Development of a Structured Year-End Sign-Out Program in an Outpatient Continuity Practice

BACKGROUND

In an effort to prevent medical errors, it has been recommended that all healthcare organizations implement a standardized approach to communicating patient information during transitions of care between providers. Most research on these transitions has been conducted in the inpatient setting, with relatively few studies conducted in the outpatient setting.

OBJECTIVES

To develop a structured transfer of care program in an academic outpatient continuity practice and evaluate whether this program improved patient safety as measured by the documented completion of patient care tasks at 3 months post-transition.

DESIGN

Graduating residents and the corresponding incoming interns inheriting their continuity patient panels were randomized to the pilot structured transfer group or the standard transfer group. The structured transfer group residents were asked to complete written and verbal sign-outs with their interns; the standard transfer group residents continued the current standard of care.

PARTICIPANTS

Thirty-two resident-intern pairs in an academic internal medicine residency program in New York City.

MAIN MEASURES

Three months after the transition, study investigators evaluated whether patient care tasks assigned by the graduating residents had been successfully completed by the interns in both groups. In addition, follow-up appointments, continuity of care and house officer satisfaction with the sign-out process were evaluated.

KEY RESULTS

Among patients seen during the first 3 months, the clinical care tasks were more likely to be completed by interns in the structured group (73 %, n?=?49) versus the standard group (46 %, n?=?28) (adjusted OR 3.21; 95 % CI 1.55–6.62; p?=?0.002). This was further enhanced if the intern who saw the patient was also the assigned primary care provider (adjusted OR 4.26; 95 % CI 1.7–10.63; p?=?0.002).

CONCLUSIONS

A structured outpatient sign-out improved the odds of follow-up of important clinical care tasks after the year-end resident clinic transition. Further efforts should be made to improve residents’ competency with regard to sign-outs in the ambulatory setting.     

Impact of 4 + 1 Block Scheduling on Patient Care Continuity in Resident Clinic

BACKGROUND

Leaders in medical education have called for redesign of internal medicine training to improve ambulatory care training. 4?+?1 block scheduling is one innovative approach to enhance ambulatory education.

AIM

To determine the impact of 4?+?1 scheduling on resident clinic continuity.

SETTING

Resident continuity clinic in traditional scheduling in which clinics are scheduled intermittently one-half day per week, compared to 4?+?1 in which residents alternate 1 week of clinic with 4 weeks of an inpatient rotation or elective.

PARTICIPANTS

First-year internal medicine residents.

PROGRAM DESCRIPTION

We measured patient–provider visit continuity, phone triage encounter continuity, and lab follow-up continuity.

PROGRAM EVALUATION

In traditional scheduling as opposed to 4?+?1 scheduling, patients saw their primary resident provider a greater percentage; 71.7 % vs. 63.0 % (p?=?0.008). In the 4?+?1 model, residents saw their own patients a greater percentage; 52.1 % vs. 37.1 % (p?=?0.0001). Residents addressed their own labs more often in 4?+?1 model; 90.7 % vs. 75.6 % (p?=?0.001). There was no significant difference in handling of triage encounters; 42.3 % vs. 35.8 % (p?=?0.12).

DISCUSSION

4?+?1 schedule improves visit continuity from a resident perspective, and may compromise visit continuity from the patient perspective, but allows for improved laboratory follow-up, which we pose should be part of an emerging modern definition of continuity.     

Randomized, Controlled Trial of a Multimodal Intervention to Improve Cancer Screening Rates in a Safety-Net Primary Care Practice

Background

Cancer screening rates are suboptimal for low-income patients.

Objective

To assess an intervention to increase cancer screening among patients in a safety-net primary care practice.

Design

Patients at an inner-city family practice who were overdue for cancer screening were randomized to intervention or usual care. Screening rates at 1 year were compared using the chi-square test, and multivariable analysis was performed to adjust for patient factors.

Subjects

All average-risk patients at an inner-city family practice overdue for mammography or colorectal cancer (CRC) screening. Patients’ ages were 40 to 74 years (mean 53.9, SD 8.7) including 40.8 % African Americans, 4.2 % Latinos, 23.2 % with Medicaid and 10.9 % without any form of insurance.

