RESUMO
BACKGROUND: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. OBJECTIVES: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. METHODS: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. RESULTS: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). CONCLUSION: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.
Assuntos
Doenças Cardiovasculares/prevenção & controle , Doenças Hematológicas/prevenção & controle , Pneumopatias/prevenção & controle , American Heart Association , Doenças Cardiovasculares/diagnóstico , Doenças Hematológicas/diagnóstico , Humanos , Pneumopatias/diagnóstico , National Heart, Lung, and Blood Institute (U.S.) , Estados UnidosRESUMO
Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.
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Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Idoso , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Pressão Sanguínea , Bloqueadores dos Canais de Cálcio/uso terapêutico , Medicina Baseada em Evidências , Humanos , Hipertensão/complicações , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Valores de ReferênciaRESUMO
BACKGROUND: Lean principles have been used at Denver Health Medical Center since 2005 to streamline nonclinical processes. Despite allocation of significant resources, particularly the expense of low molecular weight heparin (LMWH), to prophylaxis of venous thromboembolism (VTE), the incidence of postoperative VTE was significantly worse than national benchmarks. VTE risk factors were not consistently assessed, and the prescribing of prophylaxis varied widely. Lean was employed to standardize and implement risk assessment and evidence-based VTE prophylaxis for the institution. METHODS: In a rapid improvement event, a multidisciplinary group formulated an evidence-based risk assessment tool and clinical practice guideline for VTE prophylaxis, with plans for hospitalwide implementation and monitoring. RESULTS: The effects were immediate and improved steadily with feedback to clinicians. Within six months, compliance with the standard approached 100%. One year after implementation, the use of LMWH decreased more than 60% below baseline, and the use of sequential compression devices decreased by nearly 30%. With increased use of unfractionated heparin, the cost savings on VTE prophylaxis exceeded $15,000 per month, for a total of $425,000 since implementation. Moreover, the incidence of VTE decreased markedly during the same period. By reducing VTE rates, a total cost savings of $6.2 million was estimated for the past 28 months. CONCLUSIONS: Applying Lean to the clinical management of VTE prophylaxis improved compliance with standards and saved the hospital a significant amount of money. This was achieved without compromising clinical outcomes. This experience could be replicated at other institutions.
Assuntos
Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/economia , Anticoagulantes/normas , Centers for Medicare and Medicaid Services, U.S./economia , Centers for Medicare and Medicaid Services, U.S./normas , Colorado , Análise Custo-Benefício , Heparina/economia , Heparina/normas , Humanos , Dispositivos de Compressão Pneumática Intermitente , Estudos de Casos Organizacionais , Inovação Organizacional , Avaliação de Processos e Resultados em Cuidados de Saúde , Recursos Humanos em Hospital/educação , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Melhoria de Qualidade/economia , Melhoria de Qualidade/normas , Reembolso de Incentivo/normas , Medição de Risco/economia , Medição de Risco/métodos , Medição de Risco/normas , Desenvolvimento de Pessoal/métodos , Estados Unidos , Tromboembolia Venosa/economia , Tromboembolia Venosa/etiologiaRESUMO
BACKGROUND: Most studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback. METHODS: 5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews. RESULTS: Many providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources. CONCLUSIONS: Patient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00827710.
Assuntos
Diabetes Mellitus/terapia , Sistema de Registros , Adulto , Assistência Ambulatorial/normas , Atenção à Saúde , Diabetes Mellitus/enfermagem , Humanos , Ambulatório Hospitalar , Educação de Pacientes como Assunto , Sistemas Automatizados de Assistência Junto ao Leito , Autocuidado , Gestão da Qualidade TotalRESUMO
INTRODUCTION: Little has been published on the impact of telephone visits on diabetes outcome performance. RESEARCH DESIGN AND METHODS: An attending and resident physician prioritized telephone visits based on glycemic, blood pressure, and lipid performance. The resident and attending panel was compared with all other diabetic patients at the clinic for baseline and end-intervention performance. RESULTS: The intervention patients had an absolute percentage of increase versus control patients of 14.9 (p<0.01), 13.9 (p<0.01), and 8.3 (p=0.01) for HbA1c <9%, low-density lipoprotein <100 mg/dL, and blood pressure <130/80 mm Hg, respectively. CONCLUSIONS: This pilot study suggests that provider-driven telephone visits may be a means for healthcare systems to improve chronic disease outcomes as they transition to new paradigms of chronic care delivery. LIMITATIONS: This study was neither randomized nor blinded, was susceptible to an interventionist effect, and did not analyze for differences in baseline medication use.
