The Relationship Between Acuity of Organ Failure and Predictive Validity of Sepsis-3 Criteria.

The Sepsis-3 taskforce defined sepsis as suspicion of infection and an acute rise in the Sequential Organ Failure Assessment score by 2 points over the preinfection baseline. Sepsis-3 studies, though, have not distinguished between acute and chronic organ failure, and may not accurately reflect the epidemiology, natural history, or impact of sepsis. Our objective was to determine the extent to which the predictive validity of Sepsis-3 is attributable to chronic rather than acute organ failure. DESIGN: Retrospective cohort study. SETTING: General medicine inpatient service at a tertiary teaching hospital. PATIENTS: A total of 3,755 adult medical acute-care encounters (1,864 confirmed acute infections) over 1 year. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured the total Sequential Organ Failure Assessment score at the onset of infection and separated its components (baseline and acute rise) using case-by-case chart reviews. We compared the predictive validities of acuity-focused (acute rise in Sequential Organ Failure Assessment ≥ 2) and conventional (total Sequential Organ Failure Assessment ≥ 2) implementations of Sepsis-3 criteria. Measures of predictive validity were change in the rate of outcomes and change in the area under receiver operating characteristic curves after adding sepsis criteria to multivariate logistic regression models of baseline risk (age, sex, race, and Charlson comorbidity index). Outcomes were inhospital mortality (primary) and ICU transfer or inhospital mortality (secondary). Acuity-focused implementations of Sepsis-3 were associated with neither a change in mortality (2.2% vs 1.2%; p = 0.18) nor a rise in area under receiver operating characteristic curves compared with baseline models (0.67 vs 0.66; p = 0.75). In contrast, conventional implementations were associated with a six-fold change in mortality (2.4% vs 0.4%; p = 0.01) and a rise in area under receiver operating characteristic curves compared with baseline models (0.70 vs 0.66; p = 0.04). Results were similar for the secondary outcome. CONCLUSIONS: The evaluation of the validity of organ dysfunction-based clinical sepsis criteria is prone to bias, because acute organ dysfunction consequent to infection is difficult to separate from preexisting organ failure in large retrospective cohorts.

Imputation of partial pressures of arterial oxygen using oximetry and its impact on sepsis diagnosis.

OBJECTIVE: The ratio of the partial pressure of arterial oxygen to fraction of inspired oxygen is a key component of the sequential organ failure assessment score that operationally defines sepsis. But, it is calculated infrequently due to the need for the acquisition of an arterial blood gas. So, we sought to find an optimal imputation strategy for the estimation of sepsis-defining hypoxemic respiratory failure using oximetry instead of an arterial blood gas. APPROACH: We retrospectively studied a sample of non-intubated acute-care patients with oxygen saturation recorded ⩽10 min before arterial blood sampling (N = 492 from 2013-2017). We imputed ratios of the partial pressure of arterial oxygen to the fraction of inspired oxygen and sepsis criteria from existing imputation equations (Hill, Severinghaus-Ellis, Rice, and Pandharipande) and compared them with the ratios and sepsis criteria measured from arterial blood gases. We devised a modified model-based equation to eliminate the bias of the results. MAIN RESULTS: Hypoxemia severity estimates from the Severinghaus-Ellis equation were more accurate than those from other existing equations, but showed significant proportional bias towards under-estimation of hypoxemia severity, especially at oxygen saturations >96%. Our modified equation eliminated bias and surpassed others on all imputation quality metrics. SIGNIFICANCE: Our modified imputation equation, [Formula: see text] is the first one that is free of bias at all oxygen saturations. It resulted in ratios of partial pressure of arterial oxygen to fraction of inspired oxygen and sepsis respiratory criteria closest to those obtained by arterial blood gas testing and is the optimal imputation strategy for non-intubated acute-care patients.

Appointment adherence and disparities in outcomes among patients with diabetes.

