A Practice Facilitation and Academic Detailing Intervention Can Improve Cancer Screening Rates in Primary Care Safety Net Clinics.

BACKGROUND: Despite the current evidence of preventive screening effectiveness, rates of breast, cervical, and colorectal cancer in the United States fall below national targets. We evaluated the efficacy and feasibility of combining practice facilitation and academic detailing quality improvement (QI) strategies to help primary care practices increase breast, cervical, and colorectal cancer screening among patients. METHODS: Practices received a 1-hour academic detailing session addressing current cancer screening guidelines and best practices, followed by 6 months of practice facilitation to implement evidence-based interventions aimed at increasing patient screening. One-way repeated measures analysis of variance compared screening rates before and after the intervention, provider surveys, and TRANSLATE model scores. Qualitative data were gathered via participant focus groups and interviews. RESULTS: Twenty-three practices enrolled in the project: 4 federally qualified health centers, 10 practices affiliated with larger health systems, 4 physician-owned practices, 4 university hospital clinics, and 1 nonprofit clinic. Average screening rates for breast cancer increased by 13% (P = .001), and rates for colorectal cancer increased by 5.6% (P = .001). Practices implemented a mix of electronic health record data cleaning workflows, provider audits and feedback, reminder systems streamlining, and patient education and outreach interventions. Practice facilitators assisted practices in tailoring interventions to practice-specific priorities and constraints and in connecting with community resources. Practices with resource constraints benefited from the engagement of all levels of staff in the quality improvement processes and from team-based adaptations to office workflows and policies. Many practices aligned quality improvement interventions in this project with patient-centered medical home and other regulatory reporting targets. CONCLUSIONS: Combining practice facilitation and academic detailing is 1 method through which primary care practices can achieve systems-level changes to better manage patient population health.

Physician-pharmacist collaborative management of asthma in primary care.

OBJECTIVE: To determine if asthma control improves in patients who receive physician-pharmacist collaborative management (PPCM) during visits to primary care medical offices. DESIGN: Prospective pre-post study of patients who received the intervention in primary care offices for 9 months. The primary outcome was the sum of asthma-related emergency department (ED) visits and hospitalizations at 9 months before, 9 months during, and 9 months after the intervention. Events were analyzed using linear mixed-effects regression. Secondary analysis was conducted for patients with uncontrolled asthma (Asthma Control Test [ACT] less than 20). Additional secondary outcomes included the ACT, the Asthma Quality of Life Questionnaire by Marks (AQLQ-M) scores, and medication changes. INTERVENTION: Pharmacists provided patients with an asthma self-management plan and education and made pharmacotherapy recommendations to physicians when appropriate. RESULTS: Of 126 patients, the number of emergency department (ED) visits and/or hospitalizations decreased 30% during the intervention (p=0.052) and then returned to preenrollment levels after the intervention was discontinued (p=0.83). Secondary analysis of patients with uncontrolled asthma at baseline (ACT less than 20), showed 37 ED visits and hospitalizations before the intervention, 21 during the intervention, and 33 after the intervention was discontinued (p=0.019). ACT and AQLQ-M scores improved during the intervention (ACT mean absolute increase of 2.11, AQLQ-M mean absolute decrease of 4.86, p<0.0001) and sustained a stable effect after discontinuation of the intervention. Inhaled corticosteroid use increased during the intervention (p=0.024). CONCLUSIONS: The PPCM care model reduced asthma-related ED visits and hospitalizations and improved asthma control and quality of life. However, the primary outcome was not statistically significant for all patients. There was a significant reduction in ED visits and hospitalizations during the intervention for patients with uncontrolled asthma at baseline. Our findings support the need for further studies to investigate asthma outcomes achievable with the PPCM model.

Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial.

PURPOSE: Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined. METHODS: In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute's Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar's test and multivariate modeling were used to evaluate the impact of the interventions. RESULTS: Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7-3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5-3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation. CONCLUSIONS: Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.

Instrumental activity of daily living limitations and supports in a clinic population of low-income Puerto Rican elderly adults with chronic diseases.