Assuntos
Diabetes Mellitus/terapia , Consulta Remota/tendências , Telemedicina , Colorado , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Telefone , Resultado do TratamentoRESUMO
BACKGROUND: Little is known about the decline of kidney function in patients with normal kidney function at baseline. Our objectives were to (i) identify predictors of incident chronic kidney disease (CKD) and (ii) to estimate rate of decline in kidney function. METHODS: The study used a retrospective cohort of adult patients in a hypertension registry in an inner-city health care delivery system in Denver, Colorado. The primary outcome was development of incident CKD, and the secondary outcome was rate of change of estimated glomerular filtration rate (eGFR) over time. RESULTS: After a mean follow-up of 45 months, 429 (4.1%) of 10 420 patients with hypertension developed CKD. In multivariate models, factors that independently predicted incident CKD were baseline age [odds ratio (OR) 1.13 per 10 years, 95% confidence interval (CI), 1.03-1.24], baseline eGFR (OR 0.69 per 10 units, 95% CI 0.65-0.73), diabetes (OR 3.66, 95% CI 2.97-4.51) and vascular disease (OR 1.67, 95% CI 1.32-2.10). We found no independent association between age, gender or race/ethnicity and eGFR slope. In patients who did not have diabetes or vascular disease, eGFR declined at 1.5 mL/min/1.73 m(2) per year. Diabetes at baseline was associated with an additional decline of 1.38 mL/min/1.73 m(2). CONCLUSIONS: Diabetes was the strongest predictor of both incident CKD as well as eGFR slope. Rates of incident CKD or in decline of kidney function did not differ by race or ethnicity in this cohort.
Assuntos
Hipertensão/complicações , Nefropatias/epidemiologia , Nefropatias/fisiopatologia , Rim/fisiopatologia , Adulto , Idoso , Doença Crônica , Estudos de Coortes , Colorado/epidemiologia , Complicações do Diabetes/complicações , Feminino , Taxa de Filtração Glomerular/fisiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Doenças Vasculares/complicaçõesRESUMO
BACKGROUND: We conducted an Internet-based randomized trial comparing four graphical displays of the benefits of antibiotics for people with sore throat who must decide whether to go to the doctor to seek treatment. Our objective was to determine which display resulted in choices most consistent with participants' values. METHODS AND FINDINGS: This was the first of a series of televised trials undertaken in cooperation with the Norwegian Broadcasting Company. We recruited adult volunteers in Norway through a nationally televised weekly health program. Participants went to our Web site and rated the relative importance of the consequences of treatment using visual analogue scales (VAS). They viewed the graphical display (or no information) to which they were randomized and were asked to decide whether to go to the doctor for an antibiotic prescription. We compared four presentations: face icons (happy/sad) or a bar graph showing the proportion of people with symptoms on day three with and without treatment, a bar graph of the average duration of symptoms, and a bar graph of proportion with symptoms on both days three and seven. Before completing the study, all participants were shown all the displays and detailed patient information about the treatment of sore throat and were asked to decide again. We calculated a relative importance score (RIS) by subtracting the VAS scores for the undesirable consequences of antibiotics from the VAS score for the benefit of symptom relief. We used logistic regression to determine the association between participants' RIS and their choice. 1,760 participants completed the study. There were statistically significant differences in the likelihood of choosing to go to the doctor in relation to different values (RIS). Of the four presentations, the bar graph of duration of symptoms resulted in decisions that were most consistent with the more fully informed second decision. Most participants also preferred this presentation (38%) and found it easiest to understand (37%). Participants shown the other three presentations were more likely to decide to go to the doctor based on their first decision than everyone based on the second decision. Participants preferred the graph using faces the least (14.4%). CONCLUSIONS: For decisions about going to the doctor to get antibiotics for sore throat, treatment effects presented by a bar graph showing the duration of symptoms helped people make decisions more consistent with their values than treatment effects presented as graphical displays of proportions of people with sore throat following treatment. CLINICAL TRIALS REGISTRATION: ISRCTN58507086.
