The impact of an interprofessional care transitions clinic on readmission rates and costs.

The objective of this study was to assess the effectiveness of the Interprofessional Care Transitions Clinic (ICTC) in reducing preventable readmissions and their associated costs among Medicare/Medicaid patients. A prospective cohort study was conducted among adults who were discharged from the University of Maryland Prince George's Hospital Center to assess the comparative effectiveness of a clinic-based intervention in terms of readmission events, potentially avoidable utilization, length of stay, and hospital charges. Outcomes were evaluated at 1 month, 3 months, and 6 months post-discharge. There were statistically significant differences in the following outcomes (follow-up period): proportion of readmissions (3 months), potentially avoidable utilization (1 month), and mean medical charges for ICTC patients compared to non-ICTC patients (1 month). This program was aimed at testing the impact of having an interprofessional team focused on providing holistic patient-centered care.

The World Health Organization Fracture Risk Assessment Tool (FRAX) underestimates incident and recurrent fractures in consecutive patients with fragility fractures.

CONTEXT: The World Health Organization Fracture Risk Assessment tool (FRAX) was developed to identify patients at risk of sustaining a fragility fracture (FF). OBJECTIVE: The objective of the study was to evaluate estimated FRAX probabilities of FF at the time of a FF and to compare them with the observed incidence of recurrent FF. METHODS: A prospective cohort included men and women older than 50 years at the time of a FF. FRAX scores without bone mineral density [FRAX-body mass index (BMI)] were calculated prior to and after the inclusion FF. Recurrent FFs were recorded over a 4-year follow-up. Determinants associated with recurrent FF were determined by univariate and multivariate analyses. RESULTS: FRAX-BMI scores were available in 1399 of the 1409 recruited patients. A high-risk FRAX-BMI score was present in only 42.7% patients before and 56.4% after the incident FF. Most FF patients at low or moderate risk before their initial FF were men, younger than 65 years, or without previous FF. Over a median follow-up of 3 years, recurrent FF occurred in 108 patients (2.69 per 100 patient-years). The overall sensitivity of post-FF FRAX to predict a recurrent FF was 71.3% and was specifically lower in patients younger than 65 years (13%) and without previous FF (63%) at inclusion. CONCLUSIONS: The FRAX-BMI scores were below the Canadian threshold for treatment in more than half the patients at the time of a FF and in close to a third of patients with recurrent FF. FRAX-BMI severely underestimates the FF risk in patients younger than 65 years old and after a single FF.

A review of drug therapy for neonatal hypertension.

Neonatal hypertension is becoming a more common diagnosis because of higher survival rates in premature infants and the need for intravascular access and invasive blood pressure (BP) monitoring. Defining hypertension in the neonatal population has been challenging, and understanding what constitutes a normal BP is still evolving.Five general classes of antihypertensives exist for the treatment of hypertension in neonates. Few studies are available to guide clinicians in the treatment of hypertension in neonates, and limited data exist regarding outcomes of hypertension in the neonatal period.

Oral clonidine in the management of acquired opioid dependency.

Clonidine is a nonnarcotic analgesic historically used as a nasal decongestant and more recently established as an antihypertensive agent in adults. Because of its sedative properties with few adverse effects, clonidine has also been reported to be an effective pharmacologic agent for the treatment of neonatal abstinence syndrome (NAS). The use of oral clonidine as a primary or secondary agent in the treatment of NAS has been found to reduce hospitalization and duration of treatment in this population.

Levetiracetam.

The incidence of neonatal seizures varies according to gestational age, weight, and cause. Seizures occur in an estimated 1.0-3.5 per 1,000 term infants1 with an increased incidence of 10-130/1,000 in preterm infants.2 Most neonatal seizures have a specific cause.3 Hypoxic-ischemic encephalopathy has been identified as the most common etiology associated with neonatal seizures, accounting for 50-60 percent of the cases.4 Table 1 outlines common causes of neonatal seizures. Early recognition of seizures and appropriate treatment is vital in preventing multiorgan dysfunction and permanent brain damage.

