Association of Early Postoperative Pain Trajectories With Longer-term Pain Outcome After Primary Total Knee Arthroplasty.

Importance: Studies to date have not comprehensively examined pain experience after total knee arthroplasty (TKA). Discrete patterns of pain in this period might be associated with pain outcomes at 6 to 12 months after TKA. Objectives: To examine patterns of individual post-TKA pain trajectories and to assess their independent associations with longer-term pain outcome after TKA. Design, Setting, and Participants: This prospective cohort study combined data from a national US TKA cohort with ancillary pain severity data at 2 weeks and 8 weeks after the index TKA using a numeric rating scale. All participants received primary, unilateral TKA within the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) national network of community sites in 22 states or at the lead site (University of Massachusetts Medical School). Participants had a date of surgery between May 1, 2013, and December 1, 2014. The data analysis was performed between January 13, 2015, and July 5, 2016. Exposures: Pain trajectories in the postoperative period (8 weeks). Main Outcomes and Measures: Index knee pain at 6 months after TKA using the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scale. Group-based trajectory methods examined the presence of pain trajectories in the postoperative period (8 weeks) and assessed whether trajectories were independently associated with longer-term pain (6 months). Results: The cohort included 659 patients who underwent primary TKA with complete data at 4 points (preoperative, 2 weeks, 8 weeks, and 26 weeks). Their mean (SD) age was 67.1 (8.0) years, 64.5% (425 of 659) were female, the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 30.77 (5.66), 94.5% (613 of 649) were white, and the mean (SD) preoperative 36-Item Short Form Health Survey physical component summary and mental component summary scores were 34.1 (8.2) and 53.8 (11.4), respectively. Two pain trajectory subgroups were identified at 8 weeks after TKA: patients who experienced fast pain relief in the first 8 weeks after TKA (fast pain responders, composing 72.4% [477 of 659] of the sample) and patients who did not (slow pain responders, composing 27.6% [182 of 659] of the sample). After adjusting for patient factors, the pain trajectory at 8 weeks after TKA was independently associated with the mean KOOS pain score at 6 months, with a between-trajectory difference of -11.3 (95% CI, -13.9 to -8.7). Conclusions and Relevance: The trajectory among slow pain responders at 8 weeks after surgery was independently associated with improved but greater persistent index knee pain at 6 months after TKA compared with that among fast pain responders. Early identification of patients with a trajectory of slow pain response at 8 weeks after TKA may offer an opportunity for interventions in the perioperative period to potentially improve the long-term pain outcomes after TKA.

Full implementation of computerized physician order entry and medication-related quality outcomes: a study of 3364 hospitals.

This study compares quality of care measures for hospitals with fully implemented computerized physician order entry (CPOE) systems with hospitals that have not fully implemented such a system. Using a cross-sectional design, this study linked hospital quality data from the Centers for Medicare and Medicaid Services to the Health Information Management Systems Society Analytics database, which contains hospital CPOE adoption information. Performance on quality measures was assessed using univariate and multivariate methods. In all, 8% of hospitals have fully implemented CPOE systems; CPOE hospitals were more frequently larger, not-for-profit, and teaching hospitals. After controlling for confounders, CPOE hospitals outperformed comparison hospitals on 5 of 11 measures related to ordering medications and on 1 of 9 nonmedication-related quality measures. Using a large sample of hospitals, our study found significant positive associations between specific objective quality indicators and CPOE implementation.

Effect of racial differences on ability to afford prescription medications.

PURPOSE: The association of race with not filling prescription medications because of cost for African-American and white patients 65 years or older was examined. METHODS: African-American and white patients age 65 years or older were recruited from the practices of 48 Alabama primary care physicians participating in the Alabama Nonsteroidal Antiinflammatory Drug Patient Safety Study. All eligible patients were asked questions related to their ability to pay for prescription medications, comorbidities, insurance status, and socioeconomic status. Baseline and follow-up telephone surveys were completed between August 2005 and April 2006. Mediation analysis was conducted to determine whether patients' perceived income inadequacy mediated the association between race and not filling medications using staged logistic regression models and adjusting for age, comorbidities, and traditional markers of socioeconomic position (income, education, and insurance status). RESULTS: Of 399 participants, 32% were African-American, 74% were women, and 53% had an annual household income of <$15,000. Patients not filling prescription medications were more likely to be African-American (50% versus 25%) and to report inadequate income to meet basic needs (61% versus 17%) (p < 0.001 for both comparisons). After adjusting for all covariates except the mediator, the odds ratio (OR) for African Americans not filling a prescription medication was 2.3 when compared with white patients. Adding the mediator (perceived income inadequacy) to the model reduced the OR to 1.4. CONCLUSION: African Americans reported markedly greater difficulty in affording prescription medications than did white patients, even after accounting for income, education, health insurance status, and comorbidities. The inability of African Americans to afford prescription medications may be better predicted by perceived income inadequacy than more traditional measures of socioeconomic status.