Intervention

The 6-month intervention to promote cancer screening included letters, automated phone calls, prompts and a mailed Fecal Immunochemical Testing (FIT) Kit.

Main Measures

Rates of cancer screening at 1 year.

Key Results

Three hundred sixty-six patients overdue for screening were randomly assigned to intervention (n?=?185) or usual care (n?=?181). Primary analysis revealed significantly higher rates of cancer screening in intervention subjects: 29.7 % vs. 16.7 % for mammography (p?=?0.034) and 37.7 % vs. 16.7 % for CRC screening (p?=?0.0002). In the intervention group, 20 % of mammography screenings and 9.3 % of CRC screenings occurred at the early assessment, while the remainder occurred after repeated interventions. Within the CRC intervention group 44 % of screened patients used the mailed FIT kit. On multivariable analysis the CRC screening rates remained significantly higher in the intervention group, while the breast cancer screening rates were not statistically different.

Conclusions

A multimodal intervention significantly increased CRC screening rates among patients in a safety-net primary care practice. These results suggest that relatively inexpensive letters and automated calls can be combined for a larger effect. Results also suggest that mailed screening kits may be a promising way to increase average-risk CRC screening.     

Effect of a Systems Intervention on the Quality and Safety of Patient Handoffs in an Internal Medicine Residency Program

BACKGROUND

Poor quality handoffs have been identified as a major patient safety issue. In residency programs, problematic handoffs may be an unintended consequence of duty-hour restrictions, and key data are frequently omitted from written handoffs because of the lack of standardization of content.

OBJECTIVE

Determine whether an intervention that facilitates face-to-face communication supported by an electronic template improves the quality and safety of handoffs.

DESIGN

Before-after trial.

PARTICIPANTS

Thirty-nine interns providing nighttime coverage over 132 intern shifts, representing ～9,200 handoffs.

INTERVENTIONS

Two interventions were implemented serially—an alteration of the shift model to facilitate face-to-face verbal communication between the primary and nighttime covering physicians and an electronic template for the day-to-night handoff.

MEASUREMENTS

Overall satisfaction and handoff quality were measured using a survey tool administered at the end of each intern shift. Written handoff quality, specifically the documentation of key components, was also assessed before and after the template intervention by study investigators. Interns used the survey tool to report patient safety events related to poor quality handoffs, which were validated by study investigators.

RESULTS

In adjusted analyses comparing intern cohorts with similar levels of training, overall satisfaction with the new handoff processes improved significantly (p?<?0.001) post intervention. Verbal handoff quality (4/10 measures) and written handoff quality (5/6 measures) also improved significantly. Study investigators also found significant improvement in documentation of key components in the written handoff. Interns reported significantly fewer reported data omissions (p?=?0.001) and a non-significant reduction in near misses (p?=?0.056), but no significant difference in adverse events (p?=?0.41) post intervention.

CONCLUSIONS

Redesign of shift models common in residency programs to minimize the number of handoffs and facilitate face-to-face communication, along with implementation of electronic handoff templates, improves the quality of handoffs in a learning environment.     

Financial Incentives for Home-Based Health Monitoring: A Randomized Controlled Trial

BACKGROUND

Home wireless device monitoring could play an important role in improving the health of patients with poorly controlled chronic diseases, but daily engagement rates among these patients may be low.

OBJECTIVE

To test the effectiveness of two different magnitudes of financial incentives for improving adherence to remote-monitoring regimens among patients with poorly controlled diabetes.

DESIGN

Randomized, controlled trial. (Clinicaltrials.gov Identifier: NCT01282957).

PARTICIPANTS

Seventy-five patients with a hemoglobin A1c greater than or equal to 7.5 % recruited from a Primary Care Medical Home practice at the University of Pennsylvania Health System.

INTERVENTIONS

Twelve weeks of daily home-monitoring of blood glucose, blood pressure, and weight (control group; n?=?28); a lottery incentive with expected daily value of $2.80 (n?=?26) for daily monitoring; and a lottery incentive with expected daily value of $1.40 (n?=?21) for daily monitoring.

MAIN MEASURES

Daily use of three home-monitoring devices during the three-month intervention (primary outcome) and during the three-month follow-up period and change in A1c over the intervention period (secondary outcomes).