BACKGROUND: Successful control of diabetes mellitus requires lifelong adherence to multiple self-management activities in close collaboration with health professionals. We examined the association of such control with appointment keeping behavior in a rural health system. METHODS: Among 4,253 predominantly lower socioeconomic status patients with diabetes, the association of metabolic control (most recent A1c <7% or >9% in two models of respectively 'good' and 'poor' control) with 'missed appointment rate' over a 3-year period was examined using multiple logistic regression. MAIN RESULTS: For each 10% increment in missed appointment rate, the odds of good control decreased 1.12x (p < 0.001) and the odds of poor control increased 1.24x (p < 0.001). The missed appointment rate was substantially higher among African-American patients (15.9% vs. 9.3% for white patients, p < 0.001). Controlling for the missed appointment rate and insurance status in multivariate analysis attenuated the racial association with good control, and the racial association with poor control was no longer significant. Older, white patients with health insurance tended to have significantly better metabolic control. There was no independent association of metabolic control with patient income, gender, or number of primary care visits. CONCLUSION: Adherence to appointments, independent of visit frequency, was a strong predictor of diabetes metabolic control. We hypothesize that missed appointment behavior may serve as an indicator for other diabetes adherence behaviors and associated barriers that serve to undermine successful diabetes self-management.

Cardiorespiratory dynamics measured from continuous ECG monitoring improves detection of deterioration in acute care patients: A retrospective cohort study.

BACKGROUND: Charted vital signs and laboratory results represent intermittent samples of a patient's dynamic physiologic state and have been used to calculate early warning scores to identify patients at risk of clinical deterioration. We hypothesized that the addition of cardiorespiratory dynamics measured from continuous electrocardiography (ECG) monitoring to intermittently sampled data improves the predictive validity of models trained to detect clinical deterioration prior to intensive care unit (ICU) transfer or unanticipated death. METHODS AND FINDINGS: We analyzed 63 patient-years of ECG data from 8,105 acute care patient admissions at a tertiary care academic medical center. We developed models to predict deterioration resulting in ICU transfer or unanticipated death within the next 24 hours using either vital signs, laboratory results, or cardiorespiratory dynamics from continuous ECG monitoring and also evaluated models using all available data sources. We calculated the predictive validity (C-statistic), the net reclassification improvement, and the probability of achieving the difference in likelihood ratio χ2 for the additional degrees of freedom. The primary outcome occurred 755 times in 586 admissions (7%). We analyzed 395 clinical deteriorations with continuous ECG data in the 24 hours prior to an event. Using only continuous ECG measures resulted in a C-statistic of 0.65, similar to models using only laboratory results and vital signs (0.63 and 0.69 respectively). Addition of continuous ECG measures to models using conventional measurements improved the C-statistic by 0.01 and 0.07; a model integrating all data sources had a C-statistic of 0.73 with categorical net reclassification improvement of 0.09 for a change of 1 decile in risk. The difference in likelihood ratio χ2 between integrated models with and without cardiorespiratory dynamics was 2158 (p value: <0.001). CONCLUSIONS: Cardiorespiratory dynamics from continuous ECG monitoring detect clinical deterioration in acute care patients and improve performance of conventional models that use only laboratory results and vital signs.

The Clinical Health Economics System Simulation (CHESS): a teaching tool for systems- and practice-based learning.

Academic medical centers face barriers to training physicians in systems- and practice-based learning competencies needed to function in the changing health care environment. To address these problems, at the University of Virginia School of Medicine the authors developed the Clinical Health Economics System Simulation (CHESS), a computerized team-based quasi-competitive simulator to teach the principles and practical application of health economics. CHESS simulates treatment costs to patients and society as well as physician reimbursement. It is scenario based with residents grouped into three teams, each team playing CHESS using differing (fee-for-service or capitated) reimbursement models. Teams view scenarios and select from two or three treatment options that are medically justifiable yet have different potential cost implications. CHESS displays physician reimbursement and patient and societal costs for each scenario as well as costs and income summarized across all scenarios extrapolated to a physician's entire patient panel. The learners are asked to explain these findings and may change treatment options and other variables such as panel size and case mix to conduct sensitivity analyses in real time. Evaluations completed in 2003 by 68 (94%) CHESS resident and faculty participants at 19 U.S. residency programs preferred CHESS to a traditional lecture-and-discussion format to learn about medical decision making, physician reimbursement, patient costs, and societal costs. Ninety-eight percent reported increased knowledge of health economics after viewing the simulation. CHESS demonstrates the potential of computer simulation to teach health economics and other key elements of practice- and systems-based competencies.

Determinants of physician use of an ambulatory prescription expert system.

