Can we alter physician behavior by educational methods? Lessons learned from studies of the management and follow-up of hypertension

Impact of educational intervention on hypertension management by primary care physician: A randomized control trial

Objective

The current study aimed to observe hypertension educational intervention's effect on general physicians (GPs) to improve blood pressure control and patient outcomes indirectly.

Methods

This randomized control trial includes 42 GPs divided into 2 groups. GPs in group 1 receive face-to-face education with structured educational material on hypertension management strategies by a senior cardiologist. GPs in group 2 receive the print version of education material. The data was collected from six major cities in Pakistan. GPs with at least three years of experience in the broad primary care disciplines, with ages above 18 years, were included in the study.

Results

A total of 42 physicians (21 from each group) completed questionnaires, while out of 420 hypertension patients, 105 newly diagnosed and already diagnosed patients enrolled under physicians of both groups. The educational material did just as well at informing clinicians as the face-to-face group intervention did and both the interventions had a significant effect on knowledge and BP control.

Conclusion

After the 3-month follow-up, both interventions, including face-to-face and educational approaches, demonstrated significant effectiveness in improving knowledge and blood pressure control.

Innovation

The study shows that hypertension educational intervention's effect on general physicians indirectly improves blood pressure control and patient outcomes. And emphasize for developing a hypertension educational program targeted at general physicians.

Quality of care in patients with hypertension: a retrospective cohort study of primary care routine data in Germany

BACKGROUND

Hypertension is a leading cause of morbidity and mortality if not properly managed. Primary care has a major impact on these outcomes if its strengths, such as continuity of care, are deployed wisely. The analysis aimed to evaluate the quality of care for newly diagnosed hypertension in routine primary care data.

METHODS

In the retrospective cohort study, routine data (from 2016 to 2022) from eight primary care practices in Germany were exported in anonymized form directly from the electronic health record (EHR) systems and processed for this analysis. The analysis focused on five established quality indicators for the care of patients who have been recently diagnosed with hypertension.

RESULTS

A total of 30,691 patients were treated in the participating practices, 2,507 of whom have recently been diagnosed with hypertension. Prior to the pandemic outbreak, 19% of hypertensive patients had blood pressure above 140/90 mmHg and 68% received drug therapy (n = 1,372). After the pandemic outbreak, the proportion of patients with measured blood pressure increased from 63 to 87%, while the other four indicators remained relatively stable. Up to 80% of the total variation of the quality indicators could be explained by individual practices.

CONCLUSION

For the majority of patients, diagnostic procedures are not used to the extent recommended by guidelines. The analysis showed that quality indicators for outpatient care could be mapped onto the basis of routine data. The results could easily be reported to the practices in order to optimize the quality of care.

The Kinetics of an Antibiotic Stewardship Intervention: A Quasi-Experimental Study

Introduction

Little is known about the kinetics and different phases of a successful antibiotic stewardship program (ASP) intervention.

Methods

We analyzed the trends of quarterly antibiotic use measured in defined daily dose (DDD)/100 days hospitalization using the Joinpoint Regression Program and interrupted time series analysis to objectively identify shifts in the trends of antibiotic use. We correlated these changes in trends with the introduction of a hospital-wide ASP intervention.

Results

The ASP intervention reduced the overall antibiotic use by 33%, from a prior steady state of 76.5 DDD/100 days hospitalization to a post-intervention steady state of 51.2 DDD/100 days hospitalization (p < 0.001). We identified four distinct phases in the trends: prior steady state (A), early intervention (B), accelerated phase (C), and post steady state (D). From A to B a change of slope (−1.46) [SE 0.37, 95% CI −2.23, −0.69 (p = 0.002)]; B to C, a further decrease of slope (−4.70) [SE 0.64, 95% CI −6.03, −3.37 (p = 0.001)]; between periods C and D, straightening out of the slope (+ 6.84) [SE 0.55, 95% CI 5.70, 7.98 (p < 0.001)] to a new post-intervention steady state. It took 1.5 years after completion of the intervention to reach the new steady state.

Conclusions

We demonstrate that ASP interventions require time to achieve the maximal effect. Successful interventions require physicians to adapt new prescribing behaviors and gain confidence in the change; this adaptation can be a prolonged process and might even take years after the introduction of the ASP. These factors should be considered when planning and implementing ASP interventions.

Knowledge Translation in Athletic Training: Considerations for Bridging the Knowledge-to-Practice Gap

As the athletic training profession continues to embrace evidence-based practice, athletic trainers should not only critically appraise the best available evidence, but also effectively translate it into clinical practice to optimize patient outcomes. While previous research has investigated the effectiveness of educational interventions on increasing knowledge of critical appraisal of evidence, little attention has been given to strategies for both researchers and clinicians to effectively translate evidence into clinical practice. The use of knowledge translation strategies has potential to bridge the knowledge-to-practice gap, which could lead to reduced health costs, improved patient outcomes, and enhanced quality of care. The purpose of this paper is to 1) highlight current challenges prohibiting successful translation of evidence into practice, 2) discuss knowledge translation and describe conceptual frameworks behind effectively translating evidence into practice, and 3) identify considerations for athletic trainers as they continue to provide high quality patient care in an evidence-based manner.

Effects of an Electronic Software "Prompt" With Health Care Professional Training on Cardiovascular and Renal Complications in a Multiethnic Population With Type 2 Diabetes and Microalbuminuria (the GP-Prompt Study): Results of a Pragmatic Cluster-Randomized Trial

OBJECTIVE

Tight, targeted control of modifiable cardiovascular risk factors can reduce cardiovascular complications and mortality in individuals with type 2 diabetes mellitus (T2DM) and microalbuminuria. The effects of using an electronic "prompt" with a treatment algorithm to support a treat-to-target approach has not been tested in primary care.

RESEARCH DESIGN AND METHODS

A multicenter, cluster-randomized trial was conducted among primary care practices across Leicestershire, U.K. The primary outcome was the proportion of individuals achieving systolic and diastolic blood pressure (<130 and <80 mmHg, respectively) and total cholesterol (<3.5 mmol/L) targets at 24 months. Secondary outcomes included proportion of individuals with HbA_1c <58 mmol/mol (<7.5%), changes in prescribing, change in the albumin-to-creatinine ratio, major adverse cardiovascular events, cardiovascular mortality, and coding accuracy.

RESULTS

A total of 2,721 individuals from 22 practices, mean age 63 years, 41% female, and 62% from black and minority ethnic groups completed 2 years of follow-up. There were no significant differences in the proportion of individuals achieving the composite primary outcome, although the proportion of individuals achieving the prespecified outcome of total cholesterol <4.0 mmol/L (odds ratio 1.24; 95% CI 1.05-1.47; P = 0.01) increased with intensive intervention compared with control. Coding for microalbuminuria increased relative to control (odds ratio 2.05; 95% CI 1.29-3.25; P < 0.01).

