Management of adults with acute streptococcal pharyngitis: minimal value for backup strep testing and overuse of antibiotics.

BACKGROUND: Rapid antigen detection tests (RADT) are commonly used to guide appropriate antibiotic treatment of group A beta-hemolytic streptococcal (GABHS) pharyngitis. In adults, there is controversy about the need for routine backup testing of negative RADT. OBJECTIVE: Estimate the costs and benefits in adults of routine backup testing by DNA Gen-probe of negative RADT (Acceava). DESIGN: Observational follow-up study. PARTICIPANTS: All patients aged 18 years and older visiting a Cleveland Clinic generalist physician in 2009 and 2010 with a visit diagnosis of acute pharyngitis (ICD codes 462, 034.0). MAIN MEASURES: The patients were identified using the Cleveland Clinic Epic Clarity database. We determined the proportion of false negative RADT, antibiotic prescription patterns and rate of serious suppurative complications within 30 days of the office visit. KEY RESULTS: Of 25,130 patients with acute pharyngitis, 19% had no testing and 81% were tested. Of the 15,555 patients that had a negative RADT and follow-up DNA probe, 6% had a positive DNA probe. Of the 953 patients who had a negative RADT and a positive DNA strep probe, 48% received an antibiotic prescription at the time of the visit and 51% received an antibiotic prescription after an average of 2.3 days. Only one patient with a negative RADT and no follow-up DNA probe developed a peritonsillar abscess. Overall, of the 15,555 DNA probes performed, management was altered in only 3% of the patients at a total cost of $1,757,715. Fifty-six percent received an antibiotic while only 19.5% had a confirmed strep throat diagnosis. CONCLUSIONS: The false negative rate of Acceava RADT for the diagnosis of GABHS pharyngitis was 6%. We question the benefit of routine DNA probe backup testing in adults because of its substantial cost, an average delay in antibiotic prescribing of over 2 days, and because suppurative complications are very uncommon. We found a high rate of inappropriate antibiotic prescribing.

The association between personal health record use and diabetes quality measures.

BACKGROUND: Electronic personal health records (PHRs) have the potential to empower patients in self-management of chronic diseases, which should lead to improved outcomes. OBJECTIVE: To measure the association between use of an advanced electronic medical record-linked PHR and diabetes quality measures in adults with diabetes mellitus (DM). DESIGN: Retrospective audit of PHR use and multivariable regression analyses. PATIENTS: 10,746 adults 18-75-years of age with DM seen at least twice at the office of their primary care physician at the Cleveland Clinic from July 2008 through June 2009. MAIN MEASURES: PHR use was measured as number of use days. Diabetes quality measures were: hemoglobin A1c (HbA1c), LDL cholesterol, blood pressure, body mass index (BMI), HbA1c testing, ACEi/ARB use and/or microalbumin testing, pneumococcal vaccination, foot and dilated eye examination, and smoking status. KEY RESULTS: Compared to non-users, PHR users were younger, had higher incomes and educational attainment, were more likely to identify as Caucasian, and had better unadjusted and adjusted diabetes quality measure profiles. Adjusted odds ratio of HbA1c testing was 2.06 (p < 0.01) and most recent HbA1c was 0.29% lower (p < 0.01). Among PHR users, increasing number of login days was generally not associated with more favorable diabetes quality measure profiles. CONCLUSIONS: PHR use, but not intensity of use, was associated with improved diabetes quality measure profiles. It is likely that better diabetes profiles among PHR users is due to higher level of engagement with their health among those registered for the PHR rather than PHR use itself. PHR use was infrequent. To maximize value, next-generation PHRs must be designed to engage patients in everyday diabetes self-management.

Patients' question-asking behavior during primary care visits: a report from the AAFP National Research Network.

