Assessing patient work system factors for medication management during transition of care among older adults: an observational study.

OBJECTIVE: To develop and evaluate measures of patient work system factors in medication management that may be modifiable for improvement during the care transition from hospital to home among older adults. DESIGN, SETTINGS AND PARTICIPANTS: Measures were developed and evaluated in a multisite prospective observational study of older adults (≥65 years) discharged home from medical units of two US hospitals from August 2018 to July 2019. MAIN MEASURES: Patient work system factors for managing medications were assessed during hospital stays using six capacity indicators, four task indicators and three medication management practice indicators. Main outcomes were assessed at participants' homes approximately a week after discharge for (1) Medication discrepancies between the medications taken at home and those listed in the medical record, and (2) Patient experiences with new medication regimens. RESULTS: 274 of the 376 recruited participants completed home assessment (72.8%). Among capacity indicators, most older adults (80.6%) managed medications during transition without a caregiver, 41.2% expressed low self-efficacy in managing medications and 18.3% were not able to complete basic medication administration tasks. Among task indicators, more than half (57.7%) had more than 10 discharge medications and most (94.7%) had medication regimen changes. Having more than 10 discharge medications, more than two medication regimen changes and low self-efficacy in medication management increased the risk of feeling overwhelmed (OR 2.63, 95% CI 1.08 to 6.38, OR 3.16, 95% CI 1.29 to 7.74 and OR 2.56, 95% CI 1.25 to 5.26, respectively). Low transportation independence, not having a home caregiver, low medication administration skills and more than 10 discharge medications increased the risk of medication discrepancies (incidence rate ratio 1.39, 95% CI 1.01 to 1.91, incidence rate ratio 1.73, 95% CI 1.13 to 2.66, incidence rate ratio 1.99, 95% CI 1.37 to 2.89 and incidence rate ratio 1.91, 95% CI 1.24 to 2.93, respectively). CONCLUSIONS: Patient work system factors could be assessed before discharge with indicators for increased risk of poor patient experience and medication discrepancies during older adults' care transition from hospital to home.

Understanding Hazards for Adverse Drug Events Among Older Adults After Hospital Discharge: Insights From Frontline Care Professionals.

OBJECTIVES: Care transitions pose a high risk of adverse drug events (ADEs). We aimed to identify hazards to medication safety for older adults during care transitions using a systems approach. METHODS: Hospital-based professionals from 4 hospitals were interviewed about ADE risks after hospital discharge among older adults. Concerns were extracted from the interview transcript, and for each concern, hazard for medication-related harms was coded and grouped by its sources according to a human factors and systems engineering model that views postdischarge ADEs as the outcome of professional and patient home work systems. RESULTS: Thirty-eight professionals participated (5 hospitalists, 24 nurses, 4 clinical pharmacists, 3 pharmacy technicians, and 2 social workers). Hazards were classified into 6 groups, ranked by frequencies of hazards coded: (1) medication tasks related at home, (2) patient and caregiver related, (3) hospital work system related, (4) home resource related, (5) hospital professional-patient collaborative work related, and (6) external environment related. Medications most frequently cited when describing concerns included anticoagulants, insulins, and diuretics. Top coded hazard types were complex dosing, patient and caregiver knowledge gaps in medication management, errors in discharge medications, unaffordable cost, inadequate understanding about changes in medications, and gaps in access to care or in sharing medication information. CONCLUSIONS: From the perspective of hospital-based frontline health care professionals, hazards for medication-related harms during care transitions were multifactorial and represented those introduced by the hospital work system as well as defects unrecognized and unaddressed in the home work system.

Translating CKD Research into Primary Care Practice: a Group-Randomized Study.