CONCLUSIONS

Greater improvements in composite cardiovascular risk factor control with this intervention compared with standard care were not achieved in this cohort of high-risk individuals with T2DM. However, improvements in lipid profile and coding can benefit patients with diabetes to alter the high risk of atherosclerotic cardiovascular events. Future studies should consider comprehensive strategies, including patient education and health care professional engagement, in the management of T2DM.

The adoption of hypertension reference framework: An investigation among primary care physicians of Hong Kong

Background

The Hong Kong Government released a Reference Framework (RF-HT) for Hypertension Care for Adults in Primary Care Settings since 2010. No studies have evaluated its adoption by primary care physicians (PCPs) since its release.

Aim

We aimed to evaluate the level of PCPs’ adoption of the RF-HT and the potential barriers of its use in family practice.

Design and setting

A cross-sectional study was conducted by a self-administered validated survey among all PCPs in Hong Kong through various means.

Methods

We assessed the level of and factors associated with its adoption by multivariate logistic regression modelling.

Result

A total of 3,857 invitation episodes were sent to 2,297 PCPs in 2014–2015. We received 383 completed questionnaires. The average score of adoption was 3.43 out of 4.00, and 47.5% of PCPs highly adopted RF-HT in their daily consultations. Male practitioners (adjusted odds ratio [aOR] = 0.524, 95% CI = 0.290–0.948, p = 0.033) and PCPs of public sector (aOR = 0.524, 95% CI = 0.292–0.940, p = 0.030) were significantly less likely to adopt the RF-HT. PCPs with higher training completion or being academic fellow are more likely to adopt RF-HT than those who were “nil to basic training completion” (aOR = 0.479, 95% CI = 0.269–0.853, p = 0.012) or “higher trainee” (aOR = 0.302, 95% CI = 0.093–0.979, p = 0.046). Three most-supported suggestions on RF-HT improvement were simplification of RF-HT, provision of pocket version and promoting in patients.

Conclusion

Among PCP respondents, the adoption level of the RF-HT was high. These findings also highlighted some factors associated with its adoption that could inform targeted interventions for enhancing its use in clinical practice.

Management of shoulder pain by UK general practitioners (GPs): a national survey

OBJECTIVES

Studies in Canada, the USA and Australia suggested low confidence among general practitioners (GPs) in diagnosing and managing shoulder pain, with frequent use of investigations. There are no comparable studies in the UK; our objective was to describe the diagnosis and management of shoulder pain by GPs in the UK.

METHODS

A national survey of a random sample of 5000 UK GPs collected data on shoulder pain diagnosis and management using two clinical vignettes that described primary care presentations with rotator cuff tendinopathy (RCT) and adhesive capsulitis (AdhC).

RESULTS

Seven hundred and fourteen (14.7%) responses were received. 56% and 83% of GPs were confident in their diagnosis of RCT and AdhC, respectively, and a wide range of investigations and management options were reported. For the RCT presentation, plain radiographs of the shoulder were most common (60%), followed by blood tests (42%) and ultrasound scans (USS) (38%). 19% of those who recommended a radiograph and 76% of those who recommended a USS did so 'to confirm the diagnosis'. For the AdhC presentation, the most common investigations were blood tests (60%), plain shoulder radiographs (58%) and USS (31%). More than two-thirds of those recommending a USS did so 'to confirm the diagnosis'. The most commonly recommended treatment for both presentations was physiotherapy (RCT 77%, AdhC 71%) followed by non-steroidal anti-inflammatory drugs (RCT 58%, AdhC 74%). 17% opted to refer the RCT to secondary care (most often musculoskeletal interface service), compared with 31% for the AdhC.

CONCLUSIONS

This survey of GPs in the UK highlights reliance on radiographs and blood tests in the management of common shoulder pain presentations. GPs report referring more than 7 out of 10 patients with RCT and AdhC to physiotherapists. These findings need to be viewed in the context of low response to the survey and, therefore, potential non-response bias.

Changing Physician Practice Behavior to Measure and Improve Clinical Outcomes

Physician practice behavior often produces poor clinical outcomes in the management of cardiovascular disease risk factors in spite of effective treatments and guidelines. The behavior of 165 physicians in 2 settings (suburban and urban) was studied. After collecting baseline clinical data, including systolic blood pressure and low-density lipoprotein cholesterol, a series of interventions was conducted, including academic detailing. Low-density lipoprotein cholesterol decreased 10.4% in suburban patients with cardiovascular disease in the intervention group (P = .001) and 10.5% in the enhanced intervention group (P = .001). Systolic blood pressure decreased 1.11% (P = .357) in the intervention group and 5.13% in the enhanced intervention group (P < .001). In urban hypertensive patients, systolic blood pressure decreased 5.03% (P = .001) and low-density lipoprotein cholesterol decreased 7.01% (P < .001). Combining urban and suburban data, low-density lipoprotein cholesterol decreased 9.32% (P < .001) and systolic blood pressure decreased 4.00% (P < .001). Providing physicians with their clinical outcomes, reviewing national guidelines, and setting expectations, associated with modest practice systems innovations, can produce significant measurable clinical improvements.

Pharmacist Intervention in Risk Reduction Study in High-Risk Cardiac Patients: The Effect of 2 Methods of Pharmacist Training

Objective:

To assess the effect of intensive vs conventional training on pharmacist-suggested implementation of cardiac risk reduction efforts in community practice.

Methods:

Sixty-one volunteer pharmacists from 40 pharmacies were randomized to 1 of 2 educational groups: intensive or conventional training in cardiac risk reduction. With training complete, pharmacists identified and approached patients at high risk for coronary artery disease (CAD) at their practice sites to participate in the program. After a patient interview, pharmacists documented the relevant CAD risk factors and medication history, and then faxed this information, along with risk reduction recommendations, to the primary care physician. Patients were then encouraged to book a medical appointment for further assessment and treatment, if warranted. Follow-up occurred at 4, 16, and 24 weeks to determine if any pharmacist-suggested risk reduction measures had been implemented. Pharmacists were reimbursed $30 per patient accrued.

Results:

A total of 217 patients were enrolled in the study, and of those, 216 had follow-up data available for analysis. No significant differences were observed between the groups with respect to mean number of patients enrolled per pharmacist (4.3 vs 2.7) and the proportion of pharmacists completing at least 1 patient (17/27 vs 14/34). Feedback from pharmacists on program delivery indicated no significant difference in satisfaction with the training provided. The recommendations forwarded by pharmacists of the intensive group (35.8%) received greater acceptance by physicians than those in the conventional group (23.8%).

Conclusion:

Although results are preliminary, intensive training for pharmacists was more likely to result in improvements in cardiovascular risk reduction therapy than when conventional training was used.