KEY RESULTS

Incentive arm participants used devices on a higher proportion of days relative to control (81 % low incentive vs. 58 %, P?=?0.007; 77 % high incentive vs. 58 %, P?=?0.02) during the three-month intervention period. There was no difference in adherence between the two incentive arms (P?=?0.58). When incentives were removed, adherence in the high incentive arm declined while remaining relatively high in the low incentive arm. In month 6, the low incentive arm had an adherence rate of 62 % compared to 35 % in the high incentive arm (P?=?0.015) and 27 % in the control group (P?=?0.002).

CONCLUSIONS

A daily lottery incentive worth $1.40 per day improved monitoring rates relative to control and had significantly better efficacy once incentives were removed than a higher incentive.     

The Impact of a Medical Procedure Service on Patient Safety,Procedure Quality and Resident Training Opportunities

BACKGROUND

At some academic hospitals, medical procedure services are being developed to provide supervision for residents performing bedside procedures in hopes of improving patient safety and resident education. There is limited knowledge of the impact of such services on procedural complication rates and resident procedural training opportunities.

OBJECTIVE

To determine the impact of a medical procedure service (MPS) on patient safety and resident procedural training opportunities.

DESIGN

Retrospective cohort analysis comparing characteristics and outcomes of procedures performed by the MPS versus the primary medical service.

PARTICIPANTS

Consecutive adults admitted to internal medicine services at a large academic hospital who underwent a bedside medical procedure (central venous catheterization, thoracentesis, paracentesis, lumbar puncture) between 1 July 2010 and 31 December 2011.

MAIN MEASURES

The primary outcome was a composite rate of major complications. Secondary outcomes included resident participation in bedside procedures and use of “best practice” safety process measures.

KEY RESULTS

We evaluated 1,707 bedside procedures (548 by the MPS, 1,159 by the primary services). There were no differences in the composite rate of major complications (1.6 % vs. 1.9 %, p?=?0.71) or resident participation in bedside procedures (57.0 % vs. 54.3 %, p?=?0.31) between the MPS and the primary services. Procedures performed by the MPS were more likely to be successfully completed (95.8 % vs. 92.8 %, p?=?0.02) and to use best practice safety process measures, including use of ultrasound guidance when appropriate (96.8 % vs. 90.0 %, p?=?0.0004), avoidance of femoral venous catheterization (89.5 vs. 82.7 %, p?=?0.02) and involvement of attending physicians (99.3 % vs. 57.0 %, p?<?0.0001).

CONCLUSIONS

Although use of a MPS did not significantly affect the rate of major complications or resident opportunities for training in bedside procedures, it was associated with increased use of best practice safety process measures.     

Does drug-induced sleep endoscopy change the treatment concept of patients with snoring and obstructive sleep apnea?

Purpose

Success rates of non-ventilation therapies for sleep disordered breathing (SDB) remain hardly acceptable. Drug-induced sleep endoscopy (DISE) tends to show the level and mechanism of obstruction and helps to specify therapy individually. Therefore, increasing success rates are expected. The objective of this study is to detect whether locations of treatment recommendations given after DISE are different to those made after clinical basic ENT (ear, nose, throat) examination (CBE).

Methods

This study included patients with obstructive sleep apnea (OSA) and primary snoring who wish or require an alternative therapy to the gold standard, continuous positive airway pressure (CPAP). After CBE, a theoretical treatment recommendation was given comprising surgery (possible surgical target: soft palate, tonsils, tongue base, epiglottis) and mandibular advancement splints (MAS) or both. A second ENT specialist conducted a DISE and independently recommended a second therapy concept without knowing the first one. A third person compared both theoretical locations of treatment recommendations (CBE vs. DISE).

Results

A total of 97 patients (eight female and 89 male, age 30–85 years, AHI 1.9–88.6/h, body mass index [BMI] 20.3–36.3 kg/m²) received two therapy recommendations. Regarding surgical options only, 63.9% of the examined patients got a different recommendation in at least one of four levels. If MAS was included, a change was found in 78.4% of the patients. Subdivided into each type of intervention, the following changes were found in the therapy concept: 24.7% (n?=?24/97) soft palate, 12.4% (n?=?12/97) tonsils, 33.0% (n?=?32/97) tongue base, 27.8% (n?=?27/97) epiglottis, 38.1% (n?=?37/97) MAS.

