The Effectiveness of Outpatient Appointment Reminder Systems in Reducing No-Show Rates

Background

Patients who do not keep physician appointments (no-shows) represent a significant loss to healthcare providers. For patients, the cost includes their dissatisfaction and reduced quality of care. An automated telephone appointment reminder system may decrease the no-show rate. Understanding characteristics of patients who miss their appointments will aid in the formulation of interventions to reduce no-show rates.

Methods

In an academic outpatient practice, we studied patient acceptance and no-show rates among patients receiving a clinic staff reminder (STAFF), an automated appointment reminder (AUTO), and no reminder (NONE). Patients scheduled for appointments in the spring of 2007 were assigned randomly to 1 of 3 groups: STAFF (n = 3266), AUTO (n = 3219), or NONE (n = 3350). Patients in the STAFF group were called 3 days in advance by front desk personnel. Patients in the AUTO group were reminded of their appointments 3 days in advance by an automated, standardized message. To evaluate patient satisfaction with the STAFF and AUTO, we surveyed patients who arrived at the clinic (n = 10,546).

Results

The no-show rates for patients in the STAFF, AUTO, and NONE groups were 13.6%, 17.3%, and 23.1%, respectively (pairwise, P < .01 by analysis of variance for all comparisons). Cancellation rates in the AUTO and STAFF groups were significantly higher than in the NONE group (P < .004). Appointment reminder group, age, visit type, wait time, division specialty, and insurance type were significant predictors of no-show rates. Patients found appointment reminders helpful, but they could not accurately remember whether they received a clinic staff reminder or an automated appointment reminder.

Conclusions

A clinic staff reminder was significantly more effective in lowering the no-show rate compared with an automated appointment reminder system.     

An Outreach Intervention Increases Bone Densitometry Testing in Older Women

OBJECTIVES: To evaluate the performance of a patient recall intervention that relies on an outreach coordinator with a bachelor's degree to prompt women by mail and telephone about their eligibility for bone densitometry (dual-energy X-ray absorptiometry (DXA)) screening and allow them to schedule an examination without a medical provider visit ahead of time.
DESIGN: Observational.
SETTING: Academic general internal medicine practice.
INTERVENTION: Mail- and telephone-based patient recall for DXA.
PARTICIPANTS: Five hundred sixty-four women aged 65 to 79 at average risk for osteoporosis without a history of DXA.
MEASUREMENTS: Rates of DXA completion and the change in proportion of screened women during a 7-month intervention period, case finding for clinically significant bone loss, frequency of appropriate clinical follow-up, DXA no-show rates compared with usual care, and clinician satisfaction.
RESULTS: Through patient recall, rates of DXA screening rose significantly ( P <.001), and the proportion of the eligible clinic population screened increased 13%. Thirty percent of patients had clinically significant bone loss, with almost all of these receiving follow-up. DXA no-show rates were comparable with usual care, and provider acceptance was high.
CONCLUSION: A patient recall intervention substantially increased DXA screening, allowing pharmacological therapy to be started much earlier in some women with significant bone loss. It imposed minimal burden on providers and enhanced patient convenience. This type of program may have utility for additional preventive services.     

Predictors of clinic non‐attendance: opportunities to improve patient outcomes in colorectal cancer

Aim: Colorectal cancer is one of the few tumour types, where routine patient follow up has been demonstrated to impact significantly on survival. Patients who fail to attend regular clinic reviews may compromise their outcome, but the frequency at which this occurs is unknown. Identifying the extent of this problem, and the factors that predict non‐attendance, may provide opportunities to improve patient outcomes. Methods: Utilizing the Australian Comprehensive Cancer Outcomes and Research Database (ACCORD) colorectal database at Royal Melbourne and Western Hospitals and the Hospital Patient Management System (HOMER) we collected attendance data for colorectal surgical and oncology outpatient clinic appointments. Results: A total of 619 patients (368 men and 251 women) with curatively treated Australian ClinicoPathological Staging System (ACPS) Stage A, B and C colorectal cancer was identified from the two sites over 1988–2008. Twenty‐one per cent (n= 130) of patients failed to attend one or more appointments. Patients who failed to attend were more likely to require the services of an interpreter (25% vs 18%; P= 0.007), to have a smoking history and to have not received adjuvant therapy. Tumour site, patient age, sex and comorbidities were not associated with non‐attendance. Conclusion: A significant percentage of patients fail to attend routine clinic visits to colorectal speciality clinics. Patients at risk of non‐attendance can be identified. More research is needed to identify barriers as to why patients do not attend appointments and to develop measures that may improve patient attendance.     