Does interhospital transfer improve outcome of acute myocardial infarction? A propensity score analysis from the Cardiovascular Cooperative Project.

BACKGROUND: Many patients suffering acute myocardial infarction (AMI) are transferred from one hospital to another during their hospitalization. There is little information about the outcomes related to interhospital transfer. The purpose of this study was to compare processes and outcomes of AMI care among patients undergoing interhospital transfer with special attention to the impact on mortality in rural hospitals. METHODS: National sample of Medicare patients in the Cooperative Cardiovascular Study (n = 184,295). Retrospective structured medical record review of AMI hospitalizations. Descriptive study using a retrospective propensity score analysis of clinical and administrative data for 184,295 Medicare patients admitted with clinically confirmed AMI to 4,765 hospitals between February 1994 and July 1995. Main outcome measure included: 30-day mortality, administration of aspirin, beta-blockers, ACE-inhibitors, and thrombolytic therapy. RESULTS: Overall, 51,530 (28%) patients underwent interhospital transfer. Transferred patients were significantly younger, less critically ill, and had lower comorbidity than non-transferred patients. After propensity-matching, patients who underwent interhospital transfer had better quality of care anlower mortality than non-transferred patients. Patients cared for in a rural hospital had similar mortality as patients cared for in an urban hospital. CONCLUSION: Transferred patients were vastly different than non-transferred patients. However, even after a rigorous propensity-score analysis, transferred patients had lower mortality than non-transferred patients. Mortality was similar in rural and urban hospitals. Identifying patients who derive the greatest benefit from transfer may help physicians faced with the complex decision of whether to transfer a patient suffering an acute MI.

Identifying top-performing hospitals by algorithm: results from a demonstration project.

BACKGROUND: Because of the move toward performance-based reimbursement, identification of top-performing hospitals has acquired new importance. METHODS: The High Performance Algorithm (HPA) for hospitals was developed on the basis of the following principles: (1) the approach must be data driven and transparent, (2) all hospitals providing the same service are held to the same standard, (3) top-performing hospitals must perform well on easily achieved and difficult quality measures, and (4) high performance demands sustained excellence over time. The HPA algorithm was applied to 16 quality measures from the national Hospital Quality Alliance (July 2003-June 2004) for acute myocardial infarction (AMI), heart failure (HF), and pneumonia. Top-performing hospitals were defined as those with the top 1% of HPA scores (n = 45). RESULTS: From all 3,867 hospitals, median HPA scores (interquartile range) were 17.0 (16.0-19.0) for top-performing hospitals and 3.0 (1.0-6.0) for others (p < .001). Mean performance on quality measures was higher for top hospitals on all 16 measures. For example, on administration of angiotensin-converting enzyme inhibitors to patients with HF, the mean score for top-performing hospitals was 93.3%, compared with 76.5% for others (p < .001). Although many hospitals achieved excellence on individual measures, sustained top performance across multiple conditions and time periods was uncommon, with < 1% of hospitals scoring > or = 16/36 points on the HPA scale. DISCUSSION: Using national, publicly reported data, the HPA provided good discrimination between top-performing and other hospitals. This project sets the stage for future comparisons of organizational, leadership, and policy differences between top-performing and other hospitals.

Racial/ethnic disparities in patient-reported nonsteroidal antiinflammatory drug (NSAID) risk awareness, patient-doctor NSAID risk communication, and NSAID risk behavior.

