Redesign of an electronic clinical reminder to prevent falls in older adults.

BACKGROUND: Falls are the leading cause of unintentional injury among US older adults. Guidelines recommend screening patients for fall risk, and providing exercise for patients with gait and balance problems. We redesigned an electronic clinical reminder to improve identification and management of Veterans at high risk for falls, and piloted the reminder in 3 Veterans Health Administration community-based outpatient clinics. METHODS: This project had 5 key elements: (1) case finding, (2) efficient collection of condition-specific clinical data, (3) clinical reminders to prompt appropriate care, (4) patient and family education materials, and (5) primary care provider (PCP) decision support/PCP and staff education. We reviewed clinical reminder reports, interviewed nurses and PCPs, directly observed clinic operations, and watched nurses and PCPs use the clinical reminder with a dummy patient record to determine areas in need of improvement. RESULTS: Over a 1-year period, 2943 Veterans aged 75 years and older visited the 3 clinics, with 2264 screened for fall risk by the intake nurse, yielding 472 positive screens. PCPs completed gait, balance, and strength evaluations on 231 screen-positive Veterans. Among the 162 Veterans who had a gait, balance, or strength problem on evaluation and were free of advanced dementia or poor prognosis, 39 were offered physical therapy or exercise. PCPs and nurses held divergent opinions about the clinical reminder and the project, with PCPs more negative and nurses more positive. CONCLUSIONS: A fall prevention clinical reminder can be incorporated into routine care, but low referral rates to exercise programs suggest that further quality improvement cycles are needed.

Latent growth trajectories of substance use among pregnant and parenting adolescents.

We examine changes among adolescent girls in substance use during pregnancy and the postpartum period. Three separate latent growth curve analyses assessed the impact of psychosocial, behavioral, and sociodemographic factors on resumption of or change in use of cigarettes, alcohol, and marijuana. The Vulnerable Populations Model for Research and Clinical Practice (Flaskerud & Winslow, 1998) provided the theoretical foundation for this study. This is a secondary analysis of data from a sample of 305 ethnic minority females (245 Latina, 60 African American), aged 13-18 years, who were pregnant at baseline and were participating in an HIV prevention study conducted in inner-city alternative schools in Los Angeles County. Data collected at 4 time points captured changes in substance use from pregnancy through the postpartum period. Baseline predictors included ethnicity/race, partner substance use, childhood abuse history, religiosity, acculturation, depressive symptoms, length of gestation at baseline, and previous substance use. Common predictors of greater resumption and/or greater level of use included greater history of use before pregnancy, partner substance use, childhood abuse, and a longer time since childbirth. African Americans were more likely to be smoking at baseline when they were still pregnant and to use marijuana postpartum; Latinas were more likely to use alcohol over the course of pregnancy and postpartum. Other variables exerted an influence on specific substances. For instance, religiosity impacted cigarette and alcohol use. Findings may assist prenatal care providers to identify and counsel pregnant adolescents at risk for perinatal substance use and to prevent resumption or initiation of substance use after childbirth.