Assuntos
Antibacterianos/uso terapêutico , Tomada de Decisões , Faringite/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Adulto JovemRESUMO
OBJECTIVE: To systematically review the evidence supporting treatment of osteopenia and osteoporosis in patients with anorexia nervosa (AN). DATA SOURCES: We identified controlled clinical studies of interventions for low bone mass in AN via searches of MEDLINE; the Cochrane Library; EMBASE; PsycINFO; and cumulative index to nursing and allied health literature. Outcomes of interest were changes in bone mineral density and fracture incidence. RESULTS: Six randomized controlled trials (RCTs) and two cohort trials examined five classes of medical therapy on bone mineral density outcomes. One RCT of bisphosphonates showed no benefit and a second flawed RCT showed some benefit; one RCT showed a benefit of insulin-like growth factor-I; none of the five trials evaluating estrogen therapy showed benefit. DISCUSSION: Although patients with AN are often losing bone mass when they should be optimizing bone growth, there is no good evidence to guide medicinal interventions. Therefore, early detection and weight restoration are of utmost importance whereas ongoing trials define effective therapies.
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Anorexia Nervosa/fisiopatologia , Conservadores da Densidade Óssea/uso terapêutico , Densidade Óssea/efeitos dos fármacos , Doenças Ósseas Metabólicas/tratamento farmacológico , Osteoporose/tratamento farmacológico , Densidade Óssea/fisiologia , Doenças Ósseas Metabólicas/etiologia , Cálcio/uso terapêutico , Difosfonatos/uso terapêutico , Estrogênios/uso terapêutico , Medicina Baseada em Evidências , Exercício Físico/fisiologia , Fraturas Ósseas/prevenção & controle , Terapia de Reposição Hormonal , Humanos , Fator de Crescimento Insulin-Like I/uso terapêutico , Osteoporose/etiologia , Resultado do Tratamento , Aumento de Peso/fisiologiaRESUMO
BACKGROUND: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. OBJECTIVES: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. METHODS: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. RESULTS: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). CONCLUSION: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.
Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Adulto , Humanos , Guias de Prática Clínica como Assunto , Estados Unidos/epidemiologiaRESUMO
PURPOSE: We investigated the adequacy of treatment of hyperlipidemia in patients with type 2 diabetes, and assessed the temporal trends in adherence to published guidelines. METHODS: We performed a post hoc analysis of 501 patients enrolled in the Appropriate Blood Pressure Control in Diabetes trial. All patients had fasting lipid profiles at baseline and during the 5 years (1993 to 1998) of the trial. Achieving the National Cholesterol Education Panel's goals for hyperlipidemia management was the primary outcome. RESULTS: The percentage of patients with a low-density lipoprotein (LDL) cholesterol level less than 130 mg/dL was 53% (n = 266) at baseline and 54% (n = 270) at the end of 5 years (P = 0.75). Almost 14% (n = 69) of these patients continued to have an LDL cholesterol level greater than 160 mg/dL at the completion of the study. Only 19% (n = 25) of the 133 patients with known coronary artery disease had an LDL cholesterol level less than 100 mg/dL at baseline, and only 16% (n = 21) achieved this level at the completion of the study (P = 0.37). CONCLUSION: Although prevention of cardiovascular disease in patients with diabetes is a public health priority, our results suggest that hyperlipidemia is being treated suboptimally.