Design, development, and evaluation of printed educational materials for evidence-based practice dissemination

AIM

Printed educational materials (PEMs) are one of the most common dissemination strategies for communicating information about evidence-based practices (EBPs) to healthcare professionals and organizations; however, evidence is conflicting regarding the conditions and circumstances in which PEMs are effective in achieving desired outcomes. The effectiveness of PEMs is largely dependent on the manner in which they are developed. This article reports on the findings from a comprehensive review of the literature regarding best practices for creating PEMs for health professionals and illustrates how these practices were used to design, develop, and evaluate an informational packet to disseminate information about motivational interviewing.

METHODS

The informational packet was disseminated to 92 community health organizations not currently implementing motivational interviewing. Evaluation surveys were completed by 212 healthcare directors and providers to examine quality and perceived helpfulness of the packets, intention to use information from the packet, and sharing of the packet with others. Associations between these and individual and organizational characteristics were also assessed.

RESULTS

Overall, the packet was perceived as appropriate and helpful in making a decision to implement motivational interviewing. For example, 84.9% of participants stated that the content was 'about right'. Three-quarters (75.9%) of participants reported plans to use the information in the packet and almost half (46.7%) reported talking about the packet with others in the organizations. Higher levels of baseline interest in motivational interviewing adoption were significantly related to packet use and wanting to utilize additional resources presented in the packet. Positive attitudes toward EBPs were also significantly related to the desire to obtain resources in the packet. Perceptions of the packet did not differ by type of community health organization (i.e., community health center, community behavioral health organization) or whether the individual was a director or provider.

CONCLUSION

Results indicated that PEMs can be a useful tool to disseminate EBP information to healthcare professionals particularly if they have a prior interest in the EBP and have general attitudes supportive of EBPs. Recommendations for the improvement of future PEMs are discussed.

Evaluation of a randomized intervention to increase adoption of comparative effectiveness research by community health organizations

This randomized controlled trial examined the influence of two strategies (informational packets alone and in conjunction with Webinars) aimed at increasing the adoption of motivational interviewing (MI), a patient-centered behavioral health practice supported by evidence from comparative effectiveness studies, among community health organizations responsible for delivering mental and behavioral health services. Data were obtained from 311 directors and staff across 92 community organizations. Hierarchical linear modeling was used to examine changes in decision to adopt MI. The mediating effects of multiple contextual variables were also examined. Results showed that both strategies positively influenced the decision to adopt. The positive impact on decision to adopt was significantly greater among individuals that received informational packets in conjunction with Webinars. Baseline attitudes toward evidence-based practices and pressures for change appeared to mediate this effect.

Real-time electronic medical record alerts increase high blood pressure recognition in children

OBJECTIVE

Pediatric hypertension remains largely unrecognized. We hypothesized that an electronic medical record (EMR) alert would increase elevated blood pressure (BP) recognition in a pediatric primary care setting.

STUDY DESIGN

Pre-post evaluation of a real-time EMR alert and one-time provider educational session. A total of 1305 encounters of children 3 to 21 years with elevated intake BP and no prior hypertension diagnosis were included. Elevated BP recognition and relationship of recognition with cardiovascular disease (CVD) risk factors during the intervention was compared with an historical control.

RESULTS

Recognition increased from 12.5% to 42% (P < .001). Recognition increased soon after alert implementation and was sustained without evidence of "alert fatigue." During both periods, presence of CVD risk factors was associated with recognition. However, the magnitude was lesser in the intervention period.

CONCLUSIONS

Real-time EMR alerts substantially increase elevated BP recognition in children. However, underrecognition of elevated BP persisted, highlighting the need for additional strategies to improve provider recognition.

Essential pediatric hypertension: defining the educational needs of primary care pediatricians

BACKGROUND

In order to better understand the educational needs regarding appropriate recognition, diagnosis and management of pediatric hypertension (HTN), we asked practicing pediatricians questions regarding their educational needs and comfort level on this topic.

METHODS

We conducted 4 focus group sessions that included 27 participants representing pediatric residents, adolescent medicine physicians, clinic based pediatricians and office based pediatricians. Each focus group session lasted for approximately an hour and 90 pages of total transcriptions were produced verbatim from audio recordings.

RESULTS

Four reviewers read each transcript and themes were elucidated from these transcripts. Overall, 5 major themes related to educational needs and clinical concerns were found: utilization of resources to define blood pressure (BP), correct BP measurement method(s), co-morbidities, barriers to care, and experience level with HTN. Six minor themes were also identified: differences in BP measurement, accuracy of BP, recognition of HTN, practice pattern of care, education of families and patients, and differences in level of training. The focus group participants were also questioned on their preferences regarding educational methods (i.e. e-learning, small group sessions, self-study, large group presentations) and revealed varied teaching and learning preferences.

CONCLUSIONS

There are multiple methods to approach education regarding pediatric HTN for primary care pediatricians based on provider preferences and multiple educational activities should be pursued to achieve best outcomes. Based on this data, the next direction will be to develop and deliver multiple educational methods and to evaluate the impact on practice patterns of care for children and adolescents with HTN.

Impact of performance improvement continuing medical education on cardiometabolic risk factor control: the COSEHC initiative

INTRODUCTION

The Consortium for Southeastern Hypertension Control (COSEHC) implemented a study to assess benefits of a performance improvement continuing medical education (PI CME) activity focused on cardiometabolic risk factor management in primary care patients.

METHODS

Using the plan-do-study-act (PDSA) model as the foundation, this PI CME activity aimed at improving practice gaps by integrating evidence-based clinical interventions, physician-patient education, processes of care, performance metrics, and patient outcomes. The PI CME intervention was implemented in a group of South Carolina physician practices, while a comparable physician practice group served as a control. Performance outcomes at 6 months included changes in patients' cardiometabolic risk factor values and control rates from baseline. We also compared changes in diabetic, African American, the elderly (> 65 years), and female patient subpopulations and in patients with uncontrolled risk factors at baseline.

RESULTS

Only women receiving health care by intervention physicians showed a statistical improvement in their cardiometabolic risk factors as evidenced by a -3.0 mg/dL and a -3.5 mg/dL decrease in mean LDL cholesterol and non-HDL cholesterol, respectively, and a -7.0 mg/dL decrease in LDL cholesterol among females with uncontrolled baseline LDL cholesterol values. No other statistical differences were found.

DISCUSSION

These data demonstrate that our PI CME activity is a useful strategy in assisting physicians to improve their management of cardiometabolic control rates in female patients with abnormal cholesterol control. Other studies that extend across longer PI CME PDSA periods may be needed to demonstrate statistical improvements in overall cardiometabolic treatment goals in men, women, and various subpopulations.

