Incorporating performance improvement methods into a needs assessment: experience with a nutrition and exercise curriculum.

BACKGROUND: Clinical guidelines recommend that physicians counsel patients on diet and exercise; however, physician counseling remains suboptimal. OBJECTIVES: To determine if incorporating performance improvement (PI) methodologies into a needs assessment for an internal medicine (IM) residency curriculum on nutrition and exercise counseling was feasible and enhanced our understanding of the curricular needs. DESIGN AND PARTICIPANTS: One hundred and fifty-eight IM residents completed a questionnaire to assess their knowledge, attitudes, and practices (KAP) about nutrition and exercise counseling for hypertensive patients. Residents' baseline nutrition and exercise counseling rates were also obtained using chart abstraction. Fishbone diagrams were created by the residents to delineate perceived barriers to diet and exercise counseling. MAIN MEASURES: The KAP questionnaire was analyzed using descriptive statistics. Chart abstraction data was plotted on run charts and average counseling rates were calculated. Pareto charts were developed from the fishbone diagrams depicting the number of times each barrier was reported. KEY RESULTS: Almost 90% of the residents reported counseling their hypertensive patients about diet and exercise more than 20% of the time on the KAP questionnaire. In contrast, chart abstraction revealed average counseling rates of 3% and 4% for nutrition and exercise, respectively. The KAP questionnaire exposed a clinical knowledge deficit, lack of familiarity with the national guidelines, and low self-efficacy. In contrast, the fishbone analysis highlighted patient apathy, patient co-morbidities, and time pressure as the major perceived barriers. CONCLUSIONS: We found that incorporating PI methods into a needs assessment for an IM residency curriculum on nutrition and exercise counseling for patients at risk of cardiovascular disease was feasible, provided additional information not obtained through other means, and provided the opportunity to pilot the use of PI techniques as an educational strategy and means of measuring outcomes. Our findings suggest that utilization of PI principles provides a useful framework for developing and implementing a medical education curriculum and measuring its effectiveness.

Smoking rates among pregnant women in Tennessee, 1990-2001.

BACKGROUND: Pregnant smokers represent a major public health challenge. The objective of this study was to determine trends in smoking during pregnancy in Tennessee, a state with one of the highest smoking burdens in the nation, and to confirm characteristics of high-risk groups to target for smoking prevention. METHODS: Population-based cohort study of pregnant women in Tennessee who delivered live births from 1990-2001. Trends in smoking were determined by maternal age, race and insurance status using vital records and Medicaid data. Characteristics of women who smoked during pregnancy were described for 2001. RESULTS: Among 900,986 pregnant women in the cohort, there were statewide decreases in smoking rates during pregnancy; however, smoking among pregnant women younger than 25 years in Medicaid increased from 1996 to 2001: among whites from 31% to 34%, and among blacks from 6% to 9% (P values for trend shifts <0.0001). Characteristics of pregnant women who smoked during pregnancy included white race, Medicaid enrollment, nonurban residence, and less than a high school education. CONCLUSIONS: Smoking rates increased significantly among pregnant women <25 years enrolled in Medicaid between 1996 and 2001. Tennessee needs smoking cessation and prevention efforts that target young, low-income women with less than a high school education.