OBJECTIVE: Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly used and frequently lead to serious adverse events. Little is known about NSAID-related ethnic/racial disparities. We focused on differences in patient NSAID risk awareness, patient-doctor NSAID risk communication, and NSAID risk-avoidance behavior. METHODS: We performed a cross-sectional analysis of survey data from the Alabama NSAID Patient Safety Study. Eligible patients were > or = 65 years old and currently taking prescription NSAIDs (Rx NSAIDS). Generalized linear latent and mixed models accounted for nesting of patients within physicians. RESULTS: Of all 404 participants, 32% were African American and 73% were female. The mean +/- SD age was 72.8 +/- 7.5 years, and 64% reported an annual household income <$20,000. African American patients were less likely than white patients to recognize any risk associated with over-the-counter (OTC) NSAIDs (13.3% versus 29.3%; P = 0.001) and Rx NSAIDs (31.3% versus 49.6%; P = 0.001), report that their doctor discussed possible NSAID-related gastrointestinal problems (38.0% versus 52.4%; P = 0.007), and take medications to reduce ulcer risk (30.5% versus 50.2%; P = 0.001). Patients with lower income and education reported significantly less risk awareness for OTC and Rx NSAIDs. Racial/ethnic differences persisted after adjusting for multiple confounders. CONCLUSION: In this community-based study of low income elderly individuals receiving NSAIDs, we identified important racial/ethnic differences in risk awareness, communication, and behavior. Additional efforts are needed to promote safe NSAID use and reduce ethnic/racial disparities.

Randomized trial to improve fracture prevention in nursing home residents.

BACKGROUND: Interventions to improve the fracture prevention in nursing homes are needed. METHODS: Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n=67) with > or =10 residents with a diagnosis of osteoporosis or recent hip fracture (n=606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering. RESULTS: No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P=.72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models. CONCLUSIONS: Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities.

Bioterrorism training in U.S. emergency medicine residencies: has it changed since 9/11?

OBJECTIVES: To assess the change in prevalence of bioterrorism training among emergency medicine (EM) residencies from 1998 to 2005, to characterize current training, and to identify characteristics of programs that have implemented more intensive training methods. METHODS: This was a national cross sectional survey of the 133 U.S. EM residencies participating in the 2005 National Resident Matching Program; comparison with a baseline survey from 1998 was performed. Types of training provided were assessed, and programs using experiential methods were identified. RESULTS: Of 112 programs (84.2%) responding, 98% reported formal training in bioterrorism, increased from 53% (40/76) responding in 1998. In 2005, most programs with bioterrorism training (65%) used at least three methods of instruction, mostly lectures (95%) and disaster drills (80%). Fewer programs used experiential methods such as field exercises or bioterrorism-specific rotations (35% and 13%, respectively). Compared with other programs, residency programs with more complex, experiential methods were more likely to teach bioterrorism-related topics at least twice a year (83% vs. 59%; p = 0.018), to teach at least three topics (60% vs. 40%; p = 0.02), and to report funding for bioterrorism research and education (74% vs. 45%; p = 0.007). Experiential and nonexperiential programs were similar in program type (university or nonuniversity), length of program, number of residents, geographic location, and urban or rural setting. CONCLUSIONS: Training of EM residents in bioterrorism preparedness has increased markedly since 1998. However, training is often of low intensity, relying mainly on nonexperiential instruction such as lectures. Although current recommendations are that training in bioterrorism include experiential learning experiences, the authors found the rate of these experiences to be low.

Disparities by insurance status in quality of care for elderly patients with unstable angina.