PURPOSE: To determine whether physician experience with and attitude towards computers is associated with adoption of a voluntary ambulatory prescription writing expert system. METHODS: A prescription expert system was implemented in an academic internal medicine residency training clinic and physician utilization was tracked electronically. A physician attitude and behavior survey (response rate=89%) was conducted six months after implementation. RESULTS: There was wide variability in system adoption and degree of usage, though 72% of physicians reported predominant usage (> or =50% of prescriptions) of the expert system six months after implementation. Self-reported and measured technology usage were strongly correlated (r=0.70, p<0.0001). Variation in use was strongly associated with physician attitude toward issues of system efficiency and effect on quality, but not with prior computer experience, level of training, or satisfaction with their primary care practice. Non-adopters felt that electronic prescribing was more time consuming and also more likely to believe that their patients preferred hand-written prescriptions. CONCLUSION: A voluntary electronic prescription system was readily adopted by a majority of physicians who believed it would have a positive impact on the quality and efficiency of care. However, dissatisfaction with system capabilities among both adopters and non-adopters suggests the importance of user education and expectation management following system selection.

The association between diabetes metabolic control and drug adherence in an indigent population.

OBJECTIVE: Studies of the association between diabetes metabolic control and adherence to drug therapy have yielded conflicting results. Because low socioeconomic and minority populations have poorer diabetes outcomes and greater barriers to adherence, we examined the relationship between adherence and diabetes metabolic control in a large indigent population. RESEARCH DESIGN AND METHODS: The study population consisted of patients receiving medical care from a university-based internal medicine clinic serving a low-income population in rural central Virginia. The sample comprised 810 patients with type 2 diabetes who received oral diabetes medications from the clinic pharmacy and had at least one HbA(1c) determination during the study period. Multiple linear regression was used to examine the association of HbA(1c) level as well as change in HbA(1c) level with medication adherence, demographic, and clinical characteristics. RESULTS: Better metabolic control was independently associated with greater medication adherence, increasing age, white (versus African-American) race, and lower intensity of drug therapy. For each 10% increment in drug adherence, HbA(1c) decreased by 0.16% (P < 0.0001). Controlling for other demographic and clinical variables, the mean HbA(1c) of African-Americans was 0.29% higher than that of whites (P = 0.04). Additionally, the intensity of diabetes drug therapy for African-Americans was lower, as was their measured adherence to it. There was no association between metabolic control and gender, income, encounter frequency, frequency of HbA(1c) testing, or continuity of care. CONCLUSIONS: Adherence to medication regimens for type 2 diabetes is strongly associated with metabolic control in an indigent population; African-Americans have lower adherence and worse metabolic control. Greater efforts are clearly needed to facilitate diabetes self-management behaviors of low-income populations and foster culturally sensitive and appropriate care for minority groups.

Effect of pooled comparative information on judgments of quality.

Quality assessment is the focus of many health care initiatives. Yet it is not well understood how the type of information used in decision support tools to enable judgments of quality based on data impacts the accuracy, consistency and reliability of judgments made by physicians. Comparative pooled information could allow physicians to judge the quality of their practice by making comparisons to other practices or other specific populations of patients. In this study, resident physicians were provided with varying types of information derived from pooled patient data sets: quality component measures at the individual and group level, a qualitative interpretation of the quality measures using percentile rank, and an aggregate composite quality score. 32 participants viewed thirty quality profiles consisting of information applicable to the practice of thirty de-identified resident physicians. Those provided with quality component measures and a qualitative interpretation of the quality measures (rankings) judged quality of care more similarly to experts and were more internally consistent compared to participants who were provided with quality component measures alone. Reliability between participants was significantly less for those who were provided with a composite quality score compared to those who were not.

Can prescription refill feedback to physicians improve patient adherence?

BACKGROUND: Although adherence to long-term drug therapy is an important issue, the means to facilitate its assessment and improvement in clinical practice remain a challenge. OBJECTIVE: To evaluate the impact of prescription refill feedback and adherence education provided to primary care physicians. METHODS: We provided 83 resident and attending physicians at a university-based general internal medicine practice with refill adherence reports on each of 340 diabetic patients. An educational session on adherence assessment and improvement techniques was held, and all physicians received a written outline on this topic. Physician attitude toward the intervention and 6-month change in refill adherence (doses filled/doses prescribed) of their patient panels were assessed. A nonrandomized comparison group of patients receiving hypertension medications for whom the physicians did not receive feedback was also evaluated. RESULTS: The overall improvement in mean refill adherence was not significant (83.9% vs 86.0%, P=0.18). The educational session was attended by 53% of the physicians. The patient refill adherence of physicians attending the educational session improved by 5.0% (P<0.0009) with no significant change among patients of physicians not attending the session. There was no adherence change among patients for whom physicians did not receive refill feedback data, regardless of educational session attendance. CONCLUSIONS: Patients of physicians that received refill feedback and attended an educational session improved their refill adherence. After replication of these results in a randomized trial, broad implementation of this approach could have substantial impact from a public health perspective, given the ubiquity of prescription claims data.