Improving psychotherapeutic medication prescribing in Florida: implementation of the Florida Medicaid Drug Therapy Management Program (MDTMP)

This paper describes a program that was established by Florida Medicaid to improve the quality of prescribing of psychotherapeutic medications. It relates the process used for defining quality medication treatment including the definitions of unusual psychotherapeutic medication indicators (UPMI). It details the results of analysis of FY 2007-2008 pharmacy claims data using these indicators that enabled the Program to identify practices and prescribers that required targeted interventions. The most frequently triggered UPMI for adults involved the use of 2 or more antipsychotics for greater than 60 days; high doses of psychotherapeutic medications was the indicator most frequently triggered for children closely followed by the use of 2 or more antipsychotics for more than 45 days. Prescriptions that triggered UPMI were concentrated in a small number of prescribers. These results led to the Program focusing on these high frequency practices and on the prescribers most associated with them. They also led to the implementation of new quality improvement initiatives like the implementation of a psychiatric telephone consultation line for pediatricians who are treating children with serious emotional disturbances who do not have access to child psychiatrists.

What are the clinical questions of practicing veterinarians?

Clinical questions are central to learning among veterinarians and drive informal learning during clinical practice. We set out to classify the clinical questions of practicing veterinarians using a taxonomy previously validated in human medicine. This prospective observational study used a convenience sample of 12 veterinarians in private, small-animal practices. We used three methods to gather clinical questions from the veterinarians: direct observation (asking veterinarians after each encounter), self-report via e-mail, and self-report via data-collection pocket cards. We then classified these questions using a validated taxonomy of question types, as well as by clinical category. A total of 157 clinical questions were collected; 99 were about dogs, 33 were about cats, and 25 were about multiple species or did not specify a species. Nearly half of the questions were rated as high priority, and only 11.5% as low priority. Over half of the questions (53%) were about treatment and 20% were about diagnosis. The two most common question types were "Is drug X indicated in situation Y or for condition Y?" and "How should I treat finding/condition Y (given situation Z)?" Overall, 5 of 57 question-type categories accounted for over half of the questions. The most common clinical categories were pharmacology, endocrine, musculoskeletal, and general surgery. This is the first study to systematically identify and classify the clinical questions of veterinarians. A better understanding of these questions can be used to inform the development of continuing-education (CE) activities that are directly responsive to the information needs of participants.

Interim results of a national test of the rapid assessment of hospital procurement barriers in donation (RAPiD)

Organ donation remains a major public health challenge with over 114 000 people on the waitlist in the United States. Among other factors, extant research highlights the need to improve the identification and timely referral of potential donors by hospital healthcare providers (HCPs) to organ procurement organizations (OPOs). We implemented a national test of the Rapid Assessment of hospital Procurement barriers in Donation (RAPiD) to identify assets and barriers to the organ donation and patient referral processes; assess hospital-OPO relationships and offer tailored recommendations for improving these processes. Having partnered with seven OPOs, data were collected at 70 hospitals with high donor potential in the form of direct observations and interviews with 2358 HCPs. We found that donation attitudes and knowledge among HCPs were high, but use of standard referral criteria was lacking. Significant differences were found in the donation-related attitudes, knowledge and behaviors of physicians and emergency department staff as compared to other staff in intensive care units with high organ donor potential. Also, while OPO staff were generally viewed positively, they were often perceived as outsiders rather than members of healthcare teams. Recommendations for improving the referral and donation processes are discussed.

The effectiveness of face to face education using catharsis education action (CEA) method in improving the adherence of private general practitioners to national guideline on management of tuberculosis in Bandung, Indonesia

BACKGROUND

In many countries, private general practitioners are the first contact in health services for people with symptoms of tuberculosis. Targeting the private sector has been recommended in previous studies to improve tuberculosis control. A brief face-to-face intervention using Catharsis Education Action (CEA) method, repeated at periodic intervals, seems to change physicians' attitudes, beliefs and practice.The objective of the study was to determine the effectiveness of CEA method in improving the private general practitioners' (PPs) adherence to the national guideline on the management of tuberculosis patients in Bandung District, Indonesia.

METHOD

A randomized controlled trial was done. For the intervention group, a session of the CEA method was delivered to PPs while brief reminder with provision of pamphlet was used for the comparative group.

RESULTS

A total of 82 PPs were included in the analysis. The intervention group showed some positive trends in adherence especially in the use of sputum as first laboratory examination (RR = 1.24) and follow up (RR = 1.37), though not reaching statistical significance. After intervention PPs in CEA group maintained the adherence, but PPs in pamphlets group showed deterioration (score before to after: -12.5).

CONCLUSION

Face to face education using CEA method seems to be as effective as brief reminder with provision of pamphlet in improving the adherence. CEA offers additional information that can be useful in designing intervention programs to improve the adherence to guideline.

Activating peripheral arterial disease patients to reduce cholesterol: a randomized trial

BACKGROUND

Peripheral arterial disease patients are less likely than other high-risk patients to achieve ideal low-density lipoprotein (LDL) cholesterol levels. This randomized controlled trial assessed whether a telephone counseling intervention, designed to help peripheral arterial disease patients request more intensive cholesterol-lowering therapy from their physician, achieved lower LDL cholesterol levels than 2 control conditions.

METHODS

There were 355 peripheral arterial disease participants with baseline LDL cholesterol ≥70 mg/dL enrolled. The primary outcome was change in LDL cholesterol level at 12-month follow-up. There were 3 parallel arms: telephone counseling intervention, attention control condition, and usual care. The intervention consisted of patient-centered counseling, delivered every 6 weeks, encouraging participants to request increases in cholesterol-lowering therapy from their physician. The attention control condition consisted of telephone calls every 6 weeks providing information only. The usual care condition participated in baseline and follow-up testing.

RESULTS

At 12-month follow-up, participants in the intervention improved their LDL cholesterol level, compared with those in attention control (-18.4 mg/dL vs -6.8 mg/dL, P=.010) but not compared with those in usual care (-18.4 mg/dL vs -11.1 mg/dL, P=.208). Intervention participants were more likely to start a cholesterol-lowering medication or increase their cholesterol-lowering medication dose than those in the attention control (54% vs 18%, P=.001) and usual care (54% vs 31%, P <.001) conditions.

CONCLUSION

Telephone counseling that helped peripheral arterial disease patients request more intensive cholesterol-lowering therapy from their physician achieved greater LDL cholesterol decreases than an attention control arm that provided health information alone.

Office-based interventions for recognizing abnormal pediatric blood pressures

Interventions to improve pediatric blood pressure (BP) screening have not been well studied. The authors measured staff acceptance of 2 simple in-office interventions and measured the effect on physician recognition of elevated BP measurements. Group 1 used simplified normative pediatric BP tables affixed to the growth chart, group 2 used a personal digital assistant program (PDA) to calculate BP percentiles as part of the vital signs, and group 3 served as the control. Group detection rates by compliant (C) and noncompliant (NC) with the intervention were: (1) (BP table) C = 18%, NC = 12%; (2) (PDA) C = 33%, NC = 26%; and (3) (control) 18%. There was no statistically significant intervention effect with documented compliance (P = .27) nor was there an effect in the noncompliant records (P = .12). Although the interventions were used inconsistently, their presence in the medical record did not improve performance. Future education and interventions are needed to reduce barriers to elevated pediatric BP recognition.