Conclusions

DISE shows a relevant influence on the location of treatment recommendation. Thus, a change in success rates of non-CPAP therapy in OSA and snoring appears possible.     

Mindfulness-Based Stress Reduction for Residents: A Randomized Controlled Trial

Background

Burnout is highly prevalent in residents. No randomized controlled trials have been conducted measuring the effects of Mindfulness-Based Stress Reduction (MBSR) on burnout in residents.

Objective

To determine the effectiveness of MBSR in reducing burnout in residents.

Design

A randomized controlled trial comparing MBSR with a waitlist control group.

Participants

Residents from all medical, surgical and primary care disciplines were eligible to participate. Participants were self-referred.

Intervention

The MBSR consisted of eight weekly 2.5-h sessions and one 6-h silent day.

Main Measures

The primary outcome was the emotional exhaustion subscale of the Dutch version of the Maslach Burnout Inventory–Human Service Survey. Secondary outcomes included the depersonalization and reduced personal accomplishment subscales of burnout, worry, work–home interference, mindfulness skills, self-compassion, positive mental health, empathy and medical errors. Assessment took place at baseline and post-intervention approximately 3 months later.

Key Results

Of the 148 residents participating, 138 (93%) completed the post-intervention assessment. No significant difference in emotional exhaustion was found between the two groups. However, the MBSR group reported significantly greater improvements than the control group in personal accomplishment (p?=?0.028, d?=?0.24), worry (p?=?0.036, d?=?0.23), mindfulness skills (p?=?0.010, d?=?0.33), self-compassion (p?=?0.010, d?=?0.35) and perspective-taking (empathy) (p?=?0.025, d?=?0.33). No effects were found for the other measures. Exploratory moderation analysis showed that the intervention outcome was moderated by baseline severity of emotional exhaustion; those with greater emotional exhaustion did seem to benefit.

Conclusions

The results of our primary outcome analysis did not support the effectiveness of MBSR for reducing emotional exhaustion in residents. However, residents with high baseline levels of emotional exhaustion did appear to benefit from MBSR. Furthermore, they demonstrated modest improvements in personal accomplishment, worry, mindfulness skills, self-compassion and perspective-taking. More research is needed to confirm these results.

     

Association of Volume of Patient Encounters with Residents’ In-Training Examination Performance

BACKGROUND

Patient care and medical knowledge are Accreditation Council for Graduate Medical Education (ACGME) core competencies. The correlation between amount of patient contact and knowledge acquisition is not known.

OBJECTIVE

To determine if a correlation exists between the number of patient encounters and in-training exam (ITE) scores in internal medicine (IM) and pediatric residents at a large academic medical center.

DESIGN

Retrospective cohort study

PARTICIPANTS

Resident physicians at Mayo Clinic from July 2006 to June 2010 in IM (318 resident-years) and pediatrics (66 resident-years).

METHODS

We tabulated patient encounters through review of clinical notes in an electronic medical record during post graduate year (PGY)-1 and PGY-2. Using linear regression models, we investigated associations between ITE score and number of notes during the previous PGY, adjusted for previous ITE score, gender, medical school origin, and conference attendance.

KEY RESULTS

For IM, PGY-2 admission and consult encounters in the hospital and specialty clinics had a positive linear association with ITE-3 % score (β?=?0.02; p?=?0.004). For IM, PGY-1 conference attendance is positively associated with PGY-2 ITE performance. We did not detect a correlation between PGY-1 patient encounters and subsequent ITE scores for IM or pediatric residents. No association was found between IM PGY-2 ITE score and inpatient, outpatient, or total encounters in the first year of training. Resident continuity clinic and total encounters were not associated with change in PGY-3 ITE score.

CONCLUSIONS

We identified a positive association between hospital and subspecialty encounters during the second year of IM training and subsequent ITE score, such that each additional 50 encounters were associated with an increase of 1 % correct in PGY-3 ITE score after controlling for previous ITE performance and continuity clinic encounters. We did not find a correlation for volume of encounters and medical knowledge for IM PGY-1 residents or the pediatric cohort.     