Willingness and Access to Joint Replacement Among African American Patients With Knee Osteoarthritis: A Randomized,Controlled Intervention

Objective

African American patients are significantly less likely to undergo knee replacement for the management of knee osteoarthritis (OA). Racial difference in preference (willingness) has emerged as a key factor. This study was undertaken to examine the efficacy of a patient‐centered educational intervention on patient willingness and the likelihood of receiving a referral to an orthopedic clinic.

Methods

A total of 639 African American patients with moderate‐to‐severe knee OA from 3 Veterans Affairs primary care clinics were enrolled in a randomized, controlled trial with a 2 × 2 factorial design. Patients were shown a knee OA decision‐aid video with or without brief counseling. The main outcome measures were change in patient willingness and receipt of a referral to an orthopedic clinic. Also assessed were whether patients discussed knee pain with their primary care provider or saw an orthopedic surgeon within 12 months of the intervention.

Results

At baseline, 67% of the participants were definitely/probably willing to consider knee replacement, with no difference among the groups. The intervention increased patient willingness (75%) in all groups at 1 month. For those who received the decision aid intervention alone, the gains were sustained for up to 3 months. By 12 months postintervention, patients who received any intervention were more likely to report engaging their provider in a discussion about knee pain (92% versus 85%), to receive a referral to an orthopedic surgeon (18% versus 13%), and for those with a referral, to attend an orthopedic consult (61% versus 50%).

Conclusion

An educational intervention significantly increased the willingness of African American patients to consider knee replacement. It also improved the likelihood of patient–provider discussion about knee pain and access to surgical evaluation.

     

Intensive management of high‐utilizing adults with sickle cell disease lowers admissions

A minority of super‐utilizing adults with sickle cell disease (SCD) account for a disproportionate number of emergency department (ED) and hospital admissions. We performed a retrospective cohort study comparing the rate of admission before and after the opening of a clinic for adults with SCD. Unique to this clinic was an intensive management strategy, focusing on super‐utilizing adults with 12 or more admissions per year. ED/hospital and 30 days re‐admission rates were compared, 1 year pre‐ and post‐intervention, for those adults who established in the clinic. Prior to the intervention, 17 super‐utilizers, comprising 15% of the pre‐intervention cohort (n = 115), accounted for 58% of the total admissions and had an admission rate of 28 per patient‐year. When pre‐ and post‐intervention years were compared, rate of ED/hospital admission per patient‐year for super‐utilizers decreased from 27.9 to 13.5 (P < 0.001), while there was not a significant reduction for the entire cohort (7.1 vs. 6.1, P = 0.84). Similarly, the decrease in rate of 30 day re‐admission was larger for the super‐utilizers (13.5 per patient‐year to 1.8, P < 0.001), than the whole cohort (2.6 per patient‐year to 0.7, P = 0.006). Among the super‐utilizers, the reduced rate of admission from the pre‐ to post‐clinic intervention year equated to 252 fewer ED/hospital admissions and 227 fewer 30 day re‐admissions. This management strategy focusing on super‐utilizing adults with SCD lowered admission and 30 day re‐admission rate. Am. J. Hematol. 90:215–219, 2015. © 2014 Wiley Periodicals, Inc.     