Promoting Evidence-Based Health Policy, Programming, and Practice for Seniors: Lessons from a National Knowledge Transfer Project

In response to Canada's pressing need for effective evidence-based policy, services, and practices specific to seniors, national leaders representing all concerned stakeholders designed and implemented a National Consensus Process to promote spread, exchange, choice, and uptake of research evidence on social and health issues associated with an aging population. This article presents the innovative methods and evaluation of this three-year project, illuminating for all constituencies the challenges and opportunities associated with promoting seniors' independence through collaborative knowledge transfer efforts. A total of 198 organizations and 65 individuals were surveyed at baseline, throughout the intervention, immediately post-intervention, and one year post-intervention. Knowledge from 783 studies was spread to 63,387 people, 90 per cent of whom reported knowledge exchange. Over 50 per cent of stakeholders reported using the research evidence, although processes for facilitating knowledge choice did not achieve consensus. Significant knowledge uptake occurred in two of the four research theme areas.

Part II, provider perspectives: should patients be activated to request evidence-based medicine? A qualitative study of the VA project to implement diuretics (VAPID)

BACKGROUND

Hypertension guidelines recommend the use of thiazide diuretics as first-line therapy for uncomplicated hypertension, yet diuretics are under-prescribed, and hypertension is frequently inadequately treated. This qualitative evaluation of provider attitudes follows a randomized controlled trial of a patient activation strategy in which hypertensive patients received letters and incentives to discuss thiazides with their provider. The strategy prompted high discussion rates and enhanced thiazide-prescribing rates. Our objective was to interview providers to understand the effectiveness and acceptability of the intervention from their perspective, as well as the suitability of patient activation for more widespread guideline implementation.

METHODS

Semi-structured phone interviews were conducted with 21 primary care providers. Interviews were transcribed verbatim and reviewed by the interviewer before being analyzed for content. Interviews were coded, and relevant themes and specific responses were identified, grouped, and compared.

RESULTS

Of the 21 providers interviewed, 20 (95%) had a positive opinion of the intervention, and 18 of 20 (90%) thought the strategy was suitable for wider use. In explaining their opinions of the intervention, many providers discussed a positive effect on treatment, but they more often focused on the process of patient activation itself, describing how the intervention facilitated discussions by informing patients and making them more pro-active. Regarding effectiveness, providers suggested the intervention worked like a reminder, highlighted oversights, or changed their approach to hypertension management. Many providers also explained that the intervention 'aligned' patients' objectives with theirs, or made patients more likely to accept a change in medications. Negative aspects were mentioned infrequently, but concerns about the use of financial incentives were most common. Relevant barriers to initiating thiazide treatment included a hesitancy to switch medications if the patient was at or near goal blood pressure on a different anti-hypertensive.

CONCLUSIONS

Patient activation was acceptable to providers as a guideline implementation strategy, with considerable value placed on the activation process itself. By 'aligning' patients' objectives with those of their providers, this process also facilitated part of the effectiveness of the intervention. Patient activation shows promise for wider use as an implementation strategy, and should be tested in other areas of evidence-based medicine.

TRIAL REGISTRATION

National Clinical Trial Registry number NCT00265538.

The effect of continuing professional education on health care outcomes: lessons for dementia care

BACKGROUND

This review presents an overview of the published literature on the effectiveness of continuing professional education (CPE), which includes continuing medical education (CME) of different health care professionals in healthcare settings, for improving patient management and patient outcomes. This review summarizes key articles published on the subject, including those relating to dementia care.

METHODS

A literature search was carried out using the National Library of Medicine's PubMed database, Cochrane database and Eric databases.

RESULTS

Studies on CPE generally provide conflicting evidence on their effectiveness in bringing about a change in professional practices and healthcare outcomes. However interactive, multifaceted interventions, and interventions with repeated inputs appear more effective in bringing about positive changes than traditional non-interactive techniques. There are relatively few studies specifically concerning CPE and dementia care.

CONCLUSION

This review shows that CPE in dementia care needs to be targeted carefully. Much can be learnt from examining education approaches in the wider professional and medical education literature.

Creating a quality-improvement dialogue: utilizing knowledge from frontline staff, managers, and experts to foster health care quality improvement

There is a growing consensus that a hybrid of two common approaches to quality improvement (QI), local participatory QI and expert QI, might be the best method for achieving quality care. Achieving such a hybrid requires that content experts establish an ongoing dialogue with both frontline staff members and managers. In this study we examined frontline staff members' and managers' preferences regarding how to conduct such a dialogue, and we provide practical suggestions for implementation. The two groups shared a number of preferences (e.g., verbal face-to-face exchanges, discussions focused on quality of care). There were also some differences. For example, although managers were interested in discussions of business aspects (e.g., costs), frontline staff members were concerned with workload issues. Finally, although informants acknowledged that engaging in a QI dialogue was time consuming, they also believed it was essential if health care organizations are to improve the quality of care they provide.

Evaluating online continuing medical education seminars: evidence for improving clinical practices

The purpose of this study was to evaluate the potential for online continuing medical education (CME) seminars to improve quality of care. Primary care physicians (113) participated in a randomized controlled trial to evaluate an online CME series. Physicians were randomized to view either a seminar about type 2 diabetes or a seminar about systolic heart failure. Following the seminar, physicians were presented with 4 clinical vignettes and asked to describe what tests, treatments, counseling, or referrals they would recommend. Physicians who viewed the seminars were significantly more likely to recommend guideline-consistent care to patients in the vignettes. For example, physicians who viewed the diabetes seminar were significantly more likely to order an eye exam for diabetes patients (63%) compared with physicians in the control group (27%). For some guidelines there were no group differences. These results provide early evidence of the effectiveness of online CME programs to improve physician clinical practice.

Using health information technology to improve hypertension management

High-quality medical care requires implementing evidence-based best practices, with continued monitoring to improve performance. Implementation science is beginning to identify approaches to developing, implementing, and evaluating quality improvement strategies across health care systems that lead to good outcomes for patients. Health information technology has much to contribute to quality improvement for hypertension, particularly as part of multidimensional strategies for improved care. Clinical reminders closely aligned with organizational commitment to quality improvement may be one component of a successful strategy for improving blood pressure control. The ATHENA-Hypertension (Assessment and Treatment of Hypertension: Evidence-based Automation) system is an example of more complex clinical decision support. It is feasible to implement and deploy innovative health information technologies for clinical decision support with features such as clinical data visualizations and evidence to support specific recommendations. Further study is needed to determine the optimal contexts for such systems and their impact on patient outcomes.

