Meeting ACGME and ABMS Quality Improvement Requirements in a Sleep Medicine Fellowship Program.

STUDY OBJECTIVES: To describe a sustainable program of teaching and implementing quality improvement (QI) in a 12-month sleep medicine fellowship. METHODS: We created a QI curriculum based on Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialty (ABMS) Part IV Maintenance of Certification (MOC) requirements for QI. Two program faculty with prior QI training volunteered to mentor fellows. Our institution's central QI office houses QI experts who teach QI across the health system. One of these experts, referred to as the "QI consultant," helped us adapt QI teaching materials to include 4 online modules and 5 group sessions. Fellows worked in teams to complete 2 data-guided QI cycles. RESULTS: The curriculum required 29 hours for fellows, 18 hours for faculty, and 55 hours for the QI consultant; now that teaching materials have been created, the QI consultant's involvement will decrease over time. Post-curriculum surveys showed that fellows' knowledge of QI concepts increased, as did their confidence performing QI activities. Fellows' QI projects objectively improved timeliness and quality of care for patients. Sleep medicine fellows and QI faculty mentors evaluated the curriculum positively. The curriculum met ACGME requirements for QI, and fellows and mentoring faculty received ABMS Part IV MOC credit upon completion of the curriculum. CONCLUSIONS: A QI curriculum can successfully be implemented into a 12-month sleep medicine fellowship to increase sleep medicine fellows' QI knowledge and confidence, meet ACGME and MOC requirements, and contribute to care of patients with sleep disorders.

Otitis media: diagnosis and treatment.

Acute otitis media is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever. Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid. Management of acute otitis media should begin with adequate analgesia. Antibiotic therapy can be deferred in children two years or older with mild symptoms. High-dose amoxicillin (80 to 90 mg per kg per day) is the antibiotic of choice for treating acute otitis media in patients who are not allergic to penicillin. Children with persistent symptoms despite 48 to 72 hours of antibiotic therapy should be reexamined, and a second-line agent, such as amoxicillin/clavulanate, should be used if appropriate. Otitis media with effusion is defined as middle ear effusion in the absence of acute symptoms. Antibiotics, decongestants, or nasal steroids do not hasten the clearance of middle ear fluid and are not recommended. Children with evidence of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist.

Strategies for implementing and sustaining therapeutic lifestyle changes as part of hypertension management in African Americans.

African Americans with high blood pressure (BP) can benefit greatly from therapeutic lifestyle changes (TLC) such as diet modification, physical activity, and weight management. However, they and their health care providers face many barriers in modifying health behaviors. A multidisciplinary panel synthesized the scientific data on TLC in African Americans for efficacy in improving BP control, barriers to behavioral change, and strategies to overcome those barriers. Therapeutic lifestyle change interventions should emphasize patient self-management, supported by providers, family, and the community. Interventions should be tailored to an individual's cultural heritage, beliefs, and behavioral norms. Simultaneously targeting multiple factors that impede BP control will maximize the likelihood of success. The panel cited limited progress with integrating the Dietary Approaches to Stop Hypertension (DASH) eating plan into the African American diet as an example of the need for more strategically developed interventions. Culturally sensitive instruments to assess impact will help guide improved provision of TLC in special populations. The challenge of improving BP control in African Americans and delivery of hypertension care requires changes at the health system and public policy levels. At the patient level, culturally sensitive interventions that apply the strategies described and optimize community involvement will advance TLC in African Americans with high BP.

Personalized targeted mailing increases mammography among long-term noncompliant medicare beneficiaries: a randomized trial.