Cervical cancer screening in the urgent care setting

OBJECTIVE: To determine the feasibility of cervical cancer screening in an urgent care clinic. DESIGN: Prospective randomized trial. SETTING: Public teaching hospital. PATIENTS: Women presenting to the urgent care clinic whose evaluation necessitated a pelvic examination were eligible for participation. Women who had a hysterectomy, had a documented Pap test at our institution in the past year, did not speak English or Spanish, or had significant vaginal bleeding were excluded. Women presenting to the gynecology clinic for a scheduled Pap test were used as a comparison group for rates of follow-up, Pap smear adequacy, and Pap smear abnormalities. INTERVENTIONS: Women randomized to the intervention group had a Pap test performed as part of their pelvic examination, while women in the usual care group were encouraged to schedule an appointment in the gynecology clinic at a later date. The women in the two groups completed identical questionnaires regarding cervical cancer risk factors and demographic information. MEASUREMENTS AND MAIN RESULTS: Ninety-four (84.7%) of 111 women in the intervention group received a Pap test, as compared with 25 (29%) of 86 in the usual care group (P<.01). However, only 5 (24%) of 21 women with abnormal Pap smears in the intervention group received follow-up compared with 6 (60%) of 10 women seen during the same time period in the gynecology clinic for self-referred, routine annual examinations (P=.11). Pap smears obtained in the urgent care clinic were similar to those in the gynecology clinic with regard to abnormality rate (22.3% vs 20%; P=.75, respectively) and specimen adequacy (67% vs 72%; P=.54, respectively). CONCLUSIONS: Urgent care clinic visits can be used as opportunities to perform Pap test screening in women who are unlikely to adhere to cervical cancer screening recommendations. However, to accure the full potential benefit from this intervention, an improved process to ensure patient follow-up must be developed. Presented at the Society of General Internal Medicine annual meeting, San Francisco, Calif, May 1, 1999 Funding for this research was provided by the Division of General Internal Medicine, University of Colorado Health Sciences Center.     

Resource Utilization After Introduction of a Standardized Clinical Assessment and Management Plan

Introduction. A Standardized Clinical Assessment and Management Plan (SCAMP) is a novel quality improvement initiative that standardizes the assessment and management of all patients who carry a predefined diagnosis. Based on periodic review of systemically collected data the SCAMP is designed to be modified to improve its own algorithm. One of the objectives of a SCAMP is to identify and reduce resource utilization and patient care costs. Methods. We retrospectively reviewed resource utilization in the first 93 arterial switch operation (ASO) SCAMP patients and 186 age-matched control ASO patients. We compared diagnostic and laboratory testing obtained at the initial SCAMP clinic visit and control patient visits. To evaluate the effect of the SCAMP over time, the number of clinic visits per patient year and echocardiograms per patient year in historical control ASO patients were compared to the projected rates for ASO SCAMP participants. Results. Cardiac magnetic resonance imaging (MRI), stress echocardiogram, and lipid profile utilization were higher in the initial SCAMP clinic visit group than in age-matched control patients. Total echocardiogram and lung scan usage were similar. Chest X-ray and exercise stress testing were obtained less in SCAMP patients. ASO SCAMP patients are projected to have 0.5 clinic visits and 0.5 echocardiograms per year. Historical control patients had more clinic visits (1.2 vs. 0.5 visits/patient year, P < .01) and a higher echocardiogram rate (0.92 vs. 0.5 echocardiograms/patient year, P < .01) Conclusion. Implementation of a SCAMP may initially lead to increased resource utilization, but over time resource utilization is projected to decrease.     

Evaluating the effectiveness of patient education and empowerment to improve patient–provider interactions in antiretroviral therapy clinics in Namibia

In order to increase patient active engagement during patient–provider interactions, we developed and implemented patient training sessions in four antiretroviral therapy (ART) clinics in Namibia using a “Patient Empowerment” training curriculum. We examined the impact of these trainings on patient–provider interactions after the intervention. We tested the effectiveness of the intervention using a randomized parallel group design, with half of the 589 enrolled patients randomly assigned to receive the training immediately and the remaining randomized to receive the training 6 months later. The effects of the training on patient engagement during medical consultations were measured at each clinic visit for at least 8 months of follow-up. Each consultation was audiotaped and then coded using the Roter Interaction Analysis System (RIAS). RIAS outcomes were compared between study groups at 6 months. Using intention-to-treat analysis, consultations in the intervention group had significantly higher RIAS scores in doctor facilitation and patient activation (adjusted difference in score 1.19, p?=?.004), doctor information gathering (adjusted difference in score 2.96, p?=?.000), patient question asking (adjusted difference in score .48, p?=?.012), and patient positive affect (adjusted difference in score 2.08, p?=?.002). Other measures were higher in the intervention group but did not reach statistical significance. We have evidence that increased engagement of patients in clinical consultation can be achieved via a targeted training program, although outcome data were not available on all patients. The patient training program was successfully integrated into ART clinics so that the trainings complemented other services being provided.     