Latino older adults in the United States have disproportionately high rates of chronic and disabling medical conditions. Puerto Ricans have a higher prevalence of several chronic medical conditions and higher rates of functional disability than other Latinos. Earlier studies have documented that Puerto Rican older adults traditionally have relied mostly on family members for assistance with their functional needs, with low use of formal support services, but little is known about their functional help needs and caregiving practices. This study examined independent living and caregiving practices of community-dwelling Puerto Rican older adults in western New York using a mixed-methods approach with a sample of 49 individuals attending an inner-city primary care clinic. Standard instruments were used to obtain information on socioeconomic and health status and functional ability. Forty participants who needed help with any instrumental activities of daily living (IADLs) were probed qualitatively for how their needs were addressed. Participants averaged six chronic medical conditions, mean age was 76.2 ± 5.3, most reported annual household income of $15,000 or less and had low fluency in English, and all had healthcare insurance. For the most part, participants' children and spouses were primary caregivers, and few used formal support services. Nearly one-third reported having insufficient help. Qualitative findings elucidated how IADL needs were addressed. In this sample of indigent Puerto Rican older adults, most needed help with IADLs. Although family members most often helped, one-third had unmet or undermet needs. Linguistically and culturally congruent formal support services are still needed for Puerto Rican older adults and their family caregivers.

Pharmacologic therapy for acute pain.

The approach to patients with acute pain begins by identifying the underlying cause and a disease-specific treatment. The first-line pharmacologic agent for the symptomatic treatment of mild to moderate pain is acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). The choice between these two medications depends on the type of pain and patient risk factors for NSAID-related adverse effects (e.g., gastrointestinal, renovascular, or cardiovascular effects). Different NSAIDs have similar analgesic effects. However, cyclooxygenase-2 selective NSAIDs (e.g., celecoxib) must be used with caution in patients with cardiovascular risk factors and are more expensive than nonselective NSAIDs. If these first-line agents are not sufficient for mild to moderate pain, medications that target separate pathways simultaneously, such as an acetaminophen/opioid combination, are reasonable choices. Severe acute pain is typically treated with potent opioids. At each step, adjuvant medications directed at the underlying condition can be used. Newer medications with dual actions (e.g., tapentadol) are also an option. There is little evidence that one opioid is superior for pain control, but there are some pharmacologic differences among opioids. Because of the growing misuse and diversion of controlled substances, caution should be used when prescribing opioids, even for short-term treatment. Patients should be advised to properly dispose of unused medications.

Reimbursement and practice policies among providers of buprenorphine-naloxone treatment.

UNLABELLED: ABSTRACT Background: Physician acceptance of cash payment and low adherence to practice guidelines may contribute to buprenorphine-naloxone diversion. The purpose of this study was to investigate the clinical practice policies of physicians who provide office-based treatment for opioid dependence with buprenorphine-naloxone. METHODS: Data were obtained from 31 of 71 practices surveyed (response rate 43.7%) that provided answers to at least some of the survey questions. RESULTS: Of these practices, 28 (90.3%) accepted cash as payment and 6 (19.4%) accepted only cash for treatment services. Analysis of open-ended responses to questions about office policies revealed wide variation among practices and overall suboptimal adherence to recommended treatment guidelines. CONCLUSIONS: These results underscore the need for continuing education for physicians who prescribe buprenorphine-naloxone.

What happens to orders written for older primary care patients?