Assuntos
Diabetes Mellitus Tipo 2/complicações , Fidelidade a Diretrizes , Hiperlipidemias/tratamento farmacológico , Guias de Prática Clínica como Assunto , LDL-Colesterol/sangue , Doença da Artéria Coronariana/etiologia , Feminino , Humanos , Hiperlipidemias/sangue , Hiperlipidemias/complicações , Hipolipemiantes/uso terapêutico , Masculino , Pessoa de Meia-Idade , Análise MultivariadaRESUMO
BACKGROUND: Antibiotic resistance is increasing in Escherichia coli, the most common cause of urinary tract infections, but its epidemiology has not been well described. We evaluated the epidemiology of trimethoprim-sulfamethoxazole-resistant E. coli in a large, public health care system in Denver, Colorado. METHODS: Outpatients with E. coli urinary tract infections during the first 6 months of 1998 were evaluated retrospectively. A prospective study was then performed to confirm the rate of trimethoprim-sulfamethoxazole resistance. We used several strain-typing methods (pulsed-field gel electrophoresis, ribotyping, serotyping) to evaluate the molecular epidemiology of the resistance. RESULTS: The rate of trimethoprim-sulfamethoxazole resistance was similar in the retrospective (24% [161/681]) and prospective (23% [30/130]) phases of the study (P = 0.89). Almost all trimethoprim-sulfamethoxazole-resistant strains (98%) were resistant to at least one other antibiotic. Risk factors for infection with a resistant strain included age < or =3 years, Hispanic ethnicity, recent travel outside the United States, and a prior urinary tract infection. However, rates of resistance were >15% among nearly all of the subgroups. Most strains had high-level resistance (>1000 microg/mL) to trimethoprim-sulfamethoxazole. Of the 23 resistant isolates evaluated, 10 (43%) belonged to the clone A group. There was no correlation between conventional epidemiologic characteristics and the molecular mechanism of resistance or strain type. CONCLUSION: Resistance to trimethoprim-sulfamethoxazole among E. coli isolates among patients in a Denver public health care system is common, with high rates of resistance even among patients without risk factors.
Assuntos
Anti-Infecciosos Urinários/uso terapêutico , Infecções por Escherichia coli/tratamento farmacológico , Escherichia coli/efeitos dos fármacos , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Infecções Urinárias/microbiologia , Adolescente , Adulto , Criança , Pré-Escolar , Colorado/epidemiologia , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/microbiologia , Farmacorresistência Bacteriana , Escherichia coli/genética , Infecções por Escherichia coli/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Epidemiologia Molecular , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/epidemiologiaRESUMO
BACKGROUND: Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown. OBJECTIVE: To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing. DESIGN AND SETTING: Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs. METHODS: Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities. RESULTS: We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]). CONCLUSIONS: Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.
Assuntos
Antibacterianos/uso terapêutico , Infecção Hospitalar/tratamento farmacológico , Testes de Sensibilidade Microbiana , Melhoria de Qualidade , Instituições de Cuidados Especializados de Enfermagem , Idoso , Idoso de 80 Anos ou mais , Estudos Controlados Antes e Depois , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Estudos Transversais , Farmacorresistência Bacteriana , Feminino , Humanos , Masculino , Maryland/epidemiologiaRESUMO
BACKGROUND: Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. METHODS: Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period. RESULTS: In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P<.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P<.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P<.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group. CONCLUSIONS: This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.
Assuntos
Antibacterianos/uso terapêutico , Procedimentos Clínicos , Uso de Medicamentos/tendências , Prescrição Inadequada/prevenção & controle , Infecções Respiratórias/tratamento farmacológico , Assistência Ambulatorial , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Guias de Prática Clínica como Assunto , Padrões de Prática MédicaRESUMO
Rapid response activation (RRA), triggered chiefly by surpassing threshold vital sign abnormalities (TVSAs), is designed to intervene at the earliest point in a patient's deteriorating course. The authors aimed to quantify the incidence of TVSA among patients hospitalized on acute care units in a hospital that uses rapid response. During the course of 6 months, the authors compared adverse events (mortality, unexpected intensive care unit [ICU] transfers, and cardiopulmonary arrest) and TVSA among patients who triggered an RRA, patients with TVSAs and no RRA, and all other patients. At least 1 TVSA was recorded in 31.9% of stays and 12.2% of patient-days. RRA patients were more likely (22.5%) than other TVSA patients (7.9%) and other patients (1.8%) to have an adverse event (P < .01). Incidence varied by vital sign. During the investigation, only 2.5% of TVSA opportunities triggered an RRA. As systems engage electronic workflows, automatically triggering RRAs based solely on TVSAs could place a tremendous burden on systems.
Assuntos
Equipe de Respostas Rápidas de Hospitais , Hospitalização/estatística & dados numéricos , Sinais Vitais , Adulto , Alarmes Clínicos , Emergências , Feminino , Parada Cardíaca/terapia , Mortalidade Hospitalar , Equipe de Respostas Rápidas de Hospitais/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
Acute care hospitals struggle to manage complex patients who no longer require acute care services but who present medical and psychosocial challenges that make safe discharge to a lower level of care difficult. These challenges can be particularly acute at safety-net hospitals that cater predominantly to the poor and uninsured. For a person with a serious illness, such as a spinal cord injury, lack of insurance for long-term care services may add many weeks of medically unnecessary hospital days and result in higher costs. We describe safety-net system Denver Health's efforts to facilitate appropriate nonhospital care for these complex patients through the formation of a Complex Discharge Subcommittee. Successful solutions include accelerating legal guardianship approval to facilitate patient acceptance by skilled nursing facilities, as well as providing specialized equipment such as bariatric beds to nursing facilities to enable them to accommodate these patients. However, further policy interventions, such as updated reimbursement policies, are warranted.