BACKGROUND: Chronic kidney disease (CKD) is common in the primary care setting. Early interventions may prevent progression of renal disease and reduce risk for cardiovascular complications, yet quality gaps have been documented. Successful approaches to improve identification and management of CKD in primary care are needed. OBJECTIVE: To assess whether implementation of a primary care improvement model results in improved identification and management of CKD DESIGN: 18-month group-randomized study PARTICIPANTS: 21 primary care practices in 13 US states caring for 107,094 patients INTERVENTIONS: To promote implementation of CKD improvement strategies, intervention practices received clinical quality measure (CQM) reports at least quarterly, hosted an on-site visit and 2 webinars, and sent clinician/staff representatives to a "best practice" meeting. Control practices received CQM reports at least quarterly. MAIN MEASURES: Changes in practice adherence to a set of 11 CKD CQMs KEY RESULTS: We observed significantly greater improvements among intervention practices for annual screening for albuminuria in patients with diabetes or hypertension (absolute change 22% in the intervention group vs. - 2.6% in the control group, p < 0.0001) and annual monitoring for albuminuria in patients with CKD (absolute change 21% in the intervention group vs. - 2.0% in the control group, p < 0.0001). Avoidance of NSAIDs in patients with CKD declined in both intervention and control groups, with a significantly greater decline in the control practices (absolute change - 5.0% in the intervention group vs. - 10% in the control group, p < 0.0001). There were no other significant changes found for the other CQMs. Variable implementation of CKD improvement strategies was noted across the intervention practices. CONCLUSIONS: Implementation of a primary care improvement model designed to improve CKD identification and management resulted in significantly improved care on 3 out of 11 CQMs. Incomplete adoption of improvement strategies may have limited further improvement. Improving CKD identification and management likely requires a longer and more intensive intervention.

A systematic review of lifestyle counseling for diverse patients in primary care.

Prior research and systematic reviews have examined strategies related to weight management, less is known about lifestyle and behavioral counseling interventions optimally suited for implementation in primary care practices generally, and among racial and ethnic patient populations. Primary care practitioners may find it difficult to access and use available research findings on effective behavioral and lifestyle counseling strategies and to assess their effects on health behaviors among their patients. This systematic review compiled existing evidence from randomized trials to inform primary care providers about which lifestyle and behavioral change interventions are shown to be effective for changing patients' diet, physical activity and weight outcomes. Searches identified 444 abstracts from all sources (01/01/2004-05/15/2014). Duplicate abstracts were removed, selection criteria applied and dual abstractions conducted for 106 full text articles. As of June 12, 2015, 29 articles were retained for inclusion in the body of evidence. Randomized trials tested heterogeneous multi-component behavioral interventions for an equally wide array of outcomes in three population groups: diverse patient populations (23 studies), African American patients only (4 studies), and Hispanic/Mexican American/Latino patients only (2 studies). Significant and consistent findings among diverse populations showed that weight and physical activity related outcomes were more amenable to change via lifestyle and behavioral counseling interventions than those associated with diet modification. Evidence to support specific interventions for racial and ethnic minorities was promising, but insufficient based on the small number of studies.

"Meaningful" clinical quality measures for primary care physicians.

OBJECTIVES: To systematically solicit recommendations from Meaningful Use (MU) exemplars to inform Stage 3 MU clinical quality measure (CQM) requirements. STUDY DESIGN: The study combined an electronic health record (EHR)-based CQM performance assessment with focus groups among primary care practices with high performance (top tertile), or "exemplars." METHODS: This qualitative exploratory study was conducted in PPRNet, a national primary care practice-based research network. Focus groups among lead physicians from practices in the top tertile of performance on a CQM summary measure were held in early 2014 to learn their perspectives on questions posed by the Office of the National Coordinator related to Stage 3 MU CQMs. RESULTS: Twenty-three physicians attended the focus groups. There was consensus that CQMs should be evidence-based and focus on high-priority conditions relevant to primary care providers. Participants thought the emphasis of CQMs should largely be on outcomes and that reporting of CQMs should limit the burden on providers. Incorporating patient-generated data and accepting locally developed CQMs were viewed favorably. Participants unanimously concurred that platforms for population management were vital tools for improving health outcomes. CONCLUSIONS: Using a series of focus groups, we solicited Stage 3 MU CQM recommendations from a group of physicians who have already achieved "meaningful use" of their EHR, as demonstrated by their high performance on current MU CQMs. Adhering to the standards deemed to be important to high-performing real-world physicians could ensure that the MU Incentive Programs achieve their ultimate goal to improve outcomes.

Learning from primary care meaningful use exemplars.