Activating Seniors to Improve Chronic Disease Care: Results from a Pilot Intervention Study

OBJECTIVES: To evaluate the effect of an activation intervention delivered in community senior centers to improve health outcomes for chronic diseases that disproportionately affect older adults. DESIGN: Two‐group quasi‐experimental study. SETTING: Two Los Angeles community senior centers. PARTICIPANTS: One hundred sixteen senior participants. INTERVENTION: Participants were invited to attend group screenings of video programs intended to inform about and motivate self‐management of chronic conditions common in seniors. Moderated discussions reinforcing active patient participation in chronic disease management followed screenings. Screenings were scheduled over the course of 12 weeks. MEASUREMENTS: One center was assigned by coin toss to an encouragement condition in which participants received a $50 gift card if they attended at least three group screenings. Participants in the nonencouraged center received no incentive for attendance. Validated study measures for patient activation, physical activity, and health‐related quality of life were completed at baseline and 12 weeks and 6 months after enrollment. RESULTS: Participants attending the encouraged senior center were more likely to attend three or more group screenings (77.8% vs 47.2%, P=.001). At 6‐month follow‐up, participants from either center who attended three or more group screenings (n=74, 64%) reported significantly greater activation (P<.001), more minutes walking (P<.001) and engaging in vigorous physical activity (P=.006), and better health‐related quality of life (Medical Outcomes Study 12‐item Short‐Form Survey (SF‐12) mental component summary, P<.001; SF‐12 physical component summary, P=.002). CONCLUSION: Delivering this pilot intervention in community senior centers is a potentially promising approach to activating seniors that warrants further investigation for improving chronic disease outcomes.     

An educational intervention for providers to promote bone health in high-risk older patients

OBJECTIVES: To design, implement, and assess an educational intervention for providers focused on osteoporosis screening and management in older patients with chronic obstructive pulmonary disease or asthma who have been prescribed prolonged courses of oral or high‐dose inhaled corticosteroids or both and are therefore at high risk for bone loss and fractures. DESIGN: One‐group pretest–posttest. SETTING: Academic outpatient pulmonary practice. PARTICIPANTS: Nineteen pulmonary specialists at an academic medical center. INTERVENTION: Educational theory and a needs assessment and attitude survey guided the development of a multicomponent educational intervention. MEASUREMENTS: Change in provider behavior was assessed by auditing the electronic medical records for adherence to osteoporosis management guidelines in high‐risk patients seen by participants at baseline and for 6 months after the educational intervention. Knowledge transfer and changes in attitude were assessed using pre‐ and posttests and surveys. RESULTS: A 19% increase in overall rate of adherence to osteoporosis management guidelines in high‐risk patients was observed: 45% before intervention to 64% after intervention (n=249 patients, P=.003). Postintervention surveys and test scores also showed statistically significant gains from baseline. CONCLUSION: An educational intervention improved adherence to osteoporosis management guidelines of academic pulmonary specialists. The results of this study provide evidence for the positive effect of a multimodal educational program in altering practice behaviors.     