CONTEXT: Treatment disparities for socioeconomically disadvantaged populations have been widely reported, but few studies have sought explanations for these disparities. OBJECTIVE: To compare the quality of care for patients insured by Medicare alone, Medicare plus Medicaid, or Medicare plus private insurance and investigate mediators for potential disparities. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, random chart review of 3122 African American or White Medicare patients >65 years of age hospitalized for unstable angina in 22 Alabama hospitals, 1993-1999. MAIN OUTCOME MEASURES: Echocardiogram within 20 minutes of presentation; evaluation by a cardiologist; appropriate anti-platelet therapy within 24 hours of admission and at discharge, heparin for high-risk patients, beta-blockers during hospitalization, and performance of appropriate coronary angiography. RESULTS: 182 (5.8%) had Medicare only, 433 (13.9%) had Medicare plus Medicaid, and 2507 (80.3%) had Medicare plus private insurance. Medicaid patients were more frequently Black, female, >85 years old, had multiple co-morbidities, or were admitted to hospitals without cardiac catheterization facilities (P<.001). Fewer Medicaid patients were admitted to hospitals with cardiac catheterization capabilities. Even after adjustment for demographics and hospital characteristics, Medicaid patients were less likely to see a cardiologist (odds ratio [OR] .57, 95% confidence interval [CI] .44-.73), receive antiplatelet therapy within 24 hours of admission (OR .66, 95% CI .50-.87), or heparin (OR .71, 95% CI .53-.97). No differences were seen with regard to having an electrocardiogram within 20 minutes of admission. Beta-blockers were used least in the Medicare-only patients, with only 37.7% receiving them (P=.04). Suitable Medicaid patients received coronary angiography less often, even after adjustment for demographics, co-morbidity, and prior revascularization (OR .68, 95% CI .48-.97). However, when adjusted for hospital characteristics, this finding was no longer observed (OR .94, 95% CI .64-1.39). CONCLUSIONS: Elderly Medicaid patients appear to receive poorer quality of care. This finding is partially, but not completely, explained by characteristics of the facilities where they are hospitalized.

Evaluation of an online bioterrorism continuing medical education course.

INTRODUCTION: Much of the international community has an increased awareness of potential biologic, chemical, and nuclear threats and the need for physicians to rapidly acquire new knowledge and skills in order to protect the public's health. The present study evaluated the educational effectiveness of an online bioterrorism continuing medical education (CME) activity designed to address clinical issues involving suspected bioterrorism and reporting procedures in the United States. METHODS: This was a retrospective survey of physicians who had completed an online CME activity on bioterrorism compared with a nonparticipant group who had completed at least 1 unrelated online CME course from the same medical school Web site and were matched on similar characteristics. An online survey instrument was developed to assess clinical and systems knowledge and confidence in recognition of illnesses associated with a potential bioterrorism attack. A power calculation indicated that a sample size of 100 (50 in each group) would achieve 90% power to detect a 10% to 15% difference in test scores between the two groups. RESULTS: Compared with nonparticipant physicians, participants correctly diagnosed anthrax (p = .01) and viral exanthem (p = .01), but not smallpox, more frequently than nonparticipants. Participants knew more frequently than nonparticipants who to contact regarding a potential bioterrorism event (p = .03) Participants were more confident than nonparticipants about finding information to guide diagnoses of patients with biologic exposure (p = .01), chemical exposure (p = .02), and radiation exposure (p = .04). DISCUSSION: An online bioterrorism course shows promise as an educational intervention in preparing physicians to better diagnose emerging rare infections, including those that may be associated with a bioterrorist event, in increasing confidence in diagnosing these infections, and in reporting of such infections for practicing physicians.

Trends in colon cancer screening procedures in the US Medicare and Tricare populations: 1999-2001.

BACKGROUND: This study examined trends in the numbers of double contrast barium enemas, flexible sigmoidoscopies, and colonoscopies and trends in the choices of colorectal cancer screening service providers. METHODS: Descriptive statistics were used to examine Medicare and Tricare data for the years 1999 to 2001. RESULTS: The total volume of procedures increased 5% and 14%, respectively, in Tricare and Medicare. Tricare and Medicare, respectively, saw 32% and 33% reductions in barium enemas and 28% and 41% reductions in flexible sigmoidoscopies. Colonoscopies increased by 45% and 34% in Tricare and Medicare, respectively. Gastroenterologists provided the majority of colonoscopies for both groups each year. CONCLUSIONS: The volume of colonoscopies increased from 1999 to 2001 for both groups while the volumes of barium enemas and flexible sigmoidoscopies decreased. Gastroenterologists appear to be the preferred providers of colonoscopies.

Improving physician performance through Internet-based interventions: who will participate?