BACKGROUND: Submission of clinical quality measures (CQMs) data are 1 of 3 major requirements for providers to receive meaningful use (MU) incentive payments under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act. Some argue that CQMs are the most important component of MU. Developing an evidence base for how practices can successfully use electronic health records (EHRs) to achieve improvement in CQMs is essential and may benefit from the study of exemplars who have successfully implemented EHRs and demonstrated high performance on CQMs. METHODS: Conducted in PPRNet, a national primary care practice-based research network, this study used a multimethod approach combining an EHR-based CQM performance assessment, a provider survey, and focus groups among high CQM performers. Practices whose providers had attested for stage 1 MU were eligible for the study. Performance on 21 CQMs included in the 2014 MU CQM set and a summary measure was assessed as of October 1, 2013, through an automated data extract and standard analytic procedures. A web-based provider survey, conducted in November to December 2013, assessed provider agreement, staff education, use of EHR reminders, standing orders, and EHR-based patient education related to the 21 CQMs. The survey also had more general questions about the practices' use of EHR functionality and quality improvement (QI) strategies. Statistical analyses using general linear mixed models assessed the associations between responses to the survey and CQM performance, adjusted for several practice covariates. Three focus groups, held in early 2014, provided an opportunity for clinicians to provide their perspectives on the validity of the statistical analyses and to provide context-specific examples from their practice that supported their assessment. RESULTS: Seventy-one practices completed the study, and 319 (92.1%) of their providers completed the survey. There was wide variability in performance on the 21 CQMs among the practices. Mean performance ranged from 89.8% for tobacco use screening and counseling to 12.9% for chlamydia screening. In bivariate analyses, more positive associations were found between CQM performance and staff education, use of standing orders, and EHR reminders than for provider agreement or EHR-based patient education. In multivariate analyses, EHR reminders were most frequently associated with individual CQM performance; several EHR, practice QI, and administrative variables were associated with the summary quality measure. CONCLUSIONS: Purposeful use of EHR functionality coupled with staff education in a milieu where QI is valued and supported is associated with higher performance on CQM.

Organizational attributes and screening and brief intervention in primary care.

Overconsumption of alcohol is well known to lead to numerous health and social problems. Prevalence studies of United States adults found that 20% of patients meet criteria for an alcohol use disorder. Routine screening for alcohol use is recommended in primary care settings, yet little is known about the organizational factors that are related to successful implementation of screening and brief intervention (SBI) and treatment in these settings. The purpose of this study was to evaluate organizational attributes in primary care practices that were included in a practice-based research network trial to implement alcohol SBI. The Survey of Organizational Attributes in Primary Care (SOAPC) has reliably measured four factors: communication, decision-making, stress/chaos and history of change. This 21-item instrument was administered to 178 practice members at the baseline of this trial, to evaluate for relationship of organizational attributes to the implementation of alcohol SBI and treatment. No significant relationships were found correlating alcohol screening, identification of high-risk drinkers and brief intervention, to the factors measured in the SOAPC instrument. These results highlight the challenges related to the use of organizational survey instruments in explaining or predicting variations in clinical improvement. Comprehensive mixed methods approaches may be more effective in evaluations of the implementation of SBI and treatment.

Preventive services delivery in patients with chronic illnesses: parallel opportunities rather than competing obligations.

PURPOSE: Whether patients with 1 or more chronic illnesses are more or less likely to receive recommended preventive services is unclear and an important public health and health care system issue. We addressed this issue in a large national practice-based research network (PBRN) that maintains a longitudinal database derived from electronic health records. METHODS: We conducted a cross-sectional study as of October 1, 2011, of the association between being up to date with 10 preventive services and the prevalence of 24 chronic illnesses among 667,379 active patients aged 18 years or older in 148 member practices in a national PBRN. We used generalized linear mixed models to assess for the association of being up to date with each preventive service as a function of the patient's number of chronic conditions, adjusted for patient age and encounter frequency. RESULTS: Of the patients 65.4% had at least 1 of the 24 chronic illnesses. For 9 of the 10 preventive services there were strong associations between the odds of being up to date and the presence of chronic illness, even after adjustment for visit frequency and patient age. Odds ratios increased with the number of chronic conditions for 5 of the preventive services. CONCLUSIONS: Rather than a barrier, the presence of chronic illness was positively associated with receipt of recommended preventive services in this large national PBRN. This finding supports the notion that modern primary care practice can effectively deliver preventive services to the growing number of patients with multiple chronic illnesses.