Exposure to Stress-Dose Steroids and Lethal Septic Shock After In-Hospital Cardiac Arrest: Individual Patient Data Reanalysis of Two Prior Randomized Clinical Trials that Evaluated the Vasopressin–Steroids–Epinephrine Combination Versus Epinephrine Alone

Purpose

Low-dose steroids may reduce the mortality of severely ill patients with septic shock. We sought to determine whether exposure to stress-dose steroids during and/or after cardiopulmonary resuscitation is associated with reduced risk of death due to postresuscitation septic shock.

Methods

We analyzed pooled, individual patient data from two prior, randomized clinical trials (RCTs). RCTs evaluated vasopressin, steroids, and epinephrine (VSE) during resuscitation and stress-dose steroids after resuscitation in vasopressor-requiring, in-hospital cardiac arrest. In the second RCT, 15 control group patients received open-label, stress-dose steroids. Patients with postresuscitation shock were assigned to a Steroids (n?=?118) or No Steroids (n?=?73) group according to an “as-treated” principle. We used cumulative incidence competing risks Cox regression to determine cause-specific hazard ratios (CSHRs) for pre-specified predictors of lethal septic shock (primary outcome). In sensitivity analyses, data were analyzed according to the intention-to-treat (ITT) principle (VSE group, n?=?103; control group, n?=?88).

Results

Lethal septic shock was less likely in Steroids versus No Steroids group, CSHR, 0.40, 95% confidence interval (CI), 0.20–0.82; p?=?0.012. ITT analysis yielded similar results: VSE versus Control, CSHR, 0.44, 95% CI, 0.23–0.87; p?=?0.019. Adjustment for significant, between-group baseline differences in composite cardiac arrest causes such as “hypotension and/or myocardial ischemia” did not appreciably affect the aforementioned CSHRs.

Conclusions

In this reanalysis, exposure to stress-dose steroids (primarily in the context of a combined VSE intervention) was associated with lower risk of postresuscitation lethal septic shock.

     

Is Implementation of the Care Transitions Intervention Associated with Cost Avoidance After Hospital Discharge?

BACKGROUND

Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization.

OBJECTIVE

To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI).

DESIGN

A quasi-experimental cohort study using consecutive convenience sampling.

PATIENTS

Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals.

INTERVENTION

The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and one to two phone calls.

MAIN MEASURES

We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible, but not approached (external control group), using propensity score matching to control for baseline differences.

KEY RESULTS

Compared to matched internal controls (N?=?321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total health care costs ($14,729 vs. $18,779, P?=?0.03). The cost avoided per patient receiving the intervention was $3,752, compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed.

CONCLUSIONS

This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.     

High cerebral insulin sensitivity is associated with loss of body fat during lifestyle intervention

Aims/hypothesis

Loss of weight and body fat are major targets in lifestyle interventions to prevent diabetes. In the brain, insulin modulates eating behaviour and weight control, resulting in a negative energy balance. This study aimed to test whether cerebral insulin sensitivity facilitates reduction of body weight and body fat by lifestyle intervention in humans.

Methods

The study was performed as an additional arm of the TUebingen Lifestyle Intervention Program (TULIP). In 28 non-diabetic individuals (14 female/14 male; mean ± SE age 42?±?2 years; mean ± SE BMI 29.9?±?0.8 kg/m²), we measured cerebrocortical insulin sensitivity by using magnetoencephalography before lifestyle intervention. Total and visceral fat were measured by using MRI at baseline and after 9 months and 2 years of lifestyle intervention.

Results

Insulin-stimulated cerebrocortical theta activity at baseline correlated with a reduction in total adipose tissue (r?=??0.59, p?=?0.014) and visceral adipose tissue (r?=??0.76, p?=?0.001) after 9 months of lifestyle intervention, accompanied by a statistical trend for reduction in body weight change (r?=??0.37, p?=?0.069). Similar results were obtained after 2 years.

Conclusions/interpretation

Our results suggest that high insulin sensitivity of the human brain facilitates loss of body weight and body fat during lifestyle intervention.     

Clinicopathologic features and prognostic analysis of MSI-high colon cancer

Purpose

The objectives of the study were to estimate the incidence and clarify the clinicopathologic feature of sporadic microsatellite instability (MSI)-high (MSI-H) colon cancer. Furthermore, the role of MSI in colon cancer prognosis was also investigated.

