Assessing efficacy of a web-based smoking cessation tool - QuitAdvisorMD: Protocol for a practice-based, clustered, randomized control trial.

Background: Smoking remains the leading cause of preventable death, yet physicians inconsistently provide best-practices cessation advice to smokers. Point-of-care digital health tools can prompt and assist physicians to provide improved smoking cessation counseling. QuitAdvisorMD is a comprehensive web-based counseling and management digital health tool designed to guide smoking cessation counseling at the point-of-care. The tool enables clinicians to assess patient readiness to change and then deliver stage-appropriate interventions, while also incorporating Motivational Interviewing techniques. We present the research protocol to assess the efficacy of QuitAdvisorMD to change frequency and quality of smoking cessation counseling and its effect on patient quit rates. Methods: A practice-based, clustered, randomized controlled trial will be used to evaluate QuitAdvisorMD. Cluster design will be used where patients are clustered within primary care practices and practices will be randomized to either the intervention (QuitAdvisorMD) or control group. The primary outcome is frequency and quality of clinician initiated smoking cessation counseling. Secondary outcomes include, 1) changes in physician knowledge, skills and perceived self-efficacy in providing appropriate stage-based smoking cessation counseling and 2) patient quit attempts. Analyses will be conducted to determine pre- and post-test individual clinician outcomes and between intervention and control group practices for patient outcomes. Conclusion: Results from this study will provide important insights regarding the ability of an integrated, web-based counseling and management tool (QuitAdvisorMD) to impact both the quality and efficacy of smoking cessation counseling in primary care settings.

Mindfulness for healthcare providers fosters professional quality of life and mindful attention among emergency medical technicians.

OBJECTIVE: Emergency medical service (EMS) providers are systematically subjected to intense stimuli in their work that may result in distress and emotional suffering. While it is known that mindfulness-based stress reduction (MBSR) helps to foster well-being in healthcare workers, the effectiveness of MBSR among EMS providers is less understood. We explored the impact of a modified version of MBSR for healthcare workers called Mindfulness for Healthcare Providers (MHP) on reducing distress and promoting wellbeing in EMS providers. METHODS: A one-arm pilot study was conducted. We implemented eight two-and-a-half hour sessions of Mindfulness for Healthcare Providers with an additional day-long retreat at the end. Feasibility, perceived stress, professional quality of life, and trait mindfulness were assessed prior to and after the intervention. The professional quality of life scale includes measures of compassion satisfaction, burnout, and secondary trauma. RESULTS: Fifteen veteran EMS providers enrolled in the course; four participants dropped out. Prior to initiation of the study, no significant differences were revealed between those who did not participate (n = 48) and those who did (n = 11). After the intervention EMS providers endorsed statistically significant increases in compassion satisfaction, trait mindfulness, and decreases in burnout compared to the beginning of the program. These changes were sustained at six months post-completion. No significant changes over time were found for secondary trauma or perceived stress. CONCLUSIONS: To our knowledge, this study is the first to employ Mindfulness for Healthcare Providers in an EMS population and to demonstrate a positive impact on self-reported compassion, trait mindfulness, and burnout in this population. Additional research regarding mindfulness training within EMS populations should be conducted to further understand the relationship between mindfulness and perceived stress over time.

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.

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.

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.

Association of vitamin A and zinc status with altered intestinal permeability: analyses of cohort data from northeastern Brazil.

To examine the association of intestinal barrier function with vitamin A deficiency and whether supplementation of micronutrients improves intestinal function and/or linear growth, height-for-age z-score (HAZ), concentrations of serum retinol and zinc, and intestinal permeability were determined in a cross-sectional sample of 75 children in northeastern Brazil. Effects of vitamin A and supplementation of zinc on intestinal permeability and growth were also determined comparing results before and after treatment in 20 children and age-matched controls. Lactulose:mannitol (L/M) permeability ratios inversely correlated with serum retinol concentrations (r = -0.55, p < 0.0005). Increased L/M permeability ratios with reduced concentrations of serum retinol were predominantly attributable to lower absorption of mannitol (r = 0.28, p = 0.02). L/M permeability ratios (p = 0.001) and HAZ scores (p = 0.007) improved with supplementation. It is concluded that impaired intestinal barrier function and linear growth shortfalls improve following supplementation of vitamin A and zinc in this setting.

The Natural History of Smoking Cessation Among Medical Patients in a Smoke-Free Hospital.

