A technology-based quality innovation to identify undiagnosed hypertension among active primary care patients.

PURPOSE: The goal of this study was to develop a technology-based strategy to identify patients with undiagnosed hypertension in 23 primary care practices and integrate this innovation into a continuous quality improvement initiative in a large, integrated health system. METHODS: In phase 1, we reviewed electronic health records (EHRs) using algorithms designed to identify patients at risk for undiagnosed hypertension. We then invited each at-risk patient to complete an automated office blood pressure (AOBP) protocol. In phase 2, we instituted a quality improvement process that included regular physician feedback and office-based computer alerts to evaluate at-risk patients not screened in phase 1. Study patients were observed for 24 additional months to determine rates of diagnostic resolution. RESULTS: Of the 1,432 patients targeted for inclusion in the study, 475 completed the AOBP protocol during the 6 months of phase 1. Of the 1,033 at-risk patients who remained active during phase 2, 740 (72%) were classified by the end of the follow-up period: 361 had hypertension diagnosed, 290 had either white-coat hypertension, prehypertension, or elevated blood pressure diagnosed, and 89 had normal blood pressure. By the end of the follow-up period, 293 patients (28%) had not been classified and remained at risk for undiagnosed hypertension. CONCLUSIONS: Our technology-based innovation identified a large number of patients at risk for undiagnosed hypertension and successfully classified the majority, including many with hypertension. This innovation has been implemented as an ongoing quality improvement initiative in our medical group and continues to improve the accuracy of diagnosis of hypertension among primary care patients.

Houston's medical disaster response to Hurricane Katrina: part 1: the initial medical response from Trauma Service Area Q.

After Hurricane Katrina hit the Gulf Coast on August 29, 2005, thousands of ill and injured evacuees were transported to Houston, TX. Houston's regional disaster plan was quickly implemented, leading to the activation of the Regional Hospital Preparedness Council's Catastrophic Medical Operations Center and the rapid construction of a 65-examination-room medical facility within the Reliant Center. A plan for triage of arriving evacuees was quickly developed and the Astrodome/Reliant Center Complex mega-shelter was created. Herein, we discuss major elements of the regional disaster response, including regional coordination, triage and emergency medical service transfers into the region's medical centers, medical care in population shelters, and community health challenges.

Disaster medicine training in family medicine: a review of the evidence.

When disasters strike, local physicians are at the front lines of the response in their community. Curriculum guidelines have been developed to aid in preparation of family medicine residents to fulfill this role. Disaster responsiveness has recently been added to the Residency Review Committee Program Requirements in Community Medicine with little family medicine literature support. In this article, the evidence in support of disaster training in a variety of settings is reviewed. Published evidence of improved educational or patient-oriented outcomes as a result of disaster training in general, or of specific educational modalities, is weak. As disaster preparedness and disaster training continue to be implemented, the authors call for increased outcome-based research in disaster response training.

Effect of financial incentives on improvement in medical quality indicators for primary care.

PURPOSE: The efficacy of rewarding physicians financially for preventive services is unproven. The objective of this study was to evaluate the effect of a physician pay-for-performance program similar to the Medicare Physician Quality Reporting Initiative program on quality of preventive care in a network of community health centers. METHODS: A retrospective review of administrative data was done to evaluate a natural quasi-experiment in a network of publicly funded primary care clinics. Physicians in 6 of 11 clinics were given a financial incentive twice the size of the current Centers for Medicare and Medicaid Services' incentive for achieving group targets in preventive care that included cervical cancer screening, mammography, and pediatric immunization. They also received productivity incentives. Six years of performance indicators were compared between incentivized and nonincentivized clinics. We also surveyed the incentivized clinicians about their perception of the incentive program. RESULTS: Although some performance indicators improved for all measures and all clinics, there were no clinically significant differences between clinics that had incentives and those that did not. A linear trend test approached conventional significance levels for Papanicolaou smears (P = .08) but was of very modest magnitude compared with observed nonlinear variations; there was no suggestion of a linear trend for mammography or pediatric immunizations. The survey revealed that most physicians felt the incentives were not very effective in improving quality of care. CONCLUSION: We found no evidence for a clinically significant effect of financial incentives on performance of preventive care in these community health centers. Based on our findings and others, we believe there is great need for more research with strong research designs to determine the effects, both positive and negative, of financial incentives on clinical quality indicators in primary care.

Physical medicine and rehabilitation conditions in the Astrodome clinic after hurricane Katrina.

OBJECTIVE: To report the physical medicine and rehabilitation (PMR) conditions seen in the Astrodome Clinic after Hurricane Katrina. DESIGN: Retrospective chart analysis from the county hospital-sponsored disaster-relief clinic in large urban city, including a study of 239 patients with 292 PMR conditions. The total number of patients seen in the Astrodome Medical Clinic was 11,245. The Astrodome database was reviewed for PMR condition diagnostic codes. A retrospective chart analysis was conducted, including date of visit, age, gender, ethnicity, and PMR diagnosis category. Descriptive statistics were obtained for the entire sample. chi2 or t tests were used to determine gender, age, or date-of-service predominance for the most common diagnostic categories. RESULTS: Mean +/- SD age was 45.7 +/- 14.3 yrs; 56% were women, 43% were men (1% unspecified), and 76% were African American. The majority (75%) of PMR conditions presented in the first week. Most frequent were swollen feet and legs (22%), leg pain and cramps (17%), headache (12%), and neck and back pain (10%). Persons with headaches were younger than those without (41.3 vs. 46.3 yrs, P = 0.048). Persons with neck and/or back pain were older than those without those conditions (51.3 vs. 44.8 yrs, P = 0.004). Women had more headaches (20.9%) than did men (6.7%, P = 0.002). There were no Caucasians with leg pain/cramps, whereas 20.2% of African Americans had this condition (P = 0.028). CONCLUSIONS: This study documents the time of clinic presentation and most frequent types of PMR conditions of patients treated in the Astrodome Clinic after a historic hurricane. Most PMR conditions were treated by PMR personnel during the first week. Thus, future disaster planning should include PMR professionals as early responders.

Hurricane Katrina: medical response at the Houston Astrodome/Reliant Center Complex.

On September 1, 2005, with only 12 hours notice, various collaborators established a medical facility--the Katrina Clinic--at the Astrodome/Reliant Center Complex in Houston. By the time the facility closed roughly two weeks later, the Katrina Clinic medical staff had seen over 11,000 of the estimated 27,000 Hurricane Katrina evacuees who sought shelter in the Complex. Herein, we describe the scope of this medical response, citing our major challenges, successes, and recommendations for conducting similar efforts in the future.