The effect of physician feedback and an action checklist on diabetes care measures.

The objective was to evaluate whether physician feedback accompanied by an action checklist improved diabetes care process measures. Eighty-three physicians in an academic general medicine clinic were provided a single feedback report on the most recent date and result of diabetes care measures (glycosylated hemoglobin [A1c], urine microalbumin, serum creatinine, lipid levels, retinal examination) as well as recent diabetes medication refills with calculated dosing and adherence on 789 patients. An educational session regarding the feedback and adherence information was provided. The physicians were asked to complete a checklist accompanying the feedback on each of their patients, indicating requested actions with respect to follow-up, testing, and counseling. The physicians completed 82% of patient checklists, requesting actions consistent with patient needs on the basis of the feedback. Of the physicians, 93% felt the patient information and intervention format to be useful. The odds of urine microalbumin testing, serum creatinine, lipid profile, A1c, and retinal examination increased in the 6 months after the feedback. The increase was sustained at 1 year only for microalbumin and retinal exams. There was no significant change in refill adherence for the group overall after the feedback, although adherence did improve among patients of physicians attending the educational session. No significant change was noted in lipid or A1c levels during the study period. In conclusion, a simple physician feedback tool with action checklist can be both helpful and popular for improving rates of diabetes care guideline adherence. More complex interventions are likely required to improve diabetes outcomes.

Changing conversations: teaching safety and quality in residency training.

Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Predictors of medication-refill adherence in an indigent rural population.

OBJECTIVE: We evaluated the association of medication refill adherence with demographic and prescription characteristics to determine whether such factors could guide intervention strategies in an indigent rural population. METHODS: The study was conducted at a University-based internal medicine practice serving an indigent rural population. Refill data for diabetes, hypertension, and hypercholesterolemia drugs from a closed pharmacy system were used to calculate mean adherence (for all drugs taken by each patient) and minimum adherence (that of the least adhered to drug) for 1984 patients during a 9-month period. RESULTS: Mean refill adherence was <80% for 33% of the population and minimum refill adherence was <80% for 55% of the patients. Increasing age, race (white), and prescription length were associated with higher mean and minimum adherence, independent of income, prescription copay, and insurance status. Number of drugs taken had a positive mean but negative minimum adherence association. Gender, number of primary care visits, and dosage schedule were not independently associated with adherence. The model explained 6.8% of the variance in mean adherence. CONCLUSIONS: In a rural indigent population, medication refill adherence was associated with race, age, and prescription length, though these factors explained only a small amount of adherence variability. Although ingestion adherence is the goal, refill adherence is a necessary condition for ingestion adherence. To enhance adherence, physicians need better predictors to target their efforts to patients most in need of attention. Prescription claims data could serve this purpose.

Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain.

OBJECTIVE: The effect of clinical guidelines on resource utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied. We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain. DESIGN: Physician groups were randomized to receive guideline education and individual feedback, supporting patient education materials, both, or neither. The impact on guideline adherence and resource utilization was evaluated during the 12-month period before and after implementation. PARTICIPANTS: Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practices. INTERVENTIONS: Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders. The patient education component included written and videotaped materials on the care of low back pain. MAIN RESULTS: The clinician intervention was associated with an absolute increase in guideline-consistent behavior of 5.4% in the intervention group versus a decline of 2.7% in the control group (P =.04). The patient education intervention produced no significant change in guideline-consistent behavior, but was poorly adopted. Patient characteristics including duration of pain, prior history of low back pain, and number of visits during the illness episode were strong predictors of service utilization and guideline-consistent behavior. CONCLUSIONS: Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline-consistent behavior. Patient education materials did not enhance guideline effectiveness. Implementation barriers could limit the utility of this approach in usual care settings.