BACKGROUND AND OBJECTIVES: Data are limited on order completion errors in primary care. The objective of this study was to determine the incidence and nature of order completion errors among community-dwelling older adults. METHODS: This prospective, cross-sectional exploratory study was conducted at a suburban family medicine clinical teaching site. Patients ?70 years old who received ?one order at the study enrollment visit were eligible for inclusion. Errors in completion of orders for prescriptions, laboratory tests, imaging studies or screening procedures, and specialist referrals were assessed. Logistic regression was used to identify the independent variables associated with non-system-based errors. RESULTS: A total of 322 orders were written for 93 enrolled patients. An order error was identified in 59 (18.3%) orders written for 39 (41.9%) patients (mean 1.5, range 1--4, SD=0.85): 10 were system-based and 49 were non-system-based errors. Non-system-based errors included unfilled prescriptions (9.0%), uncompleted orders for imaging studies and screening procedures (13.0%), and uncompleted specialist referrals (17.4%). All laboratory orders were completed. In a logistic regression model, females were four times more likely to experience a non-system-based error than males (OR=4.02, 95% CI=1.43, 11.23). CONCLUSIONS: Order completion errors were common in this sample of community-dwelling older adults, with non-system-based errors for prescriptions, imaging studies or screening procedures, and specialist referrals occurring more frequently than system-based errors, particularly among females. Providers should not assume that patients will complete orders as intended; rather, longitudinal management requires regular patient follow-up and review to ensure order completion.

Effects of self-empowered teams on rates of adverse drug events in primary care.

Background. Most safety issues in primary care arise from adverse drug events. Team Resource Management intervention was developed to identify systemic safety issues to design and implement interventions to address prioritized issues. Objectives. Evaluate impact of intervention on rates of events and preventable events in a vulnerable population. Design. Cluster randomized trial. 12 practices randomly assigned to either: (1) Intervention; (2) Intervention with Practice Enhancement Assistants; (3) No intervention. The intervention took 12 months. Main Outcome Measure. Rate and severity of events and preventable events measured using a Trigger Tool chart review method for the 12-month periods before and after the start of the intervention. Results. In the ''intervention with Assistants" group there was a statistically significant decrease in the overall rate of events and in the rate of moderate/severe events. Analysis of Variance with study arm and time as the factors and moderate/severe events as the outcome showed a significant interaction between arm and time supporting the notion that the ''Intervention with Assistants" practices had a greater reduction in moderate/severe preventable events. Conclusions. The intervention had a significant effect on medication safety as estimated using a trigger tool. Further exploration of role of Assistants and trigger tool is warranted.

IT-enabled systems engineering approach to monitoring and reducing ADEs.

OBJECTIVES: To develop and pilot-test a Web-based implementation of a team resource management (TRM) intervention to improve medication safety in primary care. STUDY DESIGN: Randomized controlled trial. METHODS: Eight practices were randomized to either the Web-based TRM or usual practice (4 practices in each group). Primary outcome was adverse drug events (ADEs) in older adults, ascertained using a trigger tool chart review at two 12-month periods (before and after the intervention). The prospective TRM approach, designed to inculcate ownership and empowerment, facilitates systematic appraisal of risk and error reduction. This approach uses the highly adaptable and transferable Safety Enhancement and Monitoring Instrument that is Patient Centered. RESULTS: The rate of ADEs decreased from 25.8 to 18.3 per 100 patients per year in the intervention group. The rate was virtually unchanged in the control group (24.3 vs 24.8). In an analysis of covariance at the practice level, being in the intervention group was associated with a lower rate of ADEs. The interaction between time (preintervention vs postintervention) and group (intervention vs control) was not signifi cant (P = .104) but showed a trend toward a decrease in the intervention group compared with the control group over time. CONCLUSIONS: The Web-based TRM intervention proved feasible and demonstrated potential for effectiveness in various ambulatory settings. This pilot study was limited by small size and short follow-up period. Future studies should test the intervention on a larger scale over a longer period of time and should explore methods for overcoming common barriers to change.

Knowledge and use of ethnomedical treatments for asthma among Puerto Ricans in an urban community.