Recognition of patient referral desires in an academic managed care plan

OBJECTIVE: To determine the frequency and determinants of provider nonrecognition of patients’ desires for specialist referral. DESIGN: Prospective study. SETTING: Internal medicine clinic in an academic medical center providing primary care to patients enrolled in a managed care plan. PARTICIPANTS: Twelve faculty internists serving as primary care providers (PCPs) for 856 patient visits. MEASUREMENTS AND MAIN RESULTS: Patients were given previsit and postvisit questionnaires asking about referral desire and visit satisfaction. Providers, blinded to patients’ referral desire, were asked after the visit whether a referral was discussed, who initiated the referral discussion, and whether the referral was indicated. Providers failed to discuss referral with 27% of patients who indicated a definite desire for referral and with 56% of patients, who indicated a possible desire for referral. There was significant variability in provider recognition of patient referral desire. Recognition is defined as the provider indicating that a referral was discussed when the patient marked a definite or possible desire for referral. Provider recognition improved significantly (P<.05), when the patient had more than one referral desire, if the patient or a family member was a health care worker and when the patient noted a definite desire versus a possible desire for referral. Patients were more likely (P<.05) to initiate a referral discussion when they had seen the PCP previously and had more than one referral desire. Of patient-initiated referral requests, 14% were considered “not indicated” by PCPs. Satisfaction with care did not differ in patients with a referral desire that were referred and those that were nor referred. CONCLUSIONS: These PCPs frequently failed to explicitly recognize patients’ referral desires. Patients were more likely to initiate discussions of a referral desire when they saw their usual PCP and had more than a single referral desire. This work was funded by University Hospital Board of Directors, Denver, Colo.     

综合性护理对老年糖尿病合并重症脑梗塞患者的效果研究

目的研究综合性护理对老年糖尿病合并重症脑梗塞患者的效果。方法选取2015年1月—2018年12月该院收治的50例合并重症脑梗塞的老年糖尿病患者,采用随机数字表的方法将其随机分为常规组和观察组,各25例,常规组患者入院后采取常规临床护理服务进行干预;观察组患者入院后在常规组的基础上加入综合性护理服务进行干预,对比两组患者护理效果、两组患者干预前、后血糖水平及欧洲卒中量表(ESS)评分变化、两组患者护理满意度。结果观察组护理总有效率(92%)显著优于常规组(72%),差异有统计学意义(P<0.05);两组患者干预前血糖水平比较,差异无统计学意义(P>0.05);干预后两组患者均有所好转,但观察组明显优于常规组,差异有统计学意义(P<0.05);观察组的满意度(84%)明显高于常规组满意度(56%),差异有统计学意义(P<0.05)。结论对老年糖尿病合并重症脑梗塞患者采取综合性护理干预,能够有效的提高治疗效果,改善患者的病情,同时提高患者满意度,降低护患纠纷发生几率,值得积极推广与应用。     

Reducing emergency department visits utilizing a primary care asthma specialty clinic in a high-risk patient population

Objective: Asthma is a leading cause of pediatric emergency department (ED) use. Optimizing asthma outcomes is a goal of Nationwide Children's Hospital (NCH) and its affiliated Accountable Care Organization. NCH's Primary Care Network, comprised of 12 offices serving a predominantly Medicaid population, sought to determine whether an Asthma Specialty Clinic (ASC) operated within a single primary care office could reduce ED asthma rates and improve quality measures, relative to all other network offices. Methods: An ASC was piloted with four components: patient monitoring, provider continuity, standardized assessment, and multi-disciplinary education. A registry was established to contact patients at recommended intervals. At extended-length visits, a general pediatrician evaluated patients and a multi-disciplinary team provided education. Novel educational tools were utilized, guideline-based templates recorded and spirometry obtained. ED asthma rate, spirometry utilization, and controller fills by intervention office patients were compared to all other network offices before and after ASC initiation. Results: At baseline, asthma ED visits by intervention and usual care populations were similar (p = 0.43). After, rates were significantly lower for intervention office patients versus usual care office patients (p < 0.001), declining in the intervention population by 26.2%, 25.2%, and 31.8% in 2013, 2014, and 2015, respectively, from 2012 baseline, versus increases of 3.8%, 16.2%, and 9.5% in the usual care population. Spirometry completion, controller fills, and patients with favorable Asthma Medication Ratios significantly increased for intervention office patient relative to the usual care population. Conclusions: A primary care-based asthma clinic was associated with a significant and sustainable reduction in ED utilization versus usual care. What's new: This study describes a comprehensive, multi-disciplinary, and innovative model for an asthma management program within the medical home that demonstrated a significant reduction in ED visits, an increase in spirometry utilization, and an increase in controller fills in a high-risk asthma population versus comparison group.     