Discussing coronary risk with patients to improve blood pressure treatment: secondary results from the CHECK-UP study

OBJECTIVES

Hypertension is common among patients with dyslipidemia but is often poorly treated. The objective of this analysis was to evaluate how a decision aid, used by primary care physicians to improve lipid therapy, impacted on the treatment of hypertension.

STUDY DESIGN

Data were analyzed from patients enrolled in a randomized trial focusing primarily on the treatment of dyslipidemia. Patients received usual care or a coronary risk profile every three months to monitor the risk reduction following lifestyle changes and/or pharmacotherapy to treat dyslipidemia. Hypertension management was assessed based on a post hoc analysis of individuals whose blood pressure exceeded current national hypertension guidelines.

RESULTS

There were 2,631 subjects who completed the study. Among 1,352 patients without diagnosed hypertension, 30% were above target on at least three consecutive visits. Among 1,279 individuals with known hypertension, 69% were above target on at least two consecutive visits. Overall, patients receiving risk profiles were more likely to receive appropriate antihypertensive therapy (OR = 1.40, 95% CI 1.11-1.78) compared to those receiving usual care. After adjustment for inter-physician variability and potential confounders, the use of the risk profile was associated with an increased likelihood of starting therapy (OR = 1.78, 95% CI 1.06-3.00) or modifying therapy (OR = 1.40, 95% CI 1.03-1.91).

CONCLUSIONS

In this clinical trial of dyslipidemia management, inadequately controlled hypertension was common, occurring in nearly 50% of individuals. Ongoing coronary risk assessment was associated with more appropriate blood pressure management. Cardiovascular risk assessment decision aids should be further evaluated in a randomized trial of hypertension therapy.

The use of medical information in Nigeria: the influence of gender and status

INTRODUCTION

Medical doctors are important members of the health-care team, and to discharge their duties credibly, they need adequate and quick information. A search of the literature yielded a handful of studies on the provision and organization of medical information with little emphasis on the influence of personal variables on information utilization. We report the influence of gender and status on reasons for searching medical information by doctors in Nigeria.

METHODS

A pretested questionnaire was given to all 720 doctors in active practice working in the 5 Teaching Hospitals of southeastern Nigeria. The returned questionnaires were analyzed by analysis of variance (ANOVA).

RESULTS

Six hundred fourteen of 720 (85.3%) doctors responded to the questionnaire; 116 (18.9%) of the respondents were females. It was found that among the male resident doctors the most common reason for searching medical information was for examination preparation, which had 356 (89.9%) positive respondents, followed by career development, 340 (85.9%). For the female residents, updating knowledge was the most common reason, with 90 (91.8%) positive respondents followed by examination preparation, 87 (88.8%). Updating knowledge was the most common reason for both the male and female consultants, followed by research for teaching and publication.

DISCUSSION

The male resident doctors were more concerned with passing their professional examinations, and that was their main reason for searching medical information. The other groups searched information mostly to update their knowledge. Better medical practice was not an important reason to any of the groups. This attitude should be changed through continuing medical education (CME), which refers to a specific form of continuing education that helps those in the medical field maintain competence and learn about new and developing areas of their field.

Strategies for facilitating change in alcohol and other drugs (AOD) professional practice: a systematic review of the effectiveness of reminders and feedback

In all areas of health research, including the alcohol and other drugs (AOD) field, funds are committed to developing and evaluating research and resources, yet little is invested into helping potential resource users understand, adopt and implement innovations. This study evaluated the effectiveness of two professional practice change interventions (reminders and feedback) that are designed to bridge the 'research-practice gap' by increasing knowledge and changing behaviour of health-care professionals and specialist AOD workers. We conducted a systematic review of general health, AOD and mental health literature (1966 to March 2005). Fourteen existing systematic reviews and 15 primary studies were assessed. Because few studies evaluated the effectiveness of reminders and feedback in the AOD context, evidence is drawn largely from the general health-care literature. Use of reminders and feedback is supported for a range of health behaviours. AOD-specific clinical behaviours that are most likely to be improved with the use of reminders or feedback include pharmacotherapy prescribing, AOD education, screening and counselling and monitoring/management of AOD treatment and/or related problems (e.g. depression). Reminders and feedback are effective strategies to facilitate professional practice change and have potential in the AOD field. However, further well-designed empirical studies are needed to assess fully the effectiveness of these professional practice change strategies in AOD-specific contexts.

Self-reported performance improvement strategies of highly successful Veterans Health Administration facilities

The Veterans Health Administration (VHA) has achieved considerable success in improving health care through the use of clinical performance measures. This report examines the self-reported strategies used by the most successful facilities in the VHA system. For fiscal year 2002, facilities that scored the highest on any of 24 clinical performance measures were queried as to which strategies they used to achieve their level of performance. The most commonly cited strategies across all performance categories were organizational change (55.6%), clinical reminders (41.4%), audit and feedback to providers (39.6%), and staff education (32.5%). Certain strategies were more likely to be cited for 1 or more specific performance categories (eg, clinical reminders for immunization [61.1%], screening [60.6%]). These findings suggest that successful facilities are generally using evidence-based strategies to achieve high clinical performance. However, some evidence-based implementation strategies were rarely cited (eg, use of clinical champions).

The Ontario printed educational message (OPEM) trial to narrow the evidence-practice gap with respect to prescribing practices of general and family physicians: a cluster randomized controlled trial, targeting the care of individuals with diabetes and hypertension in Ontario, Canada

Background

There are gaps between what family practitioners do in clinical practice and the evidence-based ideal. The most commonly used strategy to narrow these gaps is the printed educational message (PEM); however, the attributes of successful printed educational messages and their overall effectiveness in changing physician practice are not clear. The current endeavor aims to determine whether such messages change prescribing quality in primary care practice, and whether these effects differ with the format of the message.

Methods/design

The design is a large, simple, factorial, unblinded cluster-randomized controlled trial. PEMs will be distributed with informed, a quarterly evidence-based synopsis of current clinical information produced by the Institute for Clinical Evaluative Sciences, Toronto, Canada, and will be sent to all eligible general and family practitioners in Ontario. There will be three replicates of the trial, with three different educational messages, each aimed at narrowing a specific evidence-practice gap as follows: 1) angiotensin-converting enzyme inhibitors, hypertension treatment, and cholesterol lowering agents for diabetes; 2) retinal screening for diabetes; and 3) diuretics for hypertension.

For each of the three replicates there will be three intervention groups. The first group will receive informed with an attached postcard-sized, short, directive "outsert." The second intervention group will receive informed with a two-page explanatory "insert" on the same topic. The third intervention group will receive informed, with both the above-mentioned outsert and insert. The control group will receive informed only, without either an outsert or insert.