PURPOSE: The Ask Me 3 (AM3) health communication program encourages patients to ask specific questions during office visits with the intention of improving understanding of their health conditions and adherence to treatment recommendations. This study evaluated whether implementing AM3 improves patients' question-asking behavior and increases adherence to prescription medications and lifestyle recommendations. METHODS: This randomized trial involved 20 practices from the American Academy of Family Physicians National Research Network that were assigned to an AM3 intervention group or a control group. Forty-one physicians in the practices were each asked to enroll at least 20 patients. The patients' visits were audio recorded, and recordings were reviewed to determine whether patients asked questions and which questions they asked. Patients were interviewed 1 to 3 weeks after the visit to assess their recall of physicians' recommendations, rates of prescription filling and taking, and attempts at complying with lifestyle recommendations. RESULTS: The study enrolled 834 eligible patients in 20 practices. There were no significant difference between the AM3 and control patients in the rate of asking questions, but this rate was high (92%) in both groups. There also were no differences in rates of either filling or taking prescriptions, although rates of these outcomes were fairly high, too. Control patients were more likely to recall that their physician recommended a lifestyle change, however (68% vs 59%, P = .04). CONCLUSIONS: In a patient population in which asking questions already occurs at a high rate and levels of adherence are fairly high, we found no evidence that the AM3 intervention results in patients asking specific questions or more questions in general, or in better adherence to prescription medications or lifestyle recommendations.

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System--MEADERS.

PURPOSE: In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices. METHODS: We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports. RESULTS: A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting. CONCLUSIONS: It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.

Crossing the finish line: follow-up of abnormal test results in a multisite community health center.

BACKGROUND: Inadequate follow-up of abnormal test results is a common safety problem in outpatient practice. However, it is unclear exactly where and how often failures occur in the results management process. Our goal was to determine where breakdowns occur by examining 4 high-risk abnormal test results in a group of 11 clinics of an urban community health center organization. METHODS: Using a chart audit, we counted failures in the management of abnormal results of 4 tests: Pap smears, mammograms, international normalized ratio (INR), and prostate-specific antigen (PSA). We assessed documentation that the result was filed in the chart; the provider signed and responded to the result; the patient was notified of the result; the appropriate follow-up occurred, and it occurred in a timely manner or there was explicit patient refusal of the recommended follow-up. RESULTS: There were 344 abnormal test results (105 Pap smears, 82 mammograms, 61 INRs, and 96 PSAs). The highest rate of failures in the management process was at follow-up care; 34% of the abnormal results did not have documentation that appropriate follow-up had occurred (11% for mammography, 26% for INR, 45% for Pap smears, and 46% for PSA). All of the earlier steps were performed with far fewer failures. For patients receiving follow-up care, 49% of the time, follow-up care did not occur in a timely manner. CONCLUSIONS: Most breakdowns in the testing process for these 4 abnormal tests were in the final step, documenting that appropriate follow-up care occurred. Office systems for managing abnormal results reporting and patient follow-up are needed to improve the safety and quality of care.

A comparison of frequent and infrequent visitors to an urban emergency department.

Frequent visitors account for a high proportion of Emergency Department (ED) visits and costs. Some of these visits could be handled effectively in less expensive primary care settings. Effective interventions to redirect these patients to primary care depend on an in-depth understanding of frequent visitors and the reasons they seek care in the ED. The objective of this study was to explore the differences between frequent visitors and infrequent visitors who seek medical care in one urban ED, as a first step toward developing effective interventions to direct patients to effective sources of care. In structured interviews, we asked 69 frequent visitors and 99 infrequent visitors to an inner-city, adult ED about medical diagnoses, general health, depression, alcohol abuse, physical functioning, self-perceived social support, primary care and ED service use, payment method, satisfaction with their primary care physician, and demographic characteristics. Differences in responses between groups were compared using t-tests for continuous variables and chi-square for categorical variables. Frequent visitors were more likely than infrequent visitors to be insured by Medicaid (53% vs. 39%, respectively) and less likely to be uninsured (13% vs. 24%, respectively) or have private insurance (6% vs. 15%, respectively). They reported higher levels of stress, lower levels of social support, and worse general health status. They were much more likely to screen positive for depression (47% vs. 27%, respectively, p = 0.017). Frequent visitors were more likely to have a primary care physician (75% vs. 66%, respectively), and 45% of the frequent visitors had a primary care physician at the ED hospital compared to 23% of the infrequent visitors. These findings suggest the need to improve access to frequent visitors' primary care physicians, screen them for depression, and offer psychological and social services more aggressively. These findings may apply to other inner city EDs.