Our purpose was to determine the frequency and predictors of quitting smoking among patients hospitalized on the medical services of a smoke-free hospital. All smokers admitted to the medical services of a single university teaching hospital were eligible and 129 patients were enrolled. A questionnaire detailing demographic information, stages of change, smoking behavior while hospitalized, and intention to remain abstinent on discharge was administered. The primary discharge diagnosis was obtained from the medical record. Patients were followed at 3- and 6-month intervals for continuous abstinence, with expired carbon monoxide confirmation at 6 months. A total of 7% of smoking patients receiving usual medical care were continuously abstinent at 6 months. Of those who relapsed, 45% did so by the time of discharge, 18% within the first week, 20% between 1 week and 3 months, and 10% between 3 and 6 months after discharge. All patients who were abstinent at 6 months had been admitted for coronary artery disease (CAD). Nine of the 38 patients with CAD were abstinent, versus none of 93 with another diagnosis (p <.001). Smokers admitted to a smoke-free hospital had a high rate of relapse, especially early after discharge. Patients admitted for CAD had a greater likelihood of successfully quitting. Designing hospital-based smoking cessation interventions with a focus on early relapse prevention may help improve smoking cessation rates.

Improving smoking cessation counseling using a point-of-care health intervention tool (IT): from the Virginia Practice Support and Research Network (VaPSRN).

PURPOSE: Primary care practices are an ideal setting for reducing national smoking rates because >70% of smokers visit their physician annually, yet smoking cessation counseling is inconsistently delivered to patients. We designed and created a novel software program for handheld computers and hypothesized that it would improve clinicians' ability to provide patient-tailored smoking cessation counseling at the point of care. METHODS: A handheld computer software program was created based on smoking cessation guidelines and an adaptation of widely accepted behavioral change theories. The tool was evaluated using a validated before/after survey to measure physician smoking cessation counseling behaviors, knowledge, and comfort/self-efficacy. RESULTS: Participants included 17 physicians (mean age, 41 years; 71% male; 5 resident physicians) from a practice-based research network. After 4 months of use in direct patient care, physicians were more likely to advise patients to stop smoking (P = .049) and reported an increase in use of the "5 As" (P = .03). Improved self-efficacy in counseling patients regarding smoking cessation (P = .006) was seen, as was increased comfort in providing follow-up to patients (P = .04). CONCLUSIONS: Use of a handheld computer software tool improved smoking cessation counseling among physicians and shows promise for translating evidence about smoking cessation counseling into practice and educational settings.

A mindfulness course decreases burnout and improves well-being among healthcare providers.

OBJECTIVE: Healthcare providers are under increasing stress and work-related burnout has become common. Mindfulness-based interventions have a potential role in decreasing stress and burnout. The purpose of this study was to determine if a continuing education course based on mindfulness-based stress reduction could decrease burnout and improve mental well-being among healthcare providers, from different professions. DESIGN: This was a pre-post observational study conducted in a university medical center. A total of 93 healthcare providers, including physicians from multiple specialties, nurses, psychologists, and social workers who practiced in both university and community settings, participated. The intervention was a continuing education course based on mindfulness-based stress reduction that met 2.5 hours a week for 8 weeks plus a 7-hour retreat. The classes included training in four types of formal mindfulness practices, including the body scan, mindful movement, walking meditation and sitting meditation, as well as discussion focusing on the application of mindfulness at work. The course was offered 11 times over 6 years. The main outcome measures were work-related burnout as measured by the Maslach Burnout Inventory and self-perceived mental and physical well-being as measured by the SF-12v2. RESULTS: Maslach Burnout Inventory scores improved significantly from before to after the course for both physicians and other healthcare providers for the Emotional Exhaustion (p < 0.03), Depersonalization (p < 0.04), and Personal Accomplishment (p < 0.001) scales. Mental well-being measured by the SF12v2 also improved significantly (p < 0.001). There were no significant changes in the SF12v2 physical health scores. CONCLUSION: A continuing education course based on mindfulness-based stress reduction was associated with significant improvements in burnout scores and mental well-being for a broad range of healthcare providers.

Evaluation of a screening and counseling tool for alcohol misuse: a Virginia Practice Support and Research Network (VaPSRN) trial.

BACKGROUND: Surveys reveal limited screening and counseling for alcohol misuse by primary care physicians despite evidence-based recommendations. We developed and evaluated an alcohol screening and misuse counseling tool designed to assist clinicians at the point of care (POC). METHODS: This was a mixed methods, prospective cohort study conducted with licensed clinicians in a practice-based research network. A software tool was designed to guide clinicians through evidence-based alcohol misuse assessment and interventions. RESULTS: Participants (N = 12) used the tool an average of 3 sessions and 71% were satisfied with the tool. Participants increased their ability to differentiate between patients who are "at risk" drinkers versus those with alcohol use disorders including dependence/abuse (21%; t = 2.4; P = .04). Thematic analysis of interviews suggests that barriers to overall use included perceptions of alcohol use; clinical need to intervene; time; and issues with use of technology, most often at the POC. However, the tool added confidence and a valuable framework for interventions and was valued as an educational tool. Users felt that increased training and practice could increase comfort and impact future POC use. Increased POC usability also may be achieved through simplification of the tool and additional flexibility in options for POC use. CONCLUSIONS: A computer-assisted counseling tool for alcohol misuse and abuse can be implemented in primary care settings and shows promise for improving physician screening and interventions for alcohol misuse. To enhance utility in daily clinical practice we recommend design enhancements and strategies to enhance usage as described in this research.