Use of Computed Tomography of the Head in the Hypotensive Blunt-Trauma Patient

Study objective: To identify patients presenting with hypotension due to blunt trauma who should undergo computed tomography (CT) of the head before urgent chest or abdominal operation.Design: Retrospective registry-based record review. Setting: Urban Level I trauma center. Participants: Consecutive trauma patients with suspected head injury, blunt mechanism of injury, and hypotension who were discharged between January 1, 1989, and December 31, 1991. Patients who were dead on arrival or died within 15 minutes of arrival were judged unsalvageable and excluded. Review of 3,224 trauma patients identified 212 as the study population. Interventions: Frequency of neurosurgical intervention or general surgical intervention within 6 hours of admission and the time required for completion of CT of the head were noted. Results: Overall, 40 general surgical operations (19%) and 16 craniotomies (8%) were performed, with a mortality rate of 18%. Patients with Glasgow Coma Scale scores of less than 8 had a 19% rate of craniotomy, and those with scores between 8 and 13 had a 9% rate. Sixteen patients had CT before surgery, with an average delay of 68 minutes. No patient who responded to initial resuscitation experienced hemodynamic instability in the CT suite, including 15 patients with positive diagnostic peritoneal lavage. Conclusion: CT scan of the head before general surgical operation appears to be safe in patients who respond to initial resuscitation. The likelihood of craniotomy in patients with Glasgow Coma Scale scores of 13 or less is comparable to the likelihood of general surgical operation. Physicians should be encouraged to make CT of the head a high priority in this group. [Winchell RJ, Hoyt DB, Simons RK: Use of computed tomography of the head in the hypotensive blunt-trauma patient. Ann Emerg Med June 1995;25:737-742.]     

Percutaneous vertebral artery intervention: a necessary tool in every interventional cardiologist armamentarium

OBJECTIVES: The purpose of this study was to evaluate the results of endovascular treatment of symptomatic vertebrobasilar insufficiency unresponsive to medical therapy. METHODS: Twenty-eight patients who were regularly followed up in our cardiology clinic with symptoms suggestive of posterior fossa ischemia and with diagnostic or suspicious findings on ultrasound evaluation were evaluated with selective vertebral and subclavian artery angiography. All patients (17 men, 11 women; mean age, 64 years; range, 54-87) had critical lesions (>70% stenosis) in the vertebral or subclavian arteries or both. Those lesions that were considered severe enough to explain the reported symptomatology underwent percutaneous intervention and stent placement. All patients were followed up through clinic visits for a mean of 14.2 months (range, 3.5-24.3). RESULTS: In the 28 patients treated, 25 vertebral and 10 subclavian stents were placed. Success (<20% residual diameter stenosis, without stroke or death) was achieved in 27 patients (96%). One patient who had been undergoing intervention for a subtotal occlusion of the left subclavian artery developed a posterior fossa transient ischemic attack. At follow-up, 25 patients (89%) were alive, and 22 (88%) of those had no further neurological complaints. Three (11%) patients died during follow-up from cardiac complications. One (3.5%) patient had recurrent symptoms with in-stent restenosis at 6 months with successful balloon angioplasty and resolution of symptoms. CONCLUSIONS: Posterior fossa ischemia is an underdiagnosed condition that occurs with relative frequency in the usual patient population that interventional cardiologists attend to. Endovascular treatment using coronary wires and stents including drug-eluting stents is the treatment of choice for vertebral artery revascularization due to its high technical success rate, low complication rate, and long-term durability.     