An updated and more efficient search strategy to identify primary care-relevant clinical prediction rules.

OBJECTIVES: The aim of the study was to develop an improved search strategy for clinical prediction rules. STUDY DESIGN AND SETTING: We first refined a list of 30 primary care-relevant journals and improved the efficiency of the Haynes Narrow Filter/Teljour/Murphy Inclusion Filter with 26 items by removing one term (Modified Haynes 26 filter). We then developed the "Royal College of Surgeons in Ireland (RCSI) filter" and compared it with the modified HNF/TMIF26 for its ability to detect prediction rules in the primary care literature. All abstracts and, if necessary, full text were reviewed independently in parallel by primary care physicians. The key outcomes were the percentage of prediction rules identified out of the total identified by both search strategies (sensitivity) and the number of articles that had to be reviewed to identify them (efficiency). RESULTS: The Modified Haynes 26 filter returned 1,701 abstracts vs. 1,062 for the RCSI filter. The RCSI filter identified 105 of 111 of all prediction rules identified by either filter, compared with 107 of 111 by the Modified Haynes 26 filter (94.6% vs. 96.4%; P = 0.52). In addition, 9.9% of abstracts found using the RCSI filter were prediction rules, compared with only 6.3% using the Modified Haynes 25 filter (P = 0.001). CONCLUSION: We have developed a novel "RCSI filter" that more efficiently identifies prediction rules in the medical literature.

Academic physicians use placebos in clinical practice and believe in the mind-body connection.

BACKGROUND: The placebo and the placebo effect are often investigated in the context of clinical trials. Little data exist on the use of placebos in the course of routine health care. OBJECTIVE: The aim of this study is to describe a group of academic physicians' use of placebos and their knowledge, attitudes, and beliefs about placebos and the placebo effect. DESIGN: A 16-question anonymous web-based survey of physicians from Internal Medicine departments of 3 Chicago-area medical schools was used. RESULTS: There were 231/466 (50%) physicians who responded; of these, 45% reported they had used a placebo in clinical practice. The most common reasons for placebo use were to calm the patient and as supplemental treatment. Physicians did not widely agree on the definition of a placebo and had a variety of explanations for its mechanism of action. Ninety-six percent of the respondents believed that placebos can have therapeutic effects, and up to 40% of the physicians reported that placebos could benefit patients physiologically for certain health problems. Only 12% of the respondents said that placebo use in routine medical care should be categorically prohibited. Regarding "placebo-like" treatment, 48% of respondents reported giving at least 1 type of treatment in a situation where there was no evidence of clinical efficacy. CONCLUSION: Nearly half of the respondents use placebos in clinical practice and most believe in the mind-body connection. The results of this study, based on retrospective self-reported behavior, are subject to recall bias and may not be representative of American physicians.

Data collection outcomes comparing paper forms with PDA forms in an office-based patient survey.

PURPOSE: We compared the completeness of data collection using paper forms and using electronic forms loaded on handheld computers in an office-based patient interview survey conducted within the American Academy of Family Physicians National Research Network. METHODS: We asked 19 medical assistants and nurses in family practices to administer a survey about pneumococcal immunizations to 60 older adults each, 30 using paper forms and 30 using electronic forms on handheld computers. By random assignment, the interviewers used either the paper or electronic form first. Using multilevel analyses adjusted for patient characteristics and clustering of forms by practice, we analyzed the completeness of the data. RESULTS: A total of 1,003 of the expected 1,140 forms were returned to the data center. The overall return rate was better for paper forms (537 of 570, 94%) than for electronic forms (466 of 570, 82%) because of technical difficulties experienced with electronic data collection and stolen or lost handheld computers. Errors of omission on the returned forms, however, were more common using paper forms. Of the returned forms, only 3% of those gathered electronically had errors of omission, compared with 35% of those gathered on paper. Similarly, only 0.04% of total survey items were missing on the electronic forms, compared with 3.5% of the survey items using paper forms. CONCLUSIONS: Although handheld computers produced more complete data than the paper method for the returned forms, they were not superior because of the large amount of missing data due to technical difficulties with the hand-held computers or loss or theft. Other hardware solutions, such as tablet computers or cell phones linked via a wireless network directly to a Web site, may be better electronic solutions for the future.