OBJECTIVES: The study purpose was to increase mammography screening among older women by identifying female Medicare beneficiaries without a recent mammogram and assesses the cost-effectiveness of a personalized targeted mailing encouraging them to have a mammogram. METHODS: A randomized paired controlled trial included 1229 pairs of women matched on zip code, race, and urban or rural county. Postintervention mammography claims were measured from November 1997 through December 1998. The subjects were female Medicare beneficiaries age > or = 70, living in Michigan for > or = 5 years, having no significant comorbidity likely to affect screening, and no mammogram for > or = 5 years. Intervention subjects received a personally addressed letter from the Medical Director of Michigan Medicare with materials emphasizing the individual's lack of use of the Medicare mammography screening benefit, reasons for screening, and how to be screened. RESULTS: Women who received the mailing were 60% more likely to have a subsequent mammogram (OR 1.6, P <0.005), with diagnostic mammograms increasing more than screening mammograms (2.8% vs. 0.8%). The absolute increase was greatest for women age 70 to 79, 10.6% in the intervention group versus 6.5% for controls, odds ratio 1.7 (P <0.02). A statewide Medicare intervention in Michigan would cost of 108,000 US dollars to 238,000 US dollars, producing 3500 to 4300 additional mammograms at 31 US dollars to 55 US dollars per additional mammogram. CONCLUSION: The intervention increased mammography among long-term noncompliant older women, particularly increasing diagnostic mammograms. This approach can be directly implemented in other states and nationally. It may also be useful for other preventive services.

5-Year mammography rates and associated factors for older women.

BACKGROUND: Major national interventions occurred in the early and mid-1990s to increase mammography screening rates among older women. The current study examined mammography utilization by older women during this period. Relation between mammography utilization and demographic measures and health care-related factors also were examined. METHODS: A cross-sectional design examined variations in mammography during the 5 years between 1993 to 1997 in a representative sample of 10,000 female Medicare beneficiaries in Michigan age >or= 65 years in 1993. Medicare and census data were used. Separate analyses were performed for having undergone any mammogram and, for the 5680 women who had undergone a mammogram, the number of mammograms. Relations were examined between mammography utilization and 15 demographic variables (e.g., age and African-American race) and health care-related variables (e.g., inpatient admissions and number of physicians involved in care). RESULTS: In the 5 years 43% of older women had no evidence of having undergone a mammogram. Those with any mammogram averaged 2.8 mammograms. Meaningful independent predictors of both having undergone a mammogram and having more than one mammogram were more physicians involved in care, fewer inpatient admissions, and younger age. Having undergone a mammogram also was found to be associated with seeing an obstetrician/gynecologist. CONCLUSIONS: Even with screening mammography as a covered benefit and after several national informational campaigns, the current study found that in 5 years, 60% of older women either had not undergone a mammogram or had undergone only 1. Intervention efforts should emphasize screening based on functional status, not age. This message should be targeted to physicians as well as to older women without claims for recent mammograms and who are likely to be in good health.

Faculty views of reimbursement changes and clinical training: a survey of award-winning clinical teachers.

BACKGROUND: Prominent authorities believe that managed care and governmental policies are compromising the clinical education of future physicians. PURPOSE: This study sought the views of clinical teachers to quantify the extent to which managed care and governmental policies have changed clinical education. METHODS: Questionnaires were mailed to faculty that U.S. medical schools had recognized for clinical teaching excellence. Measures included reports of change in quality of clinical teaching due to payment regulations, Liaison Committee on Medical Education (LCME) and Residency Review Committee (RRC) requirements, and institutional support for teaching; change in numbers of students-trainees in clinics; need to generate more clinical revenue; and change in enjoyment of teaching. Other measures about clinical teaching included faculty attitudes, institutional rewards, and teaching different levels of students. Characteristics of the respondents also were measured. RESULTS: Faculty reported that payment regulations have affected clinical teaching negatively and that faculty need to generate more clinical revenue. Institutions tend to provide a supportive teaching environment but do not reward teaching financially. Intrinsic incentives for teaching increase as the level of student increases. Faculty reports did not differ by medical specialty or other faculty characteristics. Differences among medical schools occurred on all measures. CONCLUSIONS: Clinical education is being negatively affected, but not yet critically. Continued clinical financial pressures on faculty will affect all levels of clinical education, particularly for medical students. Differences among institutions indicate that individual schools can moderate or exacerbate the impact of external forces on the teaching faculty. Medical schools should monitor increasing pressures on faculty and ensure that goals, processes, support, and rewards for clinical teaching are proportionate to those for clinical care.