Vasopressin for the treatment of neonatal hypotension.

Vasopressin (pitressin), also known as arginine vasopressin (AVP), is an antidiuretic hormone formed in the hypothalamus and secreted from the posterior pituitary gland. Various forms of exogenous vasopressin exist and have been used in neonates to treat conditions such as diabetes insipidus. Vasopressin has also been studied on a limited basis for use in the treatment of catecholamine-resistant hypotension in vasodilatory shock. Hypotension is a significant problem resulting in increased morbidity in preterm, septic, and postsurgical neonates. This article will discuss the role of vasopressin and its use as a therapeutic agent in the treatment of hypotension in the neonate.

Priming primary care physicians to treat osteoporosis after a fragility fracture: an integrated multidisciplinary approach.

OBJECTIVE: To evaluate 2 incremental levels of intervention designed to increase initiation of osteoporosis treatment by primary care physicians (PCP) following fragility fractures (FF). METHODS: Women and men over age 50 years were screened for incident FF in fracture clinics, and eligible outpatients were randomly assigned to standard care (SC) or to either minimal (MIN) or intensive (INT) interventions. The MIN and INT interventions were intended to educate and motivate both patients and PCP, but differed in their frequency of contact and information content. Delivery of osteoporosis medication was confirmed with pharmacists. Treatment rates were analyzed using an intention-to-treat approach. RESULTS: At inclusion, 74.3% of 881 outpatients with FF were untreated. Followup at 12 months was completed in 92.3% of patients. Up to 90% of patients treated at inclusion remained treated at 12 months. Among patients who initially were untreated, 18.8% in the SC group, 40.4% in the MIN, and 53.2% in the INT groups were treated at 12 months. Change in treatment rates (adjusted for age and initial treatment) increased significantly after both MIN and INT. Only the INT intervention significantly increased treatment rates in patients with previous fractures. Negative predictors of change in treatment status included non-major FF, age younger than 65 years, and male sex. CONCLUSION: Both interventions significantly increased initiation of osteoporosis treatment. Our multidisciplinary intervention builds on existing first-line structures and uses minimal specialized resources. Iterative and systematic interventions in the context of clinical care may modify the approach of PCP to osteoporosis management after FF and narrow the care gap in the long term.

Failure to rescue as a process measure to evaluate fetal safety during labor.

PURPOSE: To evaluate a perinatal team's clinical responses to the key components of the failure to rescue process. METHODS: This retrospective descriptive study involved a review of medical records and their accompanying fetal monitoring strips for 53 women who had a cesarean birth at term for a nonreassuring fetal heart rate pattern. The instrument was the Fetal Safety Failure to Rescue Process Tool based on the Agency for Healthcare Research and Quality's Failure to Rescue Patient Safety Indicator adapted for perinatal care processes. This tool measured four process measures: careful surveillance, timely identification of complications, appropriate interventions, and activating a team response. A mean total score was computed to determine quality of care based on all four of the process measures. RESULTS: The perinatal team's mean total score was 6.6 (SD = 1.0, range 3-8); the highest possible score was 8. The lowest score was found in the team's response with appropriate interventions (lateral positioning, intravenous fluid bolus, discontinuation of oxytocin, oxygen administration, amnioinfusion, administration of Terbutaline) based on fetal heart rate pattern. Interrater reliability of the tool was 90%. CLINICAL IMPLICATIONS: This study provided information that may be useful in evaluating processes of care to ensure quality care for mothers and babies during labor. The findings formed the basis for implementing unit-specific educational programs, including (a) certification, continuing education, and documented competence in electronic fetal monitoring education to promote consistency in language and understanding of abnormal fetal heart rate patterns; (b) review of appropriate documentation of nonreassuring fetal heart rate patterns; (c) review and revision, if necessary, of established institutional standards and guidelines for appropriate interventions for nonreassuring fetal heart rate patterns; (d) changes in standardized forms to include times for notification of team members and improved communication, and (e) mechanisms for identifying system failures.