Development and evaluation of an instrument for assessing brief behavioral change interventions.

OBJECTIVE: To develop an observational coding instrument for evaluating the fidelity and quality of brief behavioral change interventions based on the behavioral theories of the 5 A's, Stages of Change and Motivational Interviewing. METHODS: Content and face validity were assessed prior to an intervention where psychometric properties were evaluated with a prospective cohort of 116 medical students. Properties assessed included the inter-rater reliability of the instrument, internal consistency of the full scale and sub-scales and descriptive statistics of the instrument. Construct validity was assessed based on student's scores. RESULTS: Inter-rater reliability for the instrument was 0.82 (intraclass correlation). Internal consistency for the full scale was 0.70 (KR20). Internal consistencies for the sub-scales were as follows: MI intervention component (KR20=.7); stage-appropriate MI-based intervention (KR20=.55); MI spirit (KR20=.5); appropriate assessment (KR20=.45) and appropriate assisting (KR20=.56). CONCLUSIONS: The instrument demonstrated good inter-rater reliability and moderate overall internal consistency when used to assess performing brief behavioral change interventions by medical students. PRACTICE IMPLICATIONS: This practical instrument can be used with minimal training and demonstrates promising psychometric properties when evaluated with medical students counseling standardized patients. Further testing is required to evaluate its usefulness in clinical settings.

A PDA-based counseling tool for improving medical student smoking cessation counseling.

BACKGROUND AND OBJECTIVES: There is little research on training medical students in smoking cessation counseling (SCC). This study aimed to determine if a personal digital assistant (PDA)-based SCC tool can improve medical student SCC. METHODS: We conducted a randomized, controlled trial with third-year medical students. SCC behaviors, comfort, and knowledge were assessed using a validated survey before students attended a workshop on SCC. Student groups were then randomized to receive a paper-based reminder tool or the reminder plus a PDA-based SCC tool. The validated survey was repeated upon clerkship completion, and a videotaped standardized patient interview was assessed by trained reviewers using a 24-item SCC checklist. Focus groups assessed satisfaction with the PDA tool, usability, and barriers to use. RESULTS: SCC behaviors, knowledge, and comfort increased among all participants, with no statistical differences between groups. The PDA tool group performed 62% of key SCC activities during the videotaped interview, while the control group performed 69%. Students reported discomfort using the PDA with patients, lack of time, and lack of training as barriers to use of the tool. CONCLUSIONS: We demonstrated improvement of SCC skills by third-year medical students using a workshop combined with a supplemental reference tool. However, a PDA-based tool did not increase key SCC behaviors compared with a paper-based reminder. For a PDA intervention to be effective in this setting, the tool must be simplified and additional training provided.

SUPPORTING PHYSICIANS' PRACTICE-BASED LEARNING AND IMPROVEMENT (PBLI) AND QUALITY IMPROVEMENT THROUGH EXPLORATION OF POPULATION-BASED MEDICAL DATA.

Participating in self-assessment activities may stimulate improvement in practice behaviors. However, it is unclear how best to support the development of self-assessment skills, particularly in the health care domain. Exploration of population-based data is one method to enable health care providers to identify deficiencies in overall practice behavior that can motivate quality improvement initiatives. At the University of Virginia, we are developing a decision support tool to integrate and present population-based patient data to health care providers related to both clinical outcomes and non-clinical measures (e.g., demographic information). By enabling users to separate their direct impact on clinical outcomes from other factors out of their control, we may enhance the self-assessment process.

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.

Patient safety in the ambulatory setting. A clinician-based approach.

BACKGROUND: Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis. OBJECTIVES: To determine the feasibility and effectiveness of clinician-based near miss/adverse event voluntary reporting coupled with systems analysis and redesign as a model for continuous quality improvement in the ambulatory setting. DESIGN: We report the initial 1-year experience of voluntary reporting by clinicians in the ambulatory setting, coupled with root cause analysis and system redesign by a patient safety committee made up of clinicians from the practice. SETTING: Internal medicine practice site of a large teaching hospital with 25,000 visits per year. MEASUREMENTS AND MAIN RESULTS: There were 100 reports in the 1-year period, increased from 5 in the previous year. Faculty physicians reported 44% of the events versus 22% by residents, 31% by nurses, and 3% by managers. Eighty-three percent were near misses and 17% were adverse events. Errors involved medication (47%), lab or x-rays (22%), office administration (21%), and communication (10%) processes. Seventy-two interventions were recommended with 75% implemented during the study period. CONCLUSION: This model of clinician-based voluntary reporting, systems analysis, and redesign was effective in increasing error reporting, particularly among physicians, and in promoting system changes to improve care and prevent errors. This process can be a powerful tool for incorporating error reporting and analysis into the culture of medicine.