Routinely collected physician billing, prescription, and hospital data found in Ontario's administrative databases will be used to monitor pre-defined prescribing changes relevant and specific to each replicate, following delivery of the educational messages. Multi-level modeling will be used to study patterns in physician-prescribing quality over four quarters, before and after each of the three interventions. Subgroup analyses will be performed to assess the association between the characteristics of the physician's place of practice and target behaviours.

A further analysis of the immediate and delayed impacts of the PEMs will be performed using time-series analysis and interventional, auto-regressive, integrated moving average modeling.

Trial registration number

Current controlled trial ISRCTN72772651.

Gender differences among general practitioners in smoking cessation counseling practices

OBJECTIVES

To describe gender differences in smoking cessation counseling practices among general practitioners (GPs), and to investigate the association between training for cessation counseling and counseling practices according to gender.

METHODS

Data were collected in two cross-sectional mail surveys conducted in independent random samples of GPs in Montreal, the first in 1998, and the second in 2000.

RESULTS

Respondents included 653 GPs (71% of 916 eligible). All indicators of smoking cessation counseling practices were more favorable among female GPs. Higher proportions of female GPs had received training (28% vs. 17%, p=0.002), and were aware of mailed print educational materials related to cessation counseling (81% vs. 57%, p<0.0001). Training among male GPs was associated with higher scores for ascertainment of smoking status (odds ratio (OR) (95% confidence interval)=1.69 (0.97, 2.96)), provision of advice (OR=2.20 (1.23, 3.95)), and provision of adjunct support (OR=2.86 (1.58, 5.16)). Training was not associated with counseling practices among female GPs.

CONCLUSIONS

Female GPs may not benefit from formal cessation counseling training to the same extent as male GPs, possibly because they read and integrate the content of (easily available) print educational materials into their clinical practice to a greater extent than male GPs. The gender-specific impact of print educational material and formal training on cessation counseling should be evaluated among GPs.

Patient and Provider Perceptions of Hypertension Treatment: Do They Agree?

The objective of our study was to explore physician and patient attitudes regarding hypertension management. One hundred forty-five primary care providers and 189 patients with hypertension at 6 Veterans Administration clinics completed a hypertension survey. Fifty-one percent of patients were at their blood pressure goal, 58% were on guideline-concordant therapy, and 31% achieved both. Patients and providers agreed that physicians were a "very/extremely" useful source of information but differed in perceived value of pharmacists, educational material, advertising, and the Internet. They also agreed on the value of preventing cardiovascular events but differed in their perceptions of the importance of medication costs, side effects, and national guidelines. Blood pressure control and guideline-concordant therapy was higher than most prior reports, but with opportunity for improvement. Patients and providers differed in perceived value of various aspects of hypertension management; this information may help to determine trial design and quality improvement strategies in the future.

A physician self-assessment tool for quality improvement

A physician self-assessment (PSA) tool was evaluated as an alternative to full chart reviews to assess guideline adherence. PSAs, consisting of brief self-report questionnaires, were developed for asthma management and mammography screening and were mailed to participating physicians in a partially capitated Medicaid managed care insurance program. A random chart audit was conducted at each practice site, and results were compared to the PSA responses. An 85% concordance was found between the asthma PSA and chart data, and an 88% concordance was found between the mammography PSA and chart data. These findings suggest that the PSA, combined with random chart audits, can be a viable alternative to full chart reviews.

Ethnic Differences in the Treatment and Control of Hypertension in Patients With Diabetes

Among diabetic hypertensive patients, ethnic differences in blood pressure control and outcomes have been attributed in part to greater reluctance of providers to prescribe combination antihypertensive regimens to African Americans than to Caucasians. African Americans purportedly receive fewer angiotensin-converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs), which reduce target organ complications. To assess these issues, cross-sectional data were analyzed from 19,864 diabetic hypertensives from 62 primary care clinics. Among diabetic hypertensives, African Americans (N=6230) were less likely than Caucasians (N=8041) to have blood pressure (BP) <130/80 mm Hg at their last clinic visit (23.1% [23.0%-23.2%] vs. 30.7% [30.6%-30.9%]) despite a greater number of prescriptions for antihypertensive medications (2.67 [2.63-2.70] vs. 2.23 [2.20-2.26]). African Americans were more likely than Caucasians to have an ACEI and/or ARB prescribed and to receive prescriptions for at least two antihypertensive medications that included an ACEI or ARB (64.1% [63.8%-64.4%] vs. 53.1% [52.8%-53.4%]). Among diabetic hypertensives, African Americans are less likely than Caucasians to attain BP <130/80 mm Hg, despite receiving more antihypertensive medication prescriptions. African Americans receive more ACEIs and/or ARBs than Caucasians for target organ protection and/or BP control. The data suggest provider prescribing patterns are not a major contributor to ethnic differences in BP control and outcomes in diabetic hypertensives.

Physician peer assessments for compliance with methadone maintenance treatment guidelines

INTRODUCTION

Medical associations and licensing bodies face pressure to implement quality assurance programs, but evidence-based models are lacking. To improve the quality of methadone maintenance treatment (MMT), the College of Physicians and Surgeons of Ontario, Canada, conducts an innovative quality assurance program on the basis of peer assessments. Using data from this program, we assessed physician compliance with MMT guidelines and determined whether physician factors (e.g., training, years of practice), practice type, practice location, and/or caseload is associated with MMT guideline adherence.

METHODS

Secondary analysis of methadone practice assessment data collected by the College of Physicians and Surgeons of Ontario, Canada. Assessment data from methadone prescribing physicians who completed their first year of methadone practice were analyzed. We calculated the mean percentage compliance per guideline per physician and global compliance across all guidelines per physician. Linear regression was used to assess factors associated with compliance.

RESULTS

Data from 149 physician practices and 1,326 patient charts were analyzed. Compliance across all charts was greater than 90% for most areas of care. Compliance was less than 90% for take-home medication procedures; urine toxicology screening; screening for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), tuberculosis, other sexually transmitted infections, and completion of a psychosocial assessment. Mean global compliance across all charts and guidelines per physician was 94.3% (standard deviation = 7.4%) with a range of 70% to 100%. Linear regression analysis revealed that only year of medical school graduation was a significant predictor of physician compliance.

DISCUSSION

This is the first report of MMT peer assessments in Canada. Compliance is high. Few countries conduct similar assessment processes; none report physician-level results. We cannot quantify the contribution of peer assessment, training, or self-selection to the compliance rates, but compared to other areas of practice these rates suggest that peer assessment may exert a significant effect on compliance. A similar assessment process may in other areas of clinical practice improve physician compliance.