Recognizing osteoporosis and its consequences in Quebec (ROCQ): background, rationale, and methods of an anti-fracture patient health-management programme.

Recognizing Osteoporosis and its Consequences in Quebec (ROCQ) is an ongoing patient health-management programme aimed at evaluating the diagnostic and treatment care gaps for osteoporosis following a fragility fracture, and subsequently initiating and measuring interventions to decrease these gaps in women 50 years of age and over. Hospitals servicing approximately half of the population of the Province of Quebec (Canada) are participating in the ROCQ programme. Women with fragility and traumatic fractures are approached during their visit to a cast or outpatient clinic and are subsequently contacted by telephone 0 to 16 weeks after their fracture (phase 1). During the first phone contact, they are invited to answer a questionnaire aimed at identifying the specific circumstances of their fracture and asked to participate in an observational study that could last up to 18 months. Based on this initial questionnaire, patients are classified as having either experienced a fragility or traumatic fracture. During the first phone contact, there is no reference about the possible association between the fracture and osteoporosis and no investigation or intervention is proposed. Six to eight months after the fracture event (phase 2), women are again contacted by phone to complete a questionnaire that evaluates the diagnostic and treatment rates for osteoporosis. At this phase of the programme, women with fragility fractures are randomized to one of the three following intervention groups: 1) Educational Video Group, 2) Documentation Group and 3) Control Group. Participants are contacted 12 to 14 months after the intervention (phase 3) to evaluate the efficacy of the interventions on the diagnosis and treatment rates of osteoporosis. All participants with fragility or traumatic fractures who consent will be followed for 20 years using data from the Québec Ministry of Health database to measure the association between the index fracture and future fracture risk.

Impact of a general practitioner educational intervention on osteoarthritis treatment in an elderly population.

PURPOSE: We examined whether a continuing medical education intervention increased general practitioners' ability to select the proper pharmacological treatment for patients with osteoarthritis. SUBJECTS AND METHODS: Eight towns in Quebec, Canada were randomly allocated to one of four intervention options, workshop and decision tree, workshop, decision tree, or no intervention. All general practitioners practicing in each town were eligible to participate. We evaluated all dispensed prescriptions for either a cyclooxygenase (COX)-2 inhibitor, nonselective nonsteroidal anti-inflammatory drug or acetaminophen written by eligible general practitioners between May 2000 and June 2001 to elderly patients suffering from osteoarthritis. We used a multi-level Bayesian hierarchical model to assess the impact of the interventions on prescription adequacy. RESULTS: We analyzed 5318 dispensed prescriptions written by 249 general practitioners in the five-month preintervention period and 4610 dispensed prescriptions written by the same physicians in the five-month postintervention period. A score of zero or one was given to every prescription, with one indicating prescription adequacy according to guidelines provided during the interventions. Bayesian hierarchical models showed some improvement in scores in the post- versus preintervention periods in all four groups. The probability of an improvement in the towns allocated the workshop and decision tree over the control was 94%, compared with 74% in the workshop group and 55% in the decision tree group. CONCLUSION: An interactive approach offered by peers and complemented by easy to use guidelines may enhance the general practitioner's ability to manage osteoarthritis patients.

An integrated approach to improving appropriate use of anti-inflammatory medication in the treatment of osteoarthritis in Québec (Canada): the CURATA model.

