and obtaining accurate information about adherence from patients. At the conclusion of the initiative, participants reported improvements in communication within their care team, implementation of new approaches to asking about adherence, and a renewed commitment to asking patients and caregivers about adherence at each clinic visit. CONCLUSION: Structured QI interventions that bring multidisciplinary care teams together to reflect on clinic processes and elicit objective insights from outside faculty have the potential to improve practice patterns related to the assessment and improvement of patient adherence in CF.

Analysis of Mammalian sperm-egg membrane interactions during in vitro fertilization.

The interactions between egg and sperm are among the most fascinating in cell biology. These interactions include cell-cell adhesion and then membrane fusion between the two gametes. This chapter details the experimental methods used to for gamete culture and in vitro fertilization using mouse sperm and eggs.

Mammalian membrane block to polyspermy: new insights into how mammalian eggs prevent fertilisation by multiple sperm.

To inhibit fertilisation by more than one sperm (a condition known as polyspermy), eggs have developed preventative mechanisms known as blocks to polyspermy. The block at the level of the egg extracellular coat (the zona pellucida in mammals, the vitelline envelope in non-mammals) has been well characterised in many different animal species and the block at the level of the egg plasma membrane is understood in some non-mammalian species. However, virtually nothing is known about the membrane block to polyspermy in mammalian eggs, despite data dating back 50-90 years that provide evidence for its existence. In the present review, we will discuss the background on blocks to polyspermy used by animal eggs and then focus on the membrane block to polyspermy in mammalian eggs. This will include a summary of classical studies that provide evidence for this block in mammalian eggs, assays used to study the mammalian membrane block and what has been elucidated from recent experimental studies about the cellular signalling events that lead to membrane block establishment and the mechanism of how the membrane block may prevent additional fertilisation.

Manganese toxicity and Saccharomyces cerevisiae Mam3p, a member of the ACDP (ancient conserved domain protein) family.

Manganese is an essential, but potentially toxic, trace metal in biological systems. Overexposure to manganese is known to cause neurological deficits in humans, but the pathways that lead to manganese toxicity are largely unknown. We have employed the bakers' yeast Saccharomyces cerevisiae as a model system to identify genes that contribute to manganese-related damage. In a genetic screen for yeast manganese-resistance mutants, we identified S. cerevisiae MAM3 as a gene which, when deleted, would increase cellular tolerance to toxic levels of manganese and also increased the cell's resistance towards cobalt and zinc. By sequence analysis, Mam3p shares strong similarity with the mammalian ACDP (ancient conserved domain protein) family of polypeptides. Mutations in human ACDP1 have been associated with urofacial (Ochoa) syndrome. However, the functions of eukaryotic ACDPs remain unknown. We show here that S. cerevisiae MAM3 encodes an integral membrane protein of the yeast vacuole whose expression levels directly correlate with the degree of manganese toxicity. Surprisingly, Mam3p contributes to manganese toxicity without any obvious changes in vacuolar accumulation of metals. Furthermore, through genetic epistasis studies, we demonstrate that MAM3 operates independently of the well-established manganese-trafficking pathways in yeast, involving the manganese transporters Pmr1p, Smf2p and Pho84p. This is the first report of a eukaryotic ACDP family protein involved in metal homoeostasis.

A multifaceted initiative to improve clinician awareness of pain management disparities.

Patients belonging to some racial, ethnic, and socioeconomic groups are at risk of receiving suboptimal pain management. This study identifies health care provider attitudes, knowledge, and practices regarding the treatment of chronic pain in vulnerable patient populations and assesses whether a certified continuing medical education (CME) intervention can improve knowledge in this area. Survey responses revealed several knowledge gaps, including a lack of knowledge that the undertreatment of pain is more common in minority patients than others. Respondents identified language barriers, miscommunication, fear of medication diversion, and financial barriers as major obstacles to optimal pain management for this patient population. Participants who completed a CME-certified activity on pain management disparities demonstrated increased confidence in caring for disadvantaged patients, but only 1 of 3 knowledge items improved. Understanding clinician factors that underlie suboptimal pain management is necessary to develop effective strategies to overcome disparities and improve quality of care for patients with chronic pain.