Integration and sustainability of alcohol screening, brief intervention, and pharmacotherapy in primary care settings.

OBJECTIVE: At-risk drinking and alcohol use disorders are common in primary care and may adversely affect the treatment of patients with diabetes and/or hypertension. The purpose of this article is to report the impact of dissemination of a practice-based quality improvement approach (Practice Partner Research Network-Translating Research into Practice [PPRNet-TRIP]) on alcohol screening, brief intervention for at-risk drinking and alcohol use disorders, and medications for alcohol use disorders in primary care practices. METHOD: Nineteen primary care practices from 15 states representing 26,005 patients with diabetes and/or hypertension participated in a group-randomized trial (early intervention vs. delayed intervention). The 12-month intervention consisted of practice site visits for academic detailing and participatory planning and network meetings for "best practice" dissemination. RESULTS: At the end of Phase 1, eligible patients in early-intervention practices were significantly more likely than patients in delayed-intervention practices to have been screened (odds ratio [OR] = 3.30, 95% CI [1.15, 9.50]) and more likely to have been provided a brief intervention (OR = 6.58, 95% CI [1.69, 25.7]. At the end of Phase 2, patients in delayed-intervention practices were more likely than at the end of Phase 1 to have been screened (OR = 5.18, 95% CI [4.65, 5.76]) and provided a brief intervention (OR = 1.80, 95% CI [1.31, 2.47]). Early-intervention practices maintained their screening and brief intervention performance during Phase 2. Medication for alcohol use disorders was prescribed infrequently. CONCLUSIONS: PPRNet-TRIP is effective in improving and maintaining improvement in alcohol screening and brief intervention for patients with diabetes and/or hypertension in primary care settings.

Medication Safety in Primary Care Practice: results from a PPRNet quality improvement intervention.

Reducing medication errors is a fundamental patient safety goal; however, few improvement interventions have been evaluated in primary care settings. The Medication Safety in Primary Care Practice project was designed to test the impact of a multimethod quality improvement intervention on 5 categories of preventable prescribing and monitoring errors in 20 Practice Partner Research Network (PPRNet) practices. PPRNet is a primary care practice-based research network among users of a common electronic health record (EHR). The intervention was associated with significant improvements in avoidance of potentially inappropriate therapy, potential drug-disease interactions, and monitoring of potential adverse events over 2 years. Avoidance of potentially inappropriate dosages and drug-drug interactions did not change over time. Practices implemented a variety of medication safety strategies that may be relevant to other primary care audiences, including use of EHR-based audit and feedback reports, medication reconciliation, decision-support tools, and refill protocols.

Use of an electronic health record clinical decision support tool to improve antibiotic prescribing for acute respiratory infections: the ABX-TRIP study.

BACKGROUND: Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs). OBJECTIVE: To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs. DESIGN: A two-phase, 27-month demonstration project. SETTING: Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR). PARTICIPANTS: Thirty-nine providers were included in the project. INTERVENTION: A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs. MAIN OUTCOME MEASURES: 1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis. KEY RESULTS: The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57% [95% CI, -5.35%, 8.49%] in adults and -1.89% [95% CI, -9.03%, 5.26%] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, -16.30%, [95% CI, -24.81%, -7.79%] in adults and -16.30 [95%CI, -23.29%, -9.31%] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined. CONCLUSIONS: This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.

Implementing and evaluating electronic standing orders in primary care practice: a PPRNet study.