BACKGROUND: The availability of Internet-based continuing medical education is rapidly increasing, but little is known about recruitment of physicians to these interventions. OBJECTIVE: The purpose of this study was to examine predictors of physician participation in an Internet intervention designed to increase screening of young women at risk for chlamydiosis. METHODS: Eligibility was based on administrative claims data, and eligible physicians received recruitment letters via fax and/or courier. Recruited offices had at least one physician who agreed to participate in the study by providing an email address. After one physician from an office was recruited, intensive recruitment of that office ceased. Email messages reminded individual physicians to participate by logging on to the Internet site. RESULTS: Of the eligible offices, 325 (33.2%) were recruited, from which 207 physicians (52.8%) participated. Recruited versus nonrecruited offices had more eligible patients (mean number of eligible patients per office: 44.1 vs 33.6; P < .001), more eligible physicians (mean number of eligible physicians per office: 6.2 vs 4.1; P < .001), and fewer doctors of osteopathy (mean percent of eligible physicians per office who were doctors of osteopathy: 20.5% vs 26.4%; P = .02). Multivariable analysis revealed that the odds of recruiting at least one physician from an office were greater if the office had more eligible patients and more eligible physicians. More participating versus nonparticipating physicians were female (mean percent of female recruited physicians: 39.1% vs 27.0%; P = .01); fewer participating physicians were doctors of osteopathy (mean percent of recruited physicians who were doctors of osteopathy: 15.5% vs 23.9%; P = .04) or international medical graduates (mean percent of recruited physicians who were international graduates: 12.3% vs 23.8%; P = .003). Multivariable analysis revealed that the odds of a physician participating were greater if the physician was older than 55 years (OR = 2.31; 95% CI = 1.09-4.93) and was from an office with a higher Chlamydia screening rate in the upper tertile (OR = 2.26; 95% CI = 1.23-4.16). CONCLUSIONS: Physician participation in an Internet continuing medical education intervention varied significantly by physician and office characteristics.

Delay in time to receipt of thrombolytic medication among Medicare patients with kidney disease.

BACKGROUND: Patients with kidney disease and acute myocardial infarction (AMI) receive standard therapy, including thrombolytic medication, less frequently than patients with normal kidney function. Our goal is to identify potential differences in thrombolytic medication delays and thrombolytic-associated bleeding events by severity of kidney disease. METHODS: This is a retrospective cohort analysis of Cooperative Cardiovascular Project data for all Medicare patients with AMI from 4,601 hospitals. Outcome measures included time to administration of thrombolytic medication censored at 6 hours and bleeding events. RESULTS: Of 109,169 patients (mean age, 77.4 years; 50.6% women), 13.9% received thrombolysis therapy. Average time to thrombolytic therapy was longer in patients with worse kidney function. Adjusted hazard ratios for minutes to thrombolytic therapy were 0.83 (95% confidence interval [CI], 0.79 to 0.87) for patients with a serum creatinine level of 1.6 to 2.0 mg/dL (141 to 177 micromol/L) and 0.58 (95% CI, 0.53 to 0.63) for patients with a creatinine level greater than 2.0 mg/dL (>177 micromol/L) or on dialysis therapy compared with those with normal kidney function. Odds ratios for bleeding events in patients administered thrombolytics versus those who were not decreased with worse kidney function: adjusted odds ratios, 2.28 (95% CI, 2.16 to 2.42) in patients with normal kidney function and 1.84 (95% CI, 1.09 to 3.10) in dialysis patients. CONCLUSION: Patients with worse kidney function experienced treatment delays, but were not at greater risk for thrombolysis-associated excess bleeding events. Physician concerns of thrombolytic-associated bleeding may not be sufficient reason to delay the administration of thrombolytic medication.

Longitudinal patterns in the prevention of osteoporosis in glucocorticoid-treated patients.