The disposition of hepatitis C antibody-positive patients in an urban hospital

Summary. Previous studies have indicated that only 26–61% of hepatitis C virus (HCV) antibody‐positive patients are referred to specialists who treat HCV. However, these studies were conducted in homogeneous populations and before pegylated interferon and ribavirin became the standard of care for chronic HCV infection. The aims of this study were: (i) to determine the percentage of HCV antibody‐positive patients who were referred to specialists for further management in an urban, racially diverse population, (ii) to determine the percentage of referred patients who attend specialty clinics, and (iii) to identify factors that predict referral and follow‐up. All patients with a positive HCV antibody test in 2005 were identified by an inquiry of Epic^TM, our electronic medical record system. All medical records were reviewed for demographics, location where the test was ordered (inpatient vs outpatient), specialty ordering the test, referral, clinic attendance, detectability of HCV RNA and liver function tests. Univariate and multivariate logistic regression were used to evaluate each variable’s effect on referral and clinic attendance. Overall, 251 of 375 (67%) antibody positive patients were referred to HCV specialists. Of the 251 referrals, 166 (66%) attended at least one specialty clinic appointment. Patients were more likely to be referred if their HCV antibody was ordered in the outpatient setting (77% outpatient vs 38% inpatient, P < 0.001) ordered by a family practitioner (79% FP vs 64% for internal medicine doctor vs 58% for all other specialties, P = 0.01) had detectable RNA (88% detectable vs 65% not detectable vs 23% RNA status not available, P < 0.001) or elevation of alanine aminotransferase (75% elevated vs 56% not elevated, P < 0.001). Location, HCV RNA status and ALT elevation remained significant in a multivariate logistic regression model. These data confirm that up to one‐third of HCV antibody‐positive patients are not referred to HCV specialists, despite the availability of improved treatment regimens. Additional patients are lost to follow‐up after being referred. The reasons for suboptimal referral and specialty clinic attendance rates are probably multifactorial. Institution of reflexive RNA testing for positive antibody tests and additional education of those physicians who encounter HCV‐positive individuals may improve both rates.     

A Comprehensive Hip Fracture Program Reduces Complication Rates and Mortality

OBJECTIVES: To evaluate the rate of postoperative complications, length of stay, and 1‐year mortality before and after introduction of a comprehensive multidisciplinary fast‐track treatment and care program for hip fracture patients (the optimized program). DESIGN: Retrospective chart review with historical control. SETTING: Orthopedic ward (110 beds) at a university hospital (700 beds). PARTICIPANTS: Five hundred thirty‐five consecutive patients aged 40 and older (94%≥60) hospitalized for hip fracture between January 1, 2003, and March 31, 2004. Three hundred and thirty‐six patients (70.3%) were community dwellers before the fracture and 159 (29.7%) were admitted from nursing homes. INTERVENTION: The fast‐track treatment and care program included a switch from systemic opiates to a local femoral nerve catheter block; an earlier assessment by the anesthesiologist; and a more‐systematic approach to nutrition, fluid and oxygen therapy, and urinary retention. RESULTS: In the intervention group, the rate of any in‐hospital postoperative complication was reduced from 33% to 20% (odds ratio=0.61, 95% confidence interval=0.4–0.9; P=.002). Rates of confusion (P=.02), pneumonia (P=.03), and urinary tract infection (P<.001) were lower in the intervention group than in the control group, and length of stay was 15.8 days in the control group, versus 9.7 days in the intervention group (P<.001). For community dwellers, 12‐month mortality was 23% in the control group versus 12% in the intervention group (P=.02). Overall 12‐month mortality was 29% in the control group and 23% in the intervention group (P=.2). CONCLUSION: The optimized hip fracture program reduced the rate of in‐hospital postoperative complications and mortality. Randomized clinical trials are needed to confirm these results and elucidate the elements of the program that have the greatest effect on clinical outcomes and mortality.     

Improvements in advance care planning in the Veterans Affairs System: results of a multifaceted intervention