BACKGROUND: A standing order (SO) authorizes nurses and other staff to carry out medical orders per practice-approved protocol without a clinician's examination. This study implemented electronic SOs into the daily workflow of primary care practices; identified methods and strategies; determined barriers and facilitators; and measured changes in quality indicators resulting from electronic SOs. METHODS: Within 8 practices using the Practice Partner® electronic health record (EHR), a customized health maintenance template provided SOs for screening, immunization, and diabetes measures. EHR data extracts were used to calculate the presence and use of these measures on health maintenance templates and performance over 21 months. Qualitative observation/interviews at practice site visits, network meetings, and correspondence enabled synthesis of implementation issues. RESULTS: Improvements in template presence, use, and performance were found for 14 measures across all practices. Median improvements in screening ranged 6% to 10%; immunizations, 8% to 17%, and diabetes, 0% to 18%. Two practices achieved significant improvement on 14 of the 15 measures. All practices significantly improved on at least 3 of the measures. CONCLUSIONS: A small sample of primary care practices implemented SOs for screening, immunizations and diabetes measures supported by PPRNet researchers. Technical competence and leadership to adapt EHR reminder tools helped staff adopt new roles and overcome barriers.

Adoption of a clinical decision support system to promote judicious use of antibiotics for acute respiratory infections in primary care.

PURPOSE: Overuse of antibiotics for acute respiratory infections (ARIs) in primary care is an established risk factor for worsening antimicrobial resistance. The "Reducing Inappropriate Prescribing of Antibiotics by Primary Care Clinicians" study is assessing the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs using a multimethod intervention to facilitate CDSS adoption. The purpose of this report is to describe use of the CDSS, as well as facilitators and barriers to its adoption, during the first year of the 15-month intervention. METHODS: Between January 1, 2010 and December 31, 2010, 39 providers in 9 practices in US states participated in this study. Quarterly EHR based audit and feedback, practice site visits for academic detailing, performance review and CDSS training, and "best-practice" dissemination during two meetings of study participants were used to facilitate CDSS adoption. Mixed methods were used to evaluate adoption of the CDSS. Using data extracted from the EHR, CDSS use for ARI was calculated. To determine facilitators and barriers of CDSS adoption, semi-structured group interviews were conducted with providers and staff at each practice. RESULTS: During the first year of implementation, the ABX-TRIP CDSS was used 14,086 times for ARI encounters. Overall, practice use of the CDSS during ARI encounters ranged from 39.4% to 77.2%. Median use of the CDSS for adult patients was 58.2% and 68.6% for pediatric patients. Key factors associated with CDSS adoption include the perception by providers that it assists with decision making and stimulates patient discussions, engagement of non-physician staff and an iterative CDSS development process. CONCLUSIONS: Adoption of a custom designed CDSS in the first year of implementation is promising. Successful implementation of such technology requires a focus not only on the technological solution itself, but on its integration with the entire clinical workplace.

Clinician knowledge about use of intrauterine devices in adolescents in South Carolina AHEC.

BACKGROUND AND OBJECTIVES: Intrauterine devices (IUDs) are recommended as first-line choices for both nulliparous and parous adolescents by the American College of Obstetrics and Gynecology (ACOG). This study describes use of IUDs and knowledge regarding IUD use in adolescents in South Carolina family medicine residency programs. METHODS: Faculty and residents in South Carolina Area Health Education Consortium (SC AHEC) Family Medicine Residency Programs received an anonymous survey including questions about current use of IUDs and scenarios where they were asked whether they would recommend an IUD. Proportions were compared using chi-square or Fisher's Exact Test. Modified Wald method was utilized to calculate 95% confidence intervals. RESULTS: The survey response rate was 53.8% (n=133). Most respondents (78%) prescribed IUDs and 42% inserted them, but ≥ 90% reported only prescribing or inserting ≤ 10 yearly. In scenarios where IUD recommendation was appropriate, only 27% (95% CI: 20.2-35.2) recommended IUDs for a sexually active adolescent, whereas 60% (95% CI: 51.7-68.1) recommended use for a postpartum adolescent. For similar scenarios in non-adolescents, a statistically significant higher proportion recommended IUDs, with 50% (95% CI: 42.0-58.7) recommending use in a 21-year-old nulliparous woman and 77% (95% CI: 68.8-83.1) in a breast-feeding mother. Women were more likely to recommend IUD use than men in non-adolescents, but not adolescents. There was no difference in recommendations by level of training. CONCLUSIONS: Knowledge regarding IUD use in nulliparous women and adolescents is limited in this sample of family physicians. Increasing appropriate IUD recommendations may increase IUD use and improve contraceptive counseling for adolescents.