CURATA is a multifaceted continuing medical education (CME) intervention, developed with input from 12 healthcare organizations to address the gap between current and recommended osteoarthritis (OA) treatment of general practitioners in Québec, Canada. Focusing on appropriate prescription of non-steroidal anti-inflammatory drugs, including cyclooxygenase-2 selective inhibitors (coxibs), the intervention comprised small-group, case-based workshops modelled after the Script Concordance test, and a decision tool reflecting current evidence-based clinical practice guidelines. A self-reported questionnaire measured knowledge of recommended OA treatment on an eight-point scale. Participants (n = 381) showed a mean 10.1% improvement in questionnaire score immediately following the workshop (15.2% improvement relative to mean pre-workshop score). Knowledge was maintained for three months post-workshop.

CURATA: A patient health management program for the treatment of osteoarthritis in Québec: an integrated approach to improving the appropriate utilization of anti-inflammatory/analgesic medications.

OBJECTIVES: To identify gaps in current osteoarthritis (OA) care in Quebec, Canada, and to implement and evaluate interventions to promote appropriate use of evidence-based medicine. STUDY DESIGN: Pretest and posttest; analysis of the Quebec health insurance database. METHODS: CURATA is a patient health management program utilizing an evidence-based approach for OA treatment. Evaluation of the current level of care revealed major gaps in physicians' knowledge of (1) risk factors for gastrointestinal (GI) toxicity associated with nonsteroidal anti-inflammatory drugs (NSAIDs); (2) NSAID-induced toxicity associated with long-term administration and contraindications for NSAID use in patients with hypertension, cardiovascular disease, or renal insufficiency; (3) choice of cytoprotection; and (4) use of nonpharmacologic treatments for OA. The CURATA intervention consisted of educational workshops, with and without presentation of a decision tree regarding appropriate use of pharmacologic and nonpharmacologic OA treatments. Participating physicians were asked to complete an 8-item questionnaire before and after the workshop, as well as 3 and 6 months later, to test their immediate and remote knowledge of treatment choices. The prescribing patterns of GPs also were evaluated through analysis of the Quebec health insurance database. RESULTS: The participating physicians were better immediate and remote risk assessors of GI bleeding and made more appropriate treatment choices (15.2% improvement relative to mean preworkshop score). CONCLUSION: These evidence-based interventions were successful not only in improving the physicians' knowledge regarding the diagnosis and management of OA, but also--more importantly--in changing their behavior to make more appropriate therapy choices for their patients.

Integrating clinical practice guidelines into daily practice: impact of an interactive workshop on drafting of a written action plan for asthma patients.

INTRODUCTION: Written action plans (WAPs) are instructions that enable asthmatics to manage their condition appropriately and are recommended by current asthma clinical practice guidelines (CPGs). However, general practitioners (GPs) rarely draft WAPs for their patients. An interactive, case-based workshop for asthma, combined with an objective structured clinical examination (OSCE), was developed to increase GPs' knowledge and use of WAPs in Québec. METHODS: The study compared 24 GPs receiving an OSCE preworkshop and 12 months post-workshop (group 1) with 16 GPs receiving an OSCE preworkshop and at 6 and 12 months post-workshop (group 2). Participants received no feedback on their OSCE performance. During the workshop, which presented a preformatted tool to aid drafting of the WAPs, all 40 GPs worked individually and in small groups to answer questions on a hypothetical clinical case and then discussed the responses with a facilitator and an asthma specialist. RESULTS: Only group 2 GPs showed a significant improvement in knowledge of WAPs 12 months post-workshop (p = .01). The likelihood of prescribing WAPs to patients increased in group 2 to a degree approaching statistical significance (p = .070), and there was a borderline nonsignificant trend for prescribing practice to improve more among group 2 GPs than among group 1 GPs (p = .052). There was also a nonsignificant trend for 6-month OSCE to increase attendance at the 12-month OSCE. DISCUSSION: An interactive workshop employing a preformatted WAP tool and a reinforcing OSCE at 6 months yielded improved knowledge of WAPs at 1 year. Although originally developed as a form of evaluation, the OSCE appears to have formative value even when correction is not provided and may increase the effectiveness of continuing medical education interventions to enhance CPG implementation.