Assuntos
Comitês Consultivos/organização & administração , Hospitais Urbanos , Tempo de Internação/tendências , Alta do Paciente/normas , Adulto , Colorado , Continuidade da Assistência ao Paciente/organização & administração , Humanos , Pessoas sem Cobertura de Seguro de Saúde , Competência Mental/psicologia , Transtornos Mentais/psicologia , Estudos de Casos Organizacionais , Alta do Paciente/economia , Alta do Paciente/legislação & jurisprudência , Transferência de Pacientes , Índice de Gravidade de Doença , Viagem , Procedimentos Desnecessários/economiaRESUMO
BACKGROUND: There is a need for randomized, prospective trials of case management interventions with resource utilization analyses. OBJECTIVES: To determine whether algorithm-driven telephone care by nurses improves lipid control in patients with diabetes. DESIGN: Prospective, randomized, controlled trial. PARTICIPANTS: Adults with diabetes at a federally funded community health center were randomly assigned to intervention (n = 381) or usual-care (n = 381) groups. INTERVENTIONS: Nurses independently initiated and titrated lipid therapy and promoted behavioral change through motivational interviewing and self-management techniques. Other parameters of diabetes care were addressed based on time constraints. MAIN MEASURES: The primary outcome was the proportion of patients with a low-density lipoprotein (LDL) less than 100 mg/dL. Secondary outcomes included the number of hospital admissions, total hospital charges per patient, and the proportion of patients meeting other lipid, glycemic, and blood pressure guidelines. KEY RESULTS: The percent of patients with an LDL < 100 mg/dL increased from 52.0% to 58.5% in the intervention group and decreased from 55.6% to 46.7% in the control group (P < .01). Average cost per patient to the healthcare system was less for the intervention group ($6600 vs $9033, P = .03). Intervention patients trended toward fewer hospital admissions (P = .06). The intervention did not affect glycemic and blood pressure outcomes. CONCLUSIONS: Nurses can improve lipid control in patients with diabetes in a primarily indigent population through telephone care using moderately complex algorithms, but a more targeted approach is warranted. Telephone-based outreach may decrease resource utilization, but more study is needed.
Assuntos
Administração de Caso/organização & administração , Diabetes Mellitus/sangue , Lipoproteínas LDL/sangue , Cuidados de Enfermagem/métodos , Admissão do Paciente/estatística & dados numéricos , Telemedicina/métodos , Adulto , Administração de Caso/economia , Administração de Caso/normas , Colorado , Análise Custo-Benefício , Diabetes Mellitus/economia , Registros Eletrônicos de Saúde/estatística & dados numéricos , Humanos , Pessoas sem Cobertura de Seguro de Saúde , Motivação , Admissão do Paciente/economia , Estudos Prospectivos , Autocuidado/métodos , Telemedicina/economiaRESUMO
OBJECTIVES: To assess the feasibility of engaging adults with diabetes in self management behaviors between clinic visits by using cell phone text messaging to provide blood sugar measurement prompts and appointment reminders. STUDY DESIGN: Quasi-experimental pilot among adult diabetic patients with cell phones who receive regular care at a federally qualified community health center in Denver, Colorado, which serves a population that is predominantly either uninsured (41%) or on Medicaid or Medicare (56%). METHODS: Patients (N = 47) received text message prompts over a 3-month period. Blood sugar readings were requested 3 times per week (Monday, Wednesday, and Friday). Reminders were sent 7, 3, and 1 day(s) before each scheduled appointment. Acknowledgments were returned for all patient-sent messages. Focus groups were conducted in English and Spanish with selected patients (n = 8). RESULTS: Patients of all ages were active participants. Correctly formatted responses were received for 67.3% of 1585 prompts. More than three-fourths (79%) of the cohort responded to more than 50% of their prompts. The appointment analysis was underpowered to detect significant changes in attendance. Participants reported increased social support, feelings that the program "made them accountable," and increased awareness of health information. Two-thirds (66%) of patients provided glucose readings when prompted during the study, compared with 12% at 2 preceding clinic visits. CONCLUSIONS: For certain patients, cell phone-based text messaging may enhance chronic disease management support and patient-provider communications beyond the clinic setting.