Improving medication safety in primary care using electronic health records.

OBJECTIVES: Electronic health record (EHR) systems offer promising tools to assist clinicians and staff with improving medication safety, yet many of the decision support components within these information systems are not well used. The aim of this study was to identify the strategies planned by primary care practices participating in a 2-year medication safety quality improvement intervention within the Practice Partner Research Network. METHODS: A theoretical model for primary care practice improvement was used to foster team-based approaches to prioritizing performance, system redesign, better use of EHR tools, and patient activation. The intervention included network meetings, site visits and performance reports. Improvement plans were qualitatively evaluated from field notes and organized to present a comprehensive approach to improving medication safety in primary care using EHRs. RESULTS: A total of 32 distinct plans and 11 common strategies were developed by practices to improve adherence with prescribing and monitoring indicators. Common plans included enhancing medication reconciliation to improve the accuracy of medication lists, using Practice Partner Research Network reports to identify patients meeting criteria for preventable medication errors, and customizing and applying EHR decision support tools for medication dosing, drug-disease interactions, and monitoring. CONCLUSIONS: Medication safety might be improved by implementing specific strategies within the primary care setting. Further evaluation is needed to provide an evidence base for improvement.

The association of vitamin D deficiency and insufficiency with diabetic nephropathy: implications for health disparities.

OBJECTIVE: To evaluate the association between vitamin D deficiency and insufficiency with diabetic nephropathy across racial/ethnic groups. METHODS: Cross-sectional analysis of the 2001 to 2006 National Health and Nutrition Examination Survey. A nationally representative sample of 1216 adults (> or =20 years old) with diagnosed diabetes provides population estimates for >12.6 million individuals. Nephropathy was defined as urinary albumin-to-creatinine ratio > or =30 mg/g in a random spot urine sample. Serum 25-hydroxycalciferol vitamin D levels were characterized as <20 ng/mL vitamin D deficiency, 20 to 29 ng/mL vitamin D insufficiency, and > or =30 ng/mL normal vitamin D. RESULTS: Overall, 30.7% of adults with diabetes have nephropathy, 48.9% have vitamin D deficiency and 36.6% have vitamin D insufficiency. Minorities are more likely to have nephropathy (non-Hispanic whites, 27.8%; non-Hispanic blacks, 36.2%; Hispanics 38.5%; P = .02) and vitamin D deficiency (non-Hispanic whites, 39.5%; non-Hispanic blacks, 80.4%; Hispanic, 59.0%; P < .01). Higher proportions of individuals with nephropathy have vitamin D deficiency than individuals without nephropathy (53.2% vs 47.0%; P = .03). Logistic regressions demonstrate vitamin D deficiency and insufficiency are associated with the presence of nephropathy after adjustment for race/ethnicity, age, sex, hypertension, high cholesterol, smoking status, and use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (odds ratio, 1.85; 95% CI, 1.06-3.23 for vitamin D deficiency; and odds ratio, 1.79; 95% CI, 1.12-2.85 for vitamin D insufficiency). CONCLUSIONS: There is a high prevalence of vitamin D deficiency and insufficiency in individuals with diabetes; minorities have the highest prevalences. Thus, evaluating vitamin D levels in people with diabetes may be warranted. There is an independent association between vitamin D deficiency and vitamin D insufficiency with the presence of nephropathy, even after adjustment for race/ethnicity and other variables. Further studies of this relationship may lead to new interventions that decrease health disparities in the progression of diabetic nephropathy.

Two pharmacy interventions to improve refill persistence for chronic disease medications: a randomized, controlled trial.