PURPOSE: Puerto Ricans have higher lifetime and current asthma prevalence than other racial and ethnic groups in the United States. A great many Hispanics use ethnomedical therapies for asthma. This study elicited participant knowledge of ethnomedical therapies, developed a typology of the therapies, and considered whether some types are used or deemed efficacious based, in part, on information source. METHODS: Eligible participants were randomly selected from the medical records of an inner-city primary care clinic serving a predominantly Hispanic community in Buffalo, New York. Thirty adult Puerto Ricans who had asthma or were care-givers of children with asthma were interviewed in person using a semistructured instrument. Qualitative data analysis followed a content-driven immersion-crystallization approach. Outcome measures were ethnomedical treatments for asthma known to participants, whether these treatments were used or perceived effective, and the participant's information source about the treatment. RESULTS: Participants identified 75 ethnomedical treatments for asthma. Behavioral strategies were significantly more likely to be used or perceived effective compared with ingested and topical remedies (P <.001). Among information sources for ingested and topical remedies, those recommended by community members were significantly less likely to be used or perceived effective (P <.001) compared with other sources. CONCLUSIONS: This sample of Puerto Ricans with a regular source of medical care was significantly more likely to use or perceive as effective behavioral strategies compared with ingested and topical remedies. Allopathic clinicians should ask Puerto Rican patients about their use of ethnomedical therapies for asthma to better understand their health beliefs and to integrate ethnomedical therapies with allopathic medicine.

Improving quality of NSAID prescribing by internal medicine trainees with an educational intervention.

BACKGROUND: Prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) for older adults is a safety concern. Education innovations in postgraduate training designed to improve patient safety should comply with the Accreditation Council for Graduate Medical Education (ACGME). PURPOSE: The objective is to evaluate a seven-component education program for internal medicine trainees designed to change prescribing practices while addressing ACGME competencies. METHODS: Pretest, posttest data collection. RESULTS: The baseline chart review found that 28.7% (79/275) patients age 70 or older were prescribed NSAIDs. Approximately 1 year later, the proportion of patients prescribed NSAIDs had declined to 16.4% (30/183; p= .002). The proportion of patients prescribed NSAIDs in conjunction with a diuretic similarly declined from 13.6% (38/278) to 7% (13/187; p= .024). CONCLUSION: A systematically applied education program targeted to a specific prescribing pattern produced significant improvement among internal medicine trainees. This model may assist training programs in reducing polypharmacy, or in other areas of trainee practice.

The epidemiologic association between opioid prescribing, non-medical use, and emergency department visits.

INTRODUCTION: Since the 1990s prescriptions for and the non-medical use of opioids have increased. This study examines associations between opioid prescribing, non-medical use, and emergency department (ED) visits. METHODS: Data were abstracted from four federally sponsored, nationally representative, annual surveys (National Hospital Ambulatory Medical Care Survey, National Ambulatory Medical Care Survey, National Survey on Drug Use and Health, and Drug Abuse Warning Network). RESULTS: For hydrocodone and oxycodone, associations between prescribing and non-medical use, and prescribing and ED visits were statistically significant (p-values < 0.04) and strongly associated (correlation coefficient range 0.73 to 0.87). Male gender, White race, and age > or = 35 were all statistically significant (p-values < 0.0001) predictors of receiving a hydrocodone or oxycodone-containing prescription. CONCLUSION: The increased number of prescriptions written for hydrocodone and oxycodone between 1995 and 2004 was associated with similar increases in non-medical use and the number of ED visits during this time period.

Assessment of safety attitudes in a skilled nursing facility.

Safety has not been well studied in the long-term care setting. This pilot study assesses staff attitudes regarding safety culture at one 250-bed skilled nursing facility. A valid and reliable Safety Attitudes Questionnaire (SAQ) was administered once to a sample of 51 employees. Nursing staff and other health care staff were generally satisfied with their jobs (42% and 67% had a positive attitude, respectively) but gave low scores to Management (22% and 13%, respectively) and Safety Climate (28% and 33%, respectively). Registered nurses, licensed practical nurses, and nurse management/supervisors received the highest ratings for quality of collaboration and communication (range: 3.6-4.1 on a 5-point Likert scale with 1 = very low, 5 = very high), whereas nurse practitioners and physician assistants received the lowest (range: 2.5-2.9). The SAQ provided insight into employees' safety attitudes and can be used to identify opportunities for improvements in safety.