OBJECTIVE: To evaluate patient and physician factors associated with prevention of glucocorticoid-induced osteoporosis and to describe temporal trends in screening and prevention of glucocorticoid-induced osteoporosis. METHODS: Using databases from a national managed care organization, enrollees who had been prescribed glucocorticoids (taken for at least 60 days) during an 18-month period were identified. Administrative data from January 2001 through June 2003 and linked survey data from October 2003 were examined for measurement of bone mass, prescription of antiresorptive medication, and use of over-the-counter calcium and/or vitamin D treatment. Factors associated with screening and bone-protective therapies were identified using multivariable logistic regression, focusing on physician specialty and survey respondent ethnicity. Trends in glucocorticoid-induced osteoporosis prevention were assessed using administrative data from 2001-2003 versus 1995-1998. RESULTS: We identified 6,281 patients who were prescribed glucocorticoids in 2001-2003 (mean +/- SD prescribed prednisone-equivalent dosage 16 +/- 14 mg/day). Forty-two percent underwent bone mass measurement and/or were prescribed bone-protective medication; rates were lowest for men (25%). Compared with patients of internists, the odds of bone mass measurement were lowest among patients prescribed glucocorticoids by family physicians (odds ratio [OR] 0.56 [95% confidence interval] [95% CI] 0.30-1.04) and highest among patients prescribed glucocorticoids by rheumatologists (OR 1.48 [95% CI 1.06-2.08]). Patients prescribed glucocorticoids by gastroenterologists were less likely to be treated with antiresorptive agents (OR 0.49 [95% CI 0.28-0.86]). African American patients were less likely than white patients to be screened (OR 0.55 [95% CI 0.40-0.75]) or treated (OR 0.71 [95% CI 0.51-0.98]). The frequency of bone mass measurement among glucocorticoid-treated patients in 2001-2003 increased 3-fold compared with 1995-1998, and the use of prescription antiresorptive medication increased approximately 2-fold. CONCLUSION: Despite significant temporal increases in the frequency of screening for and treatment of glucocorticoid-induced osteoporosis, absolute rates remain low, especially among men, African Americans, and patients of certain physician specialties.

Chlamydia screening of at-risk young women in managed health care: characteristics of top-performing primary care offices.

OBJECTIVES: Despite effective approaches for managing chlamydial infection, asymptomatic disease remains highly prevalent. We linked administrative data with physician data from the American Medical Association physician survey to identify characteristics of primary care offices associated with best chlamydia screening practices. STUDY: Criteria from the National Committee for Quality Assurance provided chlamydia screening rates. We defined top-performing offices as those with rates in the top decile among 978 primary care offices from 26 states. RESULTS: Offices screened an average of 16.2% of at-risk, young women, but top-performing offices screened 42.2%. Top-performing offices on average had more black physicians (12.5%, 5.1%, P = 0.001) and were more often located in zip code areas with median income less than $30,000 (22.6%, 5.5%, P = 0.001). CONCLUSIONS: Although chlamydia screening rates are alarmingly low overall, there is substantial variation across offices. Understanding predictors of better office performance may lead to effective interventions to promote screening.

Multicomponent Internet continuing medical education to promote chlamydia screening.

BACKGROUND: Low Chlamydia trachomatis screening rates create an opportunity to test innovative continuing medical education (CME) programs. Few studies of Internet-based physician learning have been evaluated with objective data on practice patterns. DESIGN: This randomized controlled trial tested a multicomponent Internet CME (mCME) intervention for increasing chlamydia screening of at-risk women aged 16 to 26 years. SETTING: Eligible physician offices had > or =20 patients at risk for chlamydia as defined by the Health Plan Employer Data and Information Set (HEDIS), had at least one primary care physician (internal medicine, family medicine/general practice, pediatrics) with Internet access, and participated in the study managed care organization. The 191 randomized primary care offices represented 20 states. INTERVENTION: The intervention, available from February to December 2001, consisted of four case-based learning modules, was tailored in real time to each physician based on theory of behavior change, and included office-level feedback of chlamydia screening rates. MAIN OUTCOME MEASURE: HEDIS chlamydia screening rates for the pre-intervention (2000) and post-intervention (2002) periods. RESULTS: Pre-intervention screening rates for the intervention and comparison offices were 18.9% and 16.2% (p =0.135). Post-intervention screening rates for the intervention and comparison offices were 15.5% and 12.4%, respectively (p =0.044, adjusting for baseline performance). CONCLUSIONS: The substantial decline in chlamydia screening rates observed in the comparison offices was significantly attenuated for the intervention offices. The mCME favorably influenced chlamydia screening by primary care physicians.

Online bioterrorism continuing medical education: development and preliminary testing.