BACKGROUND: Despite the proven effectiveness of many medications for chronic diseases, many patients do not refill their prescriptions in the required timeframe. OBJECTIVE: Compare the effectiveness of 3 pharmacist strategies to decrease time to refill of prescriptions for common chronic diseases. RESEARCH DESIGN/SUBJECTS: A randomized, controlled clinical trial with patients as the unit of randomization. Nine pharmacies within a medium-sized grocery store chain in South Carolina were included, representing urban, suburban, and rural areas and patients from a variety of socioeconomic backgrounds. Patients (n = 3048) overdue for refills for selected medications were randomized into 1 of 3 treatment arms: (1) pharmacist contact with the patient via telephone, (2) pharmacist contact with the patient's prescribing physician via facsimile, and (3) usual care. MEASURES: The primary outcome was the number of days from their recommended refill date until the patient filled a prescription for any medication relevant to his/her chronic disease. Prescription refill data were obtained routinely from the pharmacy district office's centralized database. Patient disposition codes were obtained by pharmacy employees. An intent-to-treat approach was used for all analyses. RESULTS: There were no significant differences by treatment arm in the study outcomes. CONCLUSIONS: Neither of the interventions is more effective than usual care at improving persistence of prescription refills for chronic diseases in overdue patients.

Improving the translation of research into primary care practice: results of a national quality improvement demonstration project.

BACKGROUND: There is widespread evidence of inadequate translation of research findings into primary care practice. Theoretically sound demonstrations of how health care organizations can overcomes these deficiencies are needed. A demonstration project was conducted from January 1, 2003, through June 30, 2006, to evaluate the impact of a multicomponent intervention and improvement models intended to enhance adherence to clinical practice guidelines across eight broad clinical areas. METHODS: The demonstration project involving 530 clinicians and staff members from 99 primary practices in 36 states entailed practice performance reports (audit and feedback), practice site visits for academic detailing and participatory planning, and network meetings for sharing 4 of "best practice" approaches. Data from electronic medical records (EMRs) of 847,073 patients were abstracted to identify 31 process and 5 outcome quality measures for prevention and treatment of cardiovascular disease and diabetes, cancer screening, adult immunization, respiratory and infectious disease, mental health and substance abuse, obesity and nutrition, safe medication prescribing in the elderly, and a summary measure, the Summary Quality Index (SQUID). RESULTS: The yearly adjusted absolute improvement in the SQUID was 2.43% (95% confidence interval [C.I.], 2.24%-2.63%). Clinically and statistically significant improvements occurred for 29 of the 36 quality measures, including all 5 outcome measures. DISCUSSION: The findings suggest that a multicomponent quality improvement intervention involving audit and feedback, academic detailing and participatory planning activities, and sharing of "best practice" approaches in practices with EMRs can have a robust impact in quality of care for Americans seen in primary care practices.

Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices.

BACKGROUND: The use of potentially inappropriate medications (PIMs) in the elderly population is common. Interventions to decrease PIM use in primary care settings are needed. OBJECTIVE: This study was designed to assess the time trends in use of always inappropriate and rarely appropriate medications in primary care patients aged >or=65 years during a quality improvement project. METHODS: A 4-year, prospective demonstration project was delivered to 99 primary care practices that use a common electronic medical record and are members of the Practice Partner Research Network. Each participating practice received quarterly performance reports on the use of always inappropriate and rarely appropriate medications in the elderly. Optional interventions included biannual on-site visits and annual network meetings for performance review, academic detailing, and quality improvement planning. General linear mixed regression models were used to analyze the change in prescribing rates over time. RESULTS: Across 42 months of project exposure, 124,802 active patients (61% women, 39% men) aged >or=65 years were included in the analyses. Among the 33 practices that participated in all 42 months of the intervention, the proportion of patients with a prescription for an always inappropriate medication decreased from 0.41% to 0.33%, and the proportion of patients with a prescription for a rarely appropriate medication decreased from 1.48% to 1.30%. Across all 99 practices, the adjusted absolute annual declines for the comprehensive categories of always inappropriate medications (00.018%, P = 0.03) and rarely appropriate medications (0.113%, P = 0.001) were statistically significant. Propoxyphene was the only individual medication that decreased significantly in use over time (baseline proportion, 0.72%; adjusted absolute annual decline, 0.072% [P = 0.001]). CONCLUSIONS: Always inappropriate and rarely appropriate medication use decreased over time in this practice-based research network study. Additional studies of robust interventions for improving medication use in the elderly are warranted.