BACKGROUND: Advance care planning (ACP) aims to guide health care in the event of decisional incapacity. Interventions to promote ACP have had limited effectiveness. We conducted an educational and motivational intervention in Department of Veterans Affairs outpatient clinics to increase ACP use and proxy and health care provider understanding of patients' preferences and values. METHODS: We recruited 23 providers and up to 14 of each of their patients; the patients were randomized to the control or intervention group. Eligibility criteria included a preexisting relationship with the provider, age 55 years or older, chronic health condition(s), and no recorded advance directive. The intervention group (n = 119) received an ACP workbook, motivational counseling by social workers, and cues to providers to discuss ACP. The control group (n = 129) received an advance directive booklet. RESULTS: The intervention patients reported more ACP discussions with their providers (64% vs 38%; P<.001). Living wills were filed in the medical record twice as often in the intervention group (48% vs 23%; P<.001). Provider-patient dyads in the intervention group had higher agreement scores than the control group for treatment preferences, values, and personal beliefs (58% vs 48%, 57% vs 46%, and 61% vs 47%, respectively; P<.01 for all comparisons). The agreement scores for the proxy-patient dyads did not differ between groups for treatment preferences and values, but were higher in the intervention than the control group for personal beliefs (67% vs 56%). CONCLUSION: This intervention demonstrates mixed results and highlights the ongoing challenges of helping health care providers and potential proxy decision makers represent patient preferences and values.     

Meeting walk-in patients’ expectations for testing effects on satisfaction

OBJECTIVE: To examine the relation between meeting expectations for tests and visit satisfaction in walk-in patients. DESIGN: Survey of patients before and after the visit. SETTING: Walk-in medical clinic at a Veterans Affairs Medical Center. PATIENTS: 143 male veterans were eligible for this study: 128 agreed to participate; 109 completed both questionnaires. MEASUREMENTS: Before the visit, we measured health status, baseline satisfaction with care, and expectations for common tests. After the visit, we measured visit-specific satisfaction, patient perception of provider interpersonal behavior (provider humanism), and patient report of whether specific tests were received. Logistic regression was used to determine the effect of meeting expectations for tests while controlling for other factors. RESULTS: Of all patients, 62% expected one or more tests, nearly as many as expected a medication or a diagnosis. In multivariate analysis restricted to those expecting tests, provider humanism was the sole significant predictor of visit-specific satisfaction (odds ratio [OR] 6.4; 95% confidence interval [CI] 1.6, 26.1). The proportion of expectations for testing that were met was not significantly associated with satisfaction (OR 1.05; 95% CI 0.92, 1.21). CONCLUSIONS: Meeting patient expectations for tests does not have an important effect on satisfaction. Even in the walk-in setting, patient perception of the providers’ interpersonal behavior was a more important factor in satisfaction with the visit. Physicians who order tests solely to improve patient satisfaction may be able to reduce unnecessary testing without decreasing patient satisfaction. Dr. Froehlich is a Veterans Affairs Ambulatory Care Fellow. Dr. Welch is supported by a Veterans Affairs Career Development Award in health services research and development.     

Utilization of a patient-centered asthma passport tool in a subspecialty clinic

Introduction: Despite available and effective tools for asthma self-assessment (Asthma Control Test, ACT) and self-management (Asthma Action Plan, AAP), they are underutilized in outpatient specialty clinics. We evaluated the impact of a patient-centered checklist, the Asthma Passport, on improving ACT and AAP utilization in clinic. Methods: This was a randomized, interventional quality-improvement project in which the Asthma Passport was distributed to 120 pediatric asthma patients over the duration of 16 weeks. The passport's checklist consisted of tasks to be completed by the patient/family, including completion of the ACT and AAP. We compared rates of completion of the ACT and AAP for those who received the passport versus the control group, and assessed patient/caregiver and provider satisfaction. Results: Based on electronic medical record data from 222 participants, the ACT completion rate was not significantly different between the passport and control groups, however, the AAP completion rate was significantly greater than control (30.0% vs. 17.7%, p = 0.04). When per-protocol analysis was limited to groups who completed and returned their passports, ACT and AAP completion rates were significantly greater than control (73.8% vs. 44.1% (p = 0.002) and 35.7% vs. 17.7% (p = 0.04), respectively). Nearly all participants reported high satisfaction with care, and surveyed providers viewed the passport favorably. Conclusions: A patient-centered checklist significantly improved the completion rate of the AAP. For patient's who completed and returned the asthma passport, the ACT completion rate was also improved. Participants and providers reported high satisfaction with the checklist, suggesting that it can effectively promote asthma self-management and self-assessment without burdening clinicians or clinic workflow.