Methods

Microsatellite status was identified by genotyping. The clinicopathologic differences between two groups (MSI-H vs. MSI-L/S) and the prognostic value of MSI were analyzed.

Results

From 1993 to 2006, 709 sporadic colon cancer patients were enrolled. MSI-H colon cancers showed significant association with poorly differentiated (28.3% vs. 7.2%, p?=?0.001), proximally located (76.7% vs. 34.5%, p?=?0.001), more high mucin-containing tumor (10.0% vs. 5.1%, p?=?0.001) and female predominance (56.7% vs. 30.2%, p?=?0.001). In multivariate analysis, MSI-H is an independent factor for better overall survival (HR, 0.459; 95% CI, 0.241–0.872, p?=?0.017).

Conclusions

Based on the hospital-based study, MSI-H colon cancers demonstrated distinguished clinicopathologic features from MSI-L/S colon cancers. MSI-H is an independent favorable prognostic factor for overall survival in colon cancer.     

A descriptive study evaluating the circumstances of medical treatment for acute pancreatitis before publication of the new JPN guidelines based on the Japanese administrative database associated with the Diagnosis Procedure Combination system

Purpose

To examine the circumstances of medical treatment for acute pancreatitis before publication of the new Japanese (JPN) guidelines using the Japanese administrative database associated with the Diagnosis Procedure Combination system.

Methods

We collected data from 7,193 patients with acute pancreatitis in 2008 and examined the recommended medical treatment in the new JPN guidelines [from recommendations B (considered to be recommended treatments) to D (considered to be unacceptable treatments)] according to severity of acute pancreatitis. Patients were divided into two groups: mild cases (n?=?6,520) and severe cases (n?=?673).

Results

Enteral nutrition for severe cases without ileus (recommendation B) was uncommon (13.5%). In contrast, prophylactic antibiotics were administered in a large number (80.4%) of mild cases without acute cholangitis (recommendation D). Furthermore, administration of H₂ receptor antagonists, except for cases of upper gastrointestinal bleeding (recommendation D), were performed in many patients with both mild and severe cases (66.8 vs. 78.6%).

Conclusions

This study demonstrated a discrepancy between actual medical treatment performed and the new JPN guidelines with regard to some of the medical treatments. Future studies are required after publication of the new JPN guidelines to determine how they affect medical treatments.     

Survival advantage from ventricular fibrillation and pulseless electrical activity in women compared to men: the Oregon Sudden Unexpected Death Study

Objective

Studies evaluating a possible survival advantage from sudden cardiac arrest (SCA) in women have produced mixed results possibly due to a lack of comprehensive analyses. We hypothesized that race, socioeconomic status (SES), and elements of the lifetime clinical history influence gender effects and need to be incorporated within analyses of survival.

Methods

Cases of SCA were identified from the ongoing, prospective, multiple-source Oregon Sudden Unexpected Death Study (population approximately one million). Subjects included were age ??18?years who underwent attempted resuscitation by EMS providers. Pearson??s chi-square tests and independent samples t tests or analysis of variance were used for univariate comparisons. We evaluated gender and race differences in survival adjusted for age, circumstances of arrest, disease burden, and socioeconomic status using a logistic regression model predicting survival.

Results

A total of 1,296 cases had resuscitation attempted (2002?C2007; mean age 65?years, male 67%). Women were older than men (68 vs. 63?years, p?p?=?0.004). Women were more likely to present with pulseless electrical activity (PEA) and asystole (p?p?=?0.04). Higher survival to hospital discharge was observed in women compared to men presenting with ventricular fibrillation/tachycardia (34% vs. 24%, p?=?0.02) or with PEA (10% vs. 3%, p?=?0.007). In a multivariate model adjusting for age, race, presenting arrhythmia, arrest circumstances, arrest location, disease burden, and SES, women were more likely than men to survive to hospital discharge [odds ratio 1.85; 95% confidence interval (1.12?C3.04)].

Conclusions

Despite older age, higher prevalence of SCA in the home, and higher rates of PEA, women had a survival advantage from ventricular fibrillation and pulseless electrical activity.     

