Feasibility and impact of implementing a private care system's diabetes quality improvement intervention in the safety net: a cluster-randomized trial.

BACKGROUND: Integrated health care delivery systems devote considerable resources to developing quality improvement (QI) interventions. Clinics serving vulnerable populations rarely have the resources for such development but might benefit greatly from implementing approaches shown to be effective in other settings. Little trial-based research has assessed the feasibility and impact of such cross-setting translation and implementation in community health centers (CHCs). We hypothesized that it would be feasible to implement successful QI interventions from integrated care settings in CHCs and would positively impact the CHCs. METHODS: We adapted Kaiser Permanente's successful intervention, which targets guideline-based cardioprotective prescribing for patients with diabetes mellitus (DM), through an iterative, stakeholder-driven process. We then conducted a cluster-randomized pragmatic trial in 11 CHCs in a staggered process with six "early" CHCs implementing the intervention one year before five "'late" CHCs. We measured monthly rates of patients with DM currently prescribed angiotensin converting enzyme (ACE)-inhibitors/statins, if clinically indicated. Through segmented regression analysis, we evaluated the intervention's effects in June 2011-May 2013. Participants included ~6500 adult CHC patients with DM who were indicated for statins/ACE-inhibitors per national guidelines. RESULTS: Implementation of the intervention in the CHCs was feasible, with setting-specific adaptations. One year post-implementation, in the early clinics, there were estimated relative increases in guideline-concordant prescribing of 37.6 % (95 % confidence interval (CI); 29.0-46.2 %) among patients indicated for both ACE-inhibitors and statins and 38.7 % (95 % CI; 23.2-54.2 %) among patients indicated for statins. No such increases were seen in the late (control) clinics in that period. CONCLUSIONS: To our knowledge, this was the first clinical trial testing the translation and implementation of a successful QI initiative from a private, integrated care setting into CHCs. This proved feasible and had significant impact but required considerable adaptation and implementation support. These results suggest the feasibility of adapting diverse strategies developed in integrated care settings for implementation in under-resourced clinics, with important implications for efficiently improving care quality in such settings. CLINICALTRIALS.gov: NCT02299791 .

Periocular versus general anesthesia for ocular enucleation.

PURPOSE: To compare the morbidity of general anesthesia versus periocular anesthesia with monitored intravenous sedation for enucleation of the eye. METHODS: A retrospective study of 39 patients who underwent enucleation. RESULTS: For anesthesia during enucleation, 21 patients received periocular anesthesia with monitored intravenous sedation and 18 patients received general anesthesia. During recovery on the day of surgery, 94% (17/18) of general anesthesia patients required postoperative analgesics, compared with 52% (11/21) of periocular anesthesia with monitored intravenous sedation patients (p = 0.0046). Postoperative antiemetic treatment of nausea and vomiting on the day of surgery was required in 56% (10/18) of general anesthesia patients, but only 5% (1/21) of periocular anesthesia with monitored intravenous sedation patients (p = 0.0008). On contacting these patients, no patients receiving periocular anesthesia with monitored intravenous sedation had a negative memory of the surgery and all but 2 indicated they would elect the same type of anesthesia in retrospect. Periocular anesthesia with monitored intravenous sedation related costs were substantially less than those associated with general anesthesia. CONCLUSIONS: Periocular anesthesia with monitored intravenous sedation for enucleation reduces early postoperative morbidity and is more cost effective than general anesthesia. It is an anesthetic alternative that should be considered for patients undergoing enucleation of the eye.