Education,literacy, and health: Mediating effects on hypertension knowledge and control

Objective

To determine