Patient-centeredness and timeliness in a primary care network: baseline analysis and power assessment for detection of the effects of an electronic health record

Electronic health records are expected to improve all six dimensions of quality care identified by the Institute of Medicine (safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness). HealthTexas Provider Network, the ambulatory care network affiliated with the Baylor Health Care System in Dallas-Fort Worth, Texas, is implementing a networkwide ambulatory electronic health record (AEHR). To evaluate the quality of care and financial impact of the AEHR implementation, we examined the available indicators for quantitatively measuring performance in each dimension of quality. For patient-centeredness, the primary data source available is the patient satisfaction survey. To achieve a broad view of patient-centeredness, we identified two measures of satisfaction (overall satisfaction with the physician and willingness to refer the physician) to be examined individually and used additional survey items to construct physician interaction and organizational scales. These scales showed good reliability (Cronbach alpha = 0.95 and 0.89, respectively) and predictive ability ranging from 77% to 93% when applied to the overall satisfaction measures. Data from September 2003 to June 2006 showed mean pre-AEHR implementation baseline performance of 22.9 (±3.3) on the 25-point physician interaction scale and 38.0 (±5.8) on the 45-point organizational scale; 70.9% of patients reported excellent satisfaction with their physician, and 97.6% of patients reported willingness to refer. Timeliness data were collected using the same survey. Baseline performance showed that 43.4% of patients waited <2 days between making and keeping an appointment, and 50.6% of patients waited <5 minutes past appointment time. However, 12.5% waited >30 days between making and keeping an appointment, and 14.0% waited >30 minutes past appointment time. The power to detect changes in the patient-centeredness and timeliness measures in the 3-year multiple time series evaluation of the quality and financial impact of the AEHR was investigated and showed that even small changes in these measures will be detectable.

Quality of care of Medicare patients with diabetes in a metropolitan fee-for-service primary care integrated delivery system

Diabetes care in the United States is suboptimal. Although closed-panel health maintenance organizations (HMOs) and the Department of Veterans Affairs (VA) report performance superior to national norms, fee-for-service performance is uncertain. To address this issue, 3 outcome and 5 process indicators were measured for 2010 Medicare diabetes patients across 22 sites in a large, fee-for-service primary care group practice. American Diabetes Association standards for glycemic control, low-density lipoprotein cholesterol, and blood pressure were met by 53%, 46%, and 19% of patients, respectively. Diabetes Quality Improvement Project/Alliance poor control markers for the same measures were exceeded by 9%, 20%, and 54% of patients. Chart abstraction demonstrated annual eye examination, foot examination, and nephropathy screening rates of 16%, 49%, and 38%, while Medicare claims showed an annual eye examination rate of 63%. Observed processes and outcomes in this fee-for-service setting were superior to reported national performance and similar to the best performance in staff-model HMOs and the VA.

Clinical outcomes in patients with type 2 diabetes managed by a diabetes resource nurse in a primary care practice

OBJECTIVES

The purpose of this observational cohort study was to observe outcomes in geriatric (aged > or =65 years) and nongeriatric (<65 years) patients after employing a diabetes resource nurse (DRN) case manager in a suburban 12-physician family practice.

STUDY DESIGN

Data were collected by retrospective chart review of 106 patients enrolled in the diabetes care project who completed at least 6 months of the project between March 1999 and January 2001.

POPULATION

Patients were recruited by either referral from their primary physician or invitation from the DRN.

OUTCOMES MEASURED

Utilizing measures from the American Diabetes Association and the Diabetes Quality Improvement Project, comprehensive protocols were developed for implementation of process measures and management of glucose by the DRN. Active management protocols were not put in place for hypertension, lipids, or depression, but appropriate clinical measures were taken during patient visits. Data were collected at baseline, 6 months, and 12 months.

RESULTS

Improvements in process measures were seen for geriatric and nongeriatric patients: 77% of patients had foot exams, 100% had > or =2 blood pressure measurements, 92% had eye exams, and 99% had lipid profiles. Both groups had improvement in hemoglobin A1c levels (means 7.2% to 6.6% for geriatric patients and 8.9% to 6.8% for nongeriatric patients). The number of hypoglycemia incidents decreased in both groups. Depression scores improved in the nongeriatric group.

CONCLUSIONS

Results appear to corroborate a growing body of evidence supporting nurse intervention protocols as a way to improve diabetes care. A randomized controlled trial is planned to examine the effectiveness of the DRN.

D-dimer levels in blood salvage for autotransfusion

Autotransfusion of operatively salvaged blood is an increasingly attractive and used practice. The fear of precipitating a coagulopathy, however, has retarded the acceptance of autotransfusions and the efficiency and convenience of banked homologous blood has proved too competitive in recent years. The risk of transmitting diseases with bank homologous blood has seen a resurgence in the development of autotransfusion. The current alternatives to pre-operative autologous banking or dilution are the reinfusing of filtered salvaged blood, and of blood which has been further processed by washing which involves the extra cost of time, personnel and equipment. Washing removes possible harmful products, but also removes coagulation factors. D-Dimer levels were estimated by monoclonal antibody techniques in salvaged blood before and after washing in 10 patients undergoing aortic surgery and in 10 u of homologous banked blood. The D-Dimer levels in the unwashed blood were increased 85 times, but were normal in the washed blood. D-Dimers are an indication of activation of the coagulation and fibrinolytic systems and the presence of fibrin degradation products.

Timing of prophylactic antibiotics in abdominal surgery: trial of a pre-operative versus an intra-operative first dose

When prophylactic antibiotics are used in abdominal surgery it is customary to give the first dose before the operation. Whilst intra-operative antibiotics may be effective in elective surgery, there may be an advantage to starting pre-operatively when there is already an infective focus such as appendicitis. Antibiotics started pre-operatively (group P) have been compared with antibiotics started after initial abdominal exploration (group T). Three intravenous doses of 500 mg metronidazole plus 1 g cephazolin were given in a randomized, double-blind study of 700 emergency and elective high-risk abdominal operations. Antibiotic plasma concentrations at the end of the operation were significantly lower in group P but lay well within the therapeutic range. Wound infection rates, which included minor and delayed infections, were similar in both groups (group P, 57 of 342, 16.7 per cent; group T, 55 of 358, 15.4 per cent; 95 per cent confidence intervals for the difference being -4.1 to +6.7 per cent. In appendicitis, wound infection rates were 12.1 and 13.9 per cent for groups P and T respectively. However, non-fatal deep sepsis was more common in group P (nine cases) than in group T (two cases) (chi 2 = 4.9, P less than 0.05). Postoperative infection was twice as common in obese patients whose body mass index (BMI) was greater than or equal to 26 (39 of 132, 30 per cent) than in thin patients whose BMI was less than 24 (41 of 288, 14 per cent; chi 2 = 13.8, P less than 0.001). This study failed to show any advantage to starting antibiotics pre-operatively, even in appendicitis.