OBJECTIVE: Education to achieve awareness and competency in responding to incidents of bioterrorism is important for health care professionals, especially emergency physicians and nurses, who are likely first points of medical contact. The authors describe the development of a computer-based approach to initial education, incorporating a screensaver to promote awareness and a Web-based approach to provide initial content competency in the areas of smallpox and anthrax. METHODS: Screensavers were developed and tested on emergency department rotating senior medical students and internal medicine interns. Conceptually, screensavers were designed as "billboards" for attracting attention to the educational domain. Five rotating images sequenced at five-second intervals incorporated a teaser question and an interactive toolbar. An interactive toolbar was linked to a Web site that provided content on smallpox and anthrax for hospital-based specialties (emergency physicians and nurses, infection control practitioners, pathologists, and radiologists). The content included both summary and comprehensive content as well as free continuing education credits in an online, specialty-specific, case-scenario format with remediation pop-up boxes. RESULTS: Formal testing indicated that the screensaver and Web site combination deployed on computers in the emergency department and the events of the fall of 2001 significantly increased the percentage of correct responses to five standardized bioterrorism questions. Formal evaluation with a randomized trial and long-term follow-up is ongoing. CONCLUSIONS: Screensavers and Web sites can be used to increase awareness of bioterrorism. Web-based education may provide an effective means of education for bioterrorism.

Using email reminders to engage physicians in an Internet-based CME intervention.

BACKGROUND: Engaging practicing physicians in educational strategies that reinforce guideline adoption and improve the quality of healthcare may be difficult. Push technologies such as email offer new opportunities to engage physicians in online educational reinforcing strategies. The objectives are to investigate 1) the effectiveness of email announcements in engaging recruited community-based primary care physicians in an online guideline reinforcement strategy designed to promote Chlamydia screening, 2) the characteristics of physicians who respond to email announcements, as well as 3) how quickly and when they respond to email announcements. METHODS: Over a 45-week period, 445 recruited physicians received up to 33 email contacts announcing and reminding them of an online women's health guideline reinforcing CME activity. Participation was defined as physician log-on at least once to the website. Data were analyzed to determine participation, to compare characteristics of participants with recruited physicians who did not participate, and to determine at what point and when participants logged on. RESULTS: Of 445 recruited physicians with accurate email addresses, 47.2% logged on and completed at least one module. There were no significant differences by age, race, or specialty between participants and non-participants. Female physicians, US medical graduates and MDs had higher participation rates than male physicians, international medical graduates and DOs. Physicians with higher baseline screening rates were significantly more likely to log on to the course. The first 10 emails were the most effective in engaging community-based physicians to complete the intervention. Physicians were more likely to log on in the afternoon and evening and on Monday or Thursday. CONCLUSIONS: Email course reminders may enhance recruitment of physicians to interventions designed to reinforce guideline adoption; physicians' response to email reminders may vary by gender, degree, and country of medical training. Repetition of email communications contributes to physician online participation.

Nurse staffing and mortality for Medicare patients with acute myocardial infarction.

CONTEXT: Recent hospital reductions in registered nurses (RNs) for hospital care raise concerns about patient outcomes. OBJECTIVE: Assess the association of nurse staffing with in-hospital mortality for patients with acute myocardial infarction (AMI). DESIGN, SETTING, AND PATIENTS: Medical record review data from the 1994-1995 Cooperative Cardiovascular Project were linked with American Hospital Association data for 118,940 fee-for-service Medicare patients hospitalized with AMI. Staffing levels were represented as nurse to patient ratios categorized into quartiles for RNs and for licensed practical nurses (LPNs). MAIN OUTCOME MEASURES: In-hospital mortality. RESULTS: From highest to lowest quartile of RN staffing, in-hospital mortality was 17.8%, 17.4%, 18.5%, and 20.1%, respectively (P < 0.001 for trend). However, from highest to lowest quartile of LPN staffing, mortality was 20.1%, 18.7%, 17.9%, and 17.2%, respectively P < 0.001). After adjustment for patient demographic and clinical characteristics, treatment, and for hospital volume, technology index, and teaching and urban status, patients treated in environments with higher RN staffing were less likely to die in-hospital; odds ratios (95% confidence intervals) of quartiles 4, 3, and 2 versus quartile 1 were 0.91 (0.86-0.97), 0.94 (0.88-1.00), and 0.96 (0.90-1.02), respectively. Conversely, after adjustment, patients treated in environments with higher LPN staffing were more likely to die in-hospital; odds ratios (95% confidence intervals) of quartiles 4, 3, and 2 versus quartile 1 were 1.07 (1.00-1.15), 1.02 (0.96-1.09), and 1.00 (0.94-1.07), respectively. CONCLUSIONS: Even after extensive adjustment, higher RN staffing levels were associated with lower mortality. Our findings suggest an important effect of nurse staffing on in-hospital mortality.