Improving clinician performance of inpatient venous thromboembolism risk assessment and prophylaxis.

Clinicians are aware of the importance of thromboprophylaxis, and that the application of measures to prevent venous thromboembolism (VTE) occurrence in hospitalized patients must be improved. To enhance clinician execution of appropriate steps to reduce the risk of inpatient VTE, a performance improvement (PI) continuing medical education (CME) initiative consisting of 3 independent tracks for hospitalized patients-patients who are medically ill, patients receiving oncology treatment, and patients undergoing major orthopedic surgery-was designed and implemented. After a baseline chart review of select evidenced-based performance measures for VTE risk stratification and prevention, participants identified ≥ 1 area of personal improvement. Participants then engaged in a period of self-improvement and reassessed their performance with a second chart review. After participating in the PI CME activity, clinician participants in the medically ill track increased their documentation of VTE risk assessments upon patient admission from baseline (56% vs 93%, n = 250; P < 0.001) and their prescription of low-molecular-weight heparin, low-dose unfractionated heparin, or fondaparinux (72% vs 88%, n = 250; P < 0.001). Orthopedic-track participants were significantly more likely to prescribe 15 to 35 days of VTE prophylaxis after total hip arthroplasty or hip fracture surgery upon patient discharge compared with baseline (51%, n = 123 vs 61%, n = 107; P < 0.001). Oncology-track participants demonstrated a nonsignificant trend for assessing and documenting bleeding risk after participation in the PI CME activity (56% vs 68%, n = 80; P = 0.143). Improvements in evidence-based strategies to reduce the risk of inpatient VTE were associated with PI CME participation. Although areas for improvement remain, increased participant identification and use of prophylactic measures can reduce the risk of VTE in hospitalized patients.

Impact of certified CME in atrial fibrillation on administrative claims.

OBJECTIVE: To determine whether changes in physician behavior associated with a continuing medical education (CME) activity on atrial fibrillation (AF) can be measured using an administrative claims database. STUDY DESIGN: A retrospective, analytical review of physician practice changes and AF patient- related healthcare utilization and costs derived from an administrative claims database was performed on a cohort of Humana health system physicians. METHODS: The Humana physicians participated in a specified CME activity on the management of patients with AF. Treatment patterns of these providers and clinical outcomes of a cohort of established AF patients were compared 6 months before and 6 months after physician participation in the AF CME activity. RESULTS: Analysis of administrative claims data from Humana providers who participated in an AF CME activity and their patients demonstrated a significant reduction in AF-related healthcare costs and utilization, including decreased length of stay. Humana providers, in addition to the other CME activity participants, demonstrated significant gains in knowledge of evidence-based care strategies when presented with real-world scenarios of patients with AF. CONCLUSIONS: The use of administrative claims data is an innovative way of measuring the effectiveness of CME. These observations support the need for further investigation into the drivers of change in patient outcomes that may be associated with CME activities, as well as the utility of healthcare claims data as a possible valid measure of the impact of CME on physician performance and patient outcomes.

Establishment of the mammalian membrane block to polyspermy: evidence for calcium-dependent and -independent regulation.