Quality and safety in outpatient laboratory testing.

Interactions between the laboratory and outpatient physician are critical to ensure the appropriateness, accuracy, and utility of laboratory results. A recent Institute of Medicine report suggested that the consequences of medical errors in the outpatient setting-and the opportunities to improve-"may dwarf those in hospitals." This article focuses on the role of the physician's office in laboratory quality.

Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters.

BACKGROUND: Inappropriate use of indwelling urinary tract catheters (IUTCs) in the hospital setting is widespread and associated with nosocomial urinary tract infections. In a prior observational study, we found less than half of IUTCs placed in hospitalized elderly patients had appropriate indications. We tested an emergency department (ED) intervention to increase appropriate use of IUTCs. METHODS: The intervention included ED staff education and an indication checklist attached to each catheter kit for staff to complete prior to use. We completed a chart audit on appropriate use of urinary catheters in 100 consecutive catheterized ED patients and tracked catheter billing data before and after the intervention. RESULTS: Appropriate use of catheters increased from 37% to 51% (P=0.06). The presence of a physician order for catheter placement significantly increased from 43% to 63% (P< 0.01). There was a large and sustained decrease in the total number of catheters placed in the ED after the intervention (N=2029 in 2001 and N=2188 in 2002 to N=300 in 2004 and N= 512 in 2005). CONCLUSIONS: Education and use of an indication sheet produced a dramatic reduction in total number of catheters used and had a smaller impact on appropriateness of use and documentation.

A national survey of primary care practice-based research networks.

PURPOSE: Increasing numbers of primary care practice-based research networks (PBRNs) are being developed in the United States to perform research relevant to everyday practice. To assess the current status and potential value of this resource, we surveyed US primary care PBRNs in operation from late 2003 to early 2004. METHODS: We performed a Web-based survey and structured interviews with PBRN directors and administrative officers, assessing PBRNs' history, size, location, organization, resources, operations, and productivity (funding obtained, studies performed, and articles published). RESULTS: Of 111 primary care PBRNs identified, 89 (80%) responded to the survey. The 86 (77%) meeting the criteria for primary care PBRNs contained 1,871 practices, 12,957 physicians (mean 152 per PBRN, median 100), and 14.7 million patients (mean 229,880 per PBRN, median 105,000). Minority and underinsured patients were overrepresented. The average PBRN was young (4.4 +/- 5.7 years): one-half had performed 3 or fewer studies. Three-quarters were affiliated with universities. Common research foci included prevention, diabetes, cardiovascular risk factors, and mental health. Respondent PBRNs had published more than 600 articles in peer-reviewed journals. PBRNs studying questions posed by outside researchers had more federal funding (84% vs 27%, P=.006). PBRNs citing funding as a weakness relied more on local resources to fund research projects (70% vs 40%, P=.036). CONCLUSIONS: American primary care PBRNs are mainly young, diverse, and pursuing a variety of research foci. Most have university links and provide a dynamic town-gown relationship that could be a vital national resource for improving primary care, translating research into practice, and meeting the National Institutes of Health Roadmap goals. PBRNs merit further attention from both private and public funding agencies and researchers interested in studying the delivery of primary care.

Physicians' and patients' views of cancer care by family physicians: a report from the American Academy of Family Physicians National Research Network.

BACKGROUND AND OBJECTIVES: There has been little research describing the role of family physicians in the care of patients with an active diagnosis of cancer. METHODS: Using qualitative methods, we interviewed 15 family physicians and 15 of their cancer patients. We asked physicians about care of cancer patients in general and of the specific patient included in this study. Patient interviews focused on the role their family physician played in their care and their satisfactions and frustrations with that care. RESULTS: The physicians reported coordinating referrals, providing general medical care, helping with decisions, and providing emotional support. Their involvement was more intense at the time of diagnosis and near death. The patients gave similar responses and also said they valued clear explanations and spending time with and feeling comfortable with their family physicians. CONCLUSIONS: Family physicians fulfill a number of important roles in caring for their patients with an active diagnosis of cancer. More research using representative samples is needed to determine the generalizability of these findings, but this study gives us some preliminary insight into the role family physicians play in cancer care.