The case for cultural competence in health professions education

Health profession schools in the United States have to be able to meet the health and pharmaceutical care demands of a rapidly growing racial and multiethnic population. One tactic is to develop and implement or expand existing resources and didactic courses to address cultural competence in the curricula of every college and school of pharmacy. The curriculum should require a focus on the reality of evidence-based health disparities among racial and ethnic minority populations; importance of providing culturally competent care and communication to meet the health needs of diverse patient populations; and exposure to cultural diversity. Students should be grounded in cultural awareness and cultural sensitivity. This article establishes a case for integrating cultural competence into the curricula of health professions schools.

Systems for care of hypertension in the United States

Control of hypertension in recent clinical trials varies from 48% to 65%. However, in community care of hypertension in the United States, estimates of control of hypertension are far lower. The United States has no single system of care; however, several care systems can be identified for comparison, such as the Department of Veterans Affairs, managed care organizations, and the Indian Health Service. This review compares control of hypertension in certain centers in these systems with that achieved in clinical trials and in the community at large. Certain components of care systems are assessed for their contribution to the control of hypertension. The author concludes that for community control of hypertension to approach that achieved in clinical trials, the use of physician extenders, together with reduced or minimal cost of medication, improved education of providers with feedback, and computerization of management systems will be needed. In addition, specific interventions targeted to medically underserved groups will be required.

A community-based program for cardiovascular health awareness

OBJECTIVE

The objective of the Cardiovascular Health Awareness Program (CHAP) is to improve the processes of care related to the cardiovascular health of older adults.

PARTICIPANTS

Two Ontario communities including family physicians (FP), pharmacists, public health units and nurses, volunteer peer health educators, older adult patients and community organizations.

SETTING

Community pharmacies and family physician offices.

INTERVENTION

CHAP is designed to close a process of care loop around cardiovascular health awareness that originates from, and returns to, the FP. Older patients are invited by their FP to attend pharmacy CHAP sessions. At these sessions, trained volunteer peer health educators (PHEs) assist patients both in recording their blood pressure using a calibrated automated device and in completing a cardiovascular risk profile. This information is relayed to their respective FP via an automated computerized database. Pharmacists and patients receive copies of the results. Based on these cumulative risk profiles, patients are advised to follow-up with their FP.

OUTCOMES

Of the FPs and pharmacists asked, 47% and 79%, respectively, agreed to participate in the project. 39% of older adult patients invited by their FPs attended the CHAP community pharmacy sessions. Of these, 100% agreed to having their risk profile, including their blood pressure readings, forwarded to their FP. Positive feedback about CHAP was expressed by the volunteer PHEs, the FPs and the pharmacists.

CONCLUSION

The community-based pharmacy CHAP sessions are a feasible way of improving patient, physician, and pharmacist access to reliable blood pressure measurements and to cardiovascular health information. A randomized trial is in progress that will assess the impact of CHAP on monitoring of blood pressure.

The association between processes, structures and outcomes of secondary prevention care among VA ischemic heart disease patients

Background

Hyperlipidemia and hypertension are well-established risk factors for recurrent cardiovascular events among patients with ischemic heart disease (IHD). Despite national recommendations, concordance with guidelines for LDL cholesterol and blood pressure remains inadequate. The objectives of this study were to 1) determine concordance rates with LDL cholesterol and BP recommendations; and 2) identify patient factors, processes and structures of care associated with guideline concordance among VA IHD patients.

Methods

This was a cross sectional study of veterans with IHD from 8 VA hospitals. Outcomes were concordance with LDL guideline recommendations (LDL<100 mg/dl), and BP recommendations (<140/90 mm Hg). Cumulative logit and hierarchical logistic regression analyses were performed to identify patient factors, processes, and structures of care independently associated with guideline concordance.

Results

Of 14,114 veterans with IHD, 55.7% had hypertension, 71.5% had hyperlipidemia, and 41.6% had both conditions. Guideline concordance for LDL and BP were 38.9% and 53.4%, respectively. However, only 21.9% of the patients achieved both LDL <100 mg/dl and BP <140/90 mm Hg. In multivariable analyses, patient factors including older age and the presence of vascular disease were associated with worse guideline concordance. In contrast, diabetes was associated with better guideline concordance. Several process of care variables, including higher number of outpatient visits, higher number of prescribed medications, and a recent cardiac hospitalization were associated with better guideline concordance. Among structures of care, having on-site cardiology was associated with a trend towards better guideline concordance.

Conclusion

Guideline concordance with secondary prevention measures among IHD patients remains suboptimal. It is hoped that the findings of this study can serve as an impetus for quality improvement efforts to improve upon secondary prevention measures and reduce the morbidity and mortality of patients with known IHD.

Primary care practice-based research networks: working at the interface between research and quality improvement

PURPOSE

We wanted to describe the emerging role of primary care practice-based in research, quality improvement (QI), and translation of research into practice (TRIP).

METHODS

We gathered information from the published literature, discussions with PBRN leaders, case examples, and our own personal experience to describe a role for PBRNs that comfortably bridges the gap between research and QI, discovery and application, academicians and practitioners--a role that may lead to the establishment of true learning communities. We provide specific recommendations for network directors, network clinicians, and other potential stakeholders.

RESULTS

PBRNs function at the interface between research and QI, an interface called TRIP by some members of the research community. In doing so, PBRNs are helping to clarify the difficulty of applying study findings to everyday care as an inappropriate disconnect between discovery and implementation, research and practice. Participatory models are emerging in which stakeholders agree on their goals; apply their collective knowledge, skills, and resources to accomplish these goals; and use research and QI methods when appropriate.

CONCLUSIONS

PBRNs appear to be evolving from clinical laboratories into learning communities, proving grounds for generalizable solutions to clinical problems, and engines for improvement of primary care delivery systems.

A RIME perspective on the quality and relevance of current and future medical education research

In this article, the authors consider the quality and relevance of current and future medical education research by (1) presenting a framework for medical education research and reviewing basic principles of "good" empirical work, (2) extending the discussion of principles to "best practices," (3) considering the distinctive features of medical education that present challenges to the researcher, and (4) discussing opportunities for expanding the scope and influence of medical education research. Their audience is intended to be clinicians involved in education, deans and associate deans who create and direct educational curricula and processes, and those from offices critical to the educational mission such as admissions, student services and financial aid, as well as medical education researchers. The authors argue that the quality and relevance of current work can be enhanced when research is situated within a general framework and questions are asked that are based on literature and theory and push the field toward new knowledge. Obviously methods and designs must be appropriate and well-executed and sufficient data must be gathered. Multiple studies are highlighted that showcase the rigor and creativity associated with excellent quality work. However, good research is not without its challenges, most notably short timelines and the need to work within an ever-changing real-life educational environment. Most important, the field of medical education research has many opportunities to increase its impact and advance its quest to study important learners' behaviors and patients' outcomes. Programs to train and collaborate with clinical and administrative colleagues, as well as researchers in other fields, have great potential to improve the quality of research in the field.