Assuntos
Diabetes Mellitus/terapia , Gerenciamento Clínico , Autocuidado/métodos , Envio de Mensagens de Texto/estatística & dados numéricos , Adulto , Idoso , Automonitorização da Glicemia , Colorado , Feminino , Grupos Focais , Hispânico ou Latino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Projetos Piloto , Pobreza , Sistemas de Alerta/estatística & dados numéricos , Autocuidado/estatística & dados numéricosRESUMO
BACKGROUND: Over-use of antibiotics for acute respiratory infections (ARIs) increases antimicrobial resistance, treatment costs, and side effects. Patient desire for antibiotics contributes to over-use. OBJECTIVE: To explore whether a point-of-care interactive computerized education module increases patient knowledge and decreases desire for antibiotics. METHODS: Bilingual (English/Spanish) interactive kiosks were available in 8 emergency departments as part of a multidimensional intervention to reduce antibiotic prescribing for ARIs. The symptom-tailored module included assessment of symptoms, knowledge about ARIs (3 items), and desire for antibiotics on a 10-point visual analog scale. Multivariable analysis assessed predictors of change in desire for antibiotics. RESULTS: Of 686 adults with ARI symptoms, 63% initially thought antibiotics might help. The proportion of patients with low (1-3 on the scale) desire for antibiotics increased from 22% pre-module to 49% post-module (p<.001). Self-report of "learning something new" was associated with decreased desire for antibiotics, after adjusting for baseline characteristics (p=.001). CONCLUSION: An interactive educational kiosk improved knowledge about antibiotics and ARIs. Learning correlated with changes in personal desire for antibiotics. PRACTICE IMPLICATIONS: By reducing desire for antibiotics, point-of-care interactive educational computer technology may help decrease inappropriate use for antibiotics for ARIs.
Assuntos
Antibacterianos/uso terapêutico , Instrução por Computador , Conhecimentos, Atitudes e Prática em Saúde , Educação de Pacientes como Assunto/métodos , Infecções Respiratórias/tratamento farmacológico , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise por Conglomerados , Feminino , Humanos , Prescrição Inadequada , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Interface Usuário-Computador , Adulto JovemRESUMO
BACKGROUND: We conducted an Internet-based randomized trial comparing three valence framing presentations of the benefits of antihypertensive medication in preventing cardiovascular disease (CVD) for people with newly diagnosed hypertension to determine which framing presentation resulted in choices most consistent with participants' values. METHODS AND FINDINGS: In this second in a series of televised trials in cooperation with the Norwegian Broadcasting Company, adult volunteers rated the relative importance of the consequences of taking antihypertensive medication using visual analogue scales (VAS). Participants viewed information (or no information) to which they were randomized and decided whether or not to take medication. We compared positive framing over 10 years (the number escaping CVD per 1000); negative framing over 10 years (the number that will have CVD) and negative framing per year over 10 years of the effects of antihypertensive medication on the 10-year risk for CVD for a 40 year-old man with newly diagnosed hypertension without other risk factors. Finally, all participants were shown all presentations and detailed patient information about hypertension and were asked to decide again. We calculated a relative importance score (RIS) by subtracting the VAS-scores for the undesirable consequences of antihypertensive medication from the VAS-score for the benefit of CVD risk reduction. We used logistic regression to determine the association between participants' RIS and their choice. 1,528 participants completed the study. The statistically significant differences between the groups in the likelihood of choosing to take antihypertensive medication in relation to different values (RIS) increased as the RIS increased. Positively framed information lead to decisions most consistent with those made by everyone for the second, more fully informed decision. There was a statistically significant decrease in deciding to take antihypertensives on the second decision, both within groups and overall. CONCLUSIONS: For decisions about taking antihypertensive medication for people with a relatively low baseline risk of CVD (70 per 1000 over 10 years), both positive and negative framing resulted in significantly more people deciding to take medication compared to what participants decided after being shown all three of the presentations. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Register ISRCTN 33771631.