Impact of residual in situ carcinoma on postoperative survival in 125 patients with extrahepatic bile duct carcinoma

Purpose

The aim of this study was to determine the impact of the presence of carcinoma in situ at the bile duct stump on postoperative survival in patients who underwent resection of extrahepatic bile duct carcinoma.

Methods

The patients with resected extrahepatic bile duct carcinoma were divided into three groups according to resected margin status: no evidence of residual carcinoma (Negative group, n?=?96); carcinoma in situ at the bile duct stump (CIS group, n?=?10); and invasive carcinoma at any surgical margin (Invasive group, n?=?19). Cause-specific survival for these groups was compared statistically.

Results

Surgical margin status was identified as a prognostic factor on univariate analysis (p?=?0.005) and was an independent prognostic factor on multivariate analysis (p?=?0.018). The CIS group displayed significantly better survival than the Invasive group (p?=?0.006), and the survival was comparable to that for the Negative group (p?=?0.533). Two of three patients in the CIS group with local recurrence died >5?years after surgical resection.

Conclusions

Patients with positive ductal margins of carcinoma in situ of the extrahepatic bile duct do not appear to show different survival after resection compared to patients with negative margins, but remnant carcinoma in situ is likely to develop late local recurrence.     

The Patient Centered Medical Home: Mental Models and Practice Culture Driving the Transformation Process

BACKGROUND

The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. The PCMH model is a departure from more traditional models of healthcare delivery and requires significant transformation to be realized.

OBJECTIVE

To describe factors shaping mental models and practice culture driving the PCMH transformation process in a large multi-payer PCMH demonstration project.

DESIGN

Individual interviews were conducted at 17 primary care practices in South Eastern Pennsylvania.

PARTICIPANTS

A total of 118 individual interviews were conducted with clinicians (N?=?47), patient educators (N?=?4), office administrators (N?=?12), medical assistants (N?=?26), front office staff (N?=?7), nurses (N?=?4), care managers (N?=?11), social workers (N?=?4), and other stakeholders (N?=?3). A multi-disciplinary research team used a grounded theory approach to develop the key constructs describing factors shaping successful practice transformation.

KEY RESULTS

Three central themes emerged from the data related to changes in practice culture and mental models necessary for PCMH practice transformation: 1) shifting practice perspectives towards proactive, population-oriented care based in practice–patient partnerships; 2) creating a culture of self-examination; and 3) challenges to developing new roles within the practice through distribution of responsibilities and team-based care. The most tension in shifting the required mental models was displayed between clinician and medical assistant participants, revealing significant barriers towards moving away from clinician-centric care.

CONCLUSIONS

Key factors driving the PCMH transformation process require shifting mental models at the individual level and culture change at the practice level. Transformation is based upon structural and process changes that support orientation of practice mental models towards perceptions of population health, self-assessment, and the development of shared decision-making. Staff buy-in to the new roles and responsibilities driving PCMH transformation was described as central to making sustainable change at the practice level; however, key barriers related to clinician autonomy appeared to interfere with the formation of team-based care.     

An Investigation of Associations Between Clinicians’ Ethnic or Racial Bias and Hypertension Treatment,Medication Adherence and Blood Pressure Control

BACKGROUND

Few studies have directly investigated the association of clinicians’ implicit (unconscious) bias with health care disparities in clinical settings.

OBJECTIVE

To determine if clinicians’ implicit ethnic or racial bias is associated with processes and outcomes of treatment for hypertension among black and Latino patients, relative to white patients.

RESEARCH DESIGN AND PARTICIPANTS

Primary care clinicians completed Implicit Association Tests of ethnic and racial bias. Electronic medical records were queried for a stratified, random sample of the clinicians’ black, Latino and white patients to assess treatment intensification, adherence and control of hypertension. Multilevel random coefficient models assessed the associations between clinicians’ implicit biases and ethnic or racial differences in hypertension care and outcomes.

MAIN MEASURES

Standard measures of treatment intensification and medication adherence were calculated from pharmacy refills. Hypertension control was assessed by the percentage of time that patients met blood pressure goals recorded during primary care visits.