One crucial result of egg activation is the establishment of blocks on the zona pellucida and the egg plasma membrane to prevent fertilization by additional sperm. The mechanism(s) by which a mammalian egg regulates the establishment of the membrane block to polyspermy is largely unknown. Since Ca(2+) signaling regulates several egg activation events, this study investigates how sperm-induced Ca(2+) transients affect the membrane block to polyspermy, building on our previous work (Biology of Reproduction 67:1342). We demonstrate that mouse eggs that experience only one sperm-induced Ca(2+) transient establish a membrane block that is less effective, than in eggs that experience normal sperm-induced Ca(2+) transients but that is more effective than in eggs with completely suppressed [Ca(2+)](cyt) increases. Sperm-induced increases in [Ca(2+)](cyt) regulate the timing of membrane block establishment, as this block is established more slowly in eggs that experience one or no sperm-induced Ca(2+) transients. Finally, our studies produce the intriguing discovery that there is also a Ca(2+)-independent event that is associated with fertilization in the pathway leading to membrane block establishment. Taken together, these data indicate that Ca(2+) plays a role in facilitating membrane block establishment by regulating the timing with which this change in egg membrane function occurs, and also that the membrane block differs from other post-fertilization egg activation responses as Ca(2+) is not the only stimulus. The membrane block to polyspermy in mammalian eggs is likely to be the culmination of multiple post-fertilization events that together modify the egg membrane's receptivity to sperm.

CaMKII can participate in but is not sufficient for the establishment of the membrane block to polyspermy in mouse eggs.

Fertilization triggers initiation of development and establishment of blocks on the egg coat and plasma membrane to prevent fertilization by multiple sperm (polyspermy). The mechanism(s) by which mammalian eggs establish the membrane block to polyspermy is largely unknown. Ca(2+)/calmodulin-dependent protein kinase II (CaMKII) appears to be the key regulator of several egg activation events (completion of meiosis, progression to embryonic interphase, recruitment of maternal mRNAs). Since sperm-induced increases in cytosolic Ca(2+) play a role in establishment of the membrane block to polyspermy in mouse eggs, we hypothesized that CaMKII was a Ca(2+)-dependent effector leading to this change in egg membrane function. To test this hypothesis, we modulated CaMKII activity in two ways: activating eggs parthenogenetically by introducing constitutively active CaMKIIalpha (CA-CaMKII) into unfertilized eggs, and inhibiting endogenous CaMKII in fertilized eggs with myristoylated autocamtide 2-related inhibitory peptide (myrAIP). We find that eggs treated with myrAIP establish a less effective membrane block to polyspermy than do control eggs, but that CA-CaMKII is not sufficient for membrane block establishment, despite the fact that CA-CaMKII-activated eggs undergo other egg activation events. This suggests that: (1) CaMKII activity contributes to the membrane block, but this not faithfully mimicked by CA-CaMKII and furthermore, other pathways, in addition to those activated by Ca(2+) and CaMKII, also participate in membrane block establishment; (2) CA-CaMKII has a range of effects as a parthenogenetic trigger of egg activation (high levels of cell cycle resumption, modest levels of cortical granule exocytosis, and no membrane block establishment).

Calmodulin-dependent protein kinase II triggers mouse egg activation and embryo development in the absence of Ca2+ oscillations.

Fertilization in mammalian eggs is accompanied by oscillatory changes in intracellular Ca(2+) concentration, which are critical for initiating and completing egg activation events and the developmental program. Ca(2+)/Camodulin-dependent protein kinase II (CaMKII) is a multifunctional enzyme that is postulated to be the downstream transducer of the Ca(2+) signal in many cell types. We tested the hypothesis that CaMKII is the major integrator of Ca(2+)-induced egg activation events and embryo development by microinjecting a cRNA that encodes a constitutively active (Ca(2+)-independent) mutant form of CaMKII (CA-CaMKII) into mouse eggs. Expression of this cRNA, which does not increase intracellular Ca(2+), induced a sustained rise in CaMKII activity and triggered egg activation events, including cell cycle resumption, and degradation and recruitment of maternal mRNAs; cortical granule exocytosis, however, did not occur normally. Furthermore, when mouse eggs were injected with sperm devoid of Ca(2+)-releasing activity and activated with either CA-CaMKII cRNA or by SrCl(2), similar rates and incidence of development to the blastocyst stage were observed. These results strongly suggest that CaMKII is a major integrator of the Ca(2+) changes that occur following fertilization.