KEY RESULTS

One hundred and thirty-eight primary care clinicians and 4,794 patients with hypertension participated. Black patients received equivalent treatment intensification, but had lower medication adherence and worse hypertension control than white patients; Latino patients received equivalent treatment intensification and had similar hypertension control, but lower medication adherence than white patients. Differences in treatment intensification, medication adherence and hypertension control were unrelated to clinician implicit bias for black patients (P?=?0.85, P?=?0.06 and P?=?0.31, respectively) and for Latino patients (P?=?0.55, P?=?0.40 and P?=?0.79, respectively). An increase in clinician bias from average to strong was associated with a relative change of less than 5 % in all outcomes for black and Latino patients.

CONCLUSIONS

Implicit bias did not affect clinicians’ provision of care to their minority patients, nor did it affect the patients’ outcomes. The identification of health care contexts in which bias does not impact outcomes can assist both patients and clinicians in their efforts to build trust and partnership.     

Serum EPO and VEGF levels in patients with sleep-disordered breathing and acute myocardial infarction

Background

A high level of endogenous erythropoietin (EPO) may be associated with a smaller infarct size determined by the release of necrosis markers. Sleep-disordered breathing (SDB) is a well-known risk factor for cardiovascular diseases. In contrast, protective effects of SDB have also been described. The potential role of increased levels of EPO and vascular endothelial growth factor (VEGF) is suggested in this process. The study aimed to explore the EPO and VEGF serum levels in SDB and non-SDB patients during the acute phase of myocardial infarction.

Methods

Thirty-seven patients undergoing successful primary percutaneous coronary intervention in the acute myocardial infarction have been examined for the levels of EPO, VEGF, and troponin I (Tn). In the following, patients had an overnight polysomnography to determine breathing disturbances during sleep.

Results

Both on admission day (day 1) and day 3 of hospitalization, EPO levels showed statistically significant differences in both SDB-positive and SDB-negative patient groups (p?=?0.003 and p?=?0.018, respectively). There was no statistically significant difference in VEGF levels. No correlation was found between the EPO and Tn levels.

Conclusions

SDB patients tend to have higher levels of EPO during acute myocardial infarction. No statistically significant differences in VEGF levels were observed.     

Weight Loss Success in Metabolic Syndrome by Telephone Interventions: Results from the SHINE Study

BACKGROUND

The Diabetes Prevention Program (DPP) intensive lifestyle intervention resulted in significant weight loss, reducing the development of diabetes, but needs to be adapted to primary care provider (PCP) practices.

OBJECTIVES

To compare a DPP-translation using individual (IC) vs. conference (CC) calls delivered by PCP staff for the outcome of percent weight loss over 2 years.

DESIGN

Randomized clinical trial.

SETTING

Five PCP sites.

PARTICIPANTS

Obese patients with metabolic syndrome, without diabetes (IC, n?=?129; CC, n?=?128).

INTERVENTION

Telephone delivery of the DPP Lifestyle Balance intervention [16-session core curriculum in year 1, 12-session continued telephone contact in year 2 plus telephone coaching sessions (dietitians).

MAIN MEASURES

Weight (kg), body mass index (BMI), and waist circumference.

KEY RESULTS

Baseline data: age?=?52 years, BMI?=?39 kg/m², 75 % female, 85 % non-Hispanic White, 13 % non-Hispanic Black, and 48 % annual incomes <$40,000/year. In the intention-to-treat analyses at year 2, mean percent weight loss was ?5.6 % (CC, p?<?0.001) and ?1.8 % (IC, p?=?0.046) and was greater for CC than for IC (p?=?0.016). At year 2, mean weight loss was 6.2 kg (CC) and 2.2 kg (IC) (p?<?0.001). There was similar weight loss at year 1, but between year 1 and year 2 CC participants continued to lose while IC participants regained. At year 2, 52 % and 43 % (CC) and 29 % and 22 % (IC) of participants lost at least 5 % and 7 % of initial weight. BMI also decreased more for CC than IC (?2.1 kg/m² vs. ?0.8 kg/m² p?<?0.001). Waist circumference decreased by 3.1 cm (CC) and 2.4 cm (IC) at year 2. Completers (≥9 of 16 sessions; mean 13.3 sessions) lost significantly more weight than non-completers (mean 4.3 sessions).

CONCLUSIONS

PCP staff delivery of the DPP lifestyle intervention by telephone can be effective in achieving weight loss in obese people with metabolic syndrome. Greater weight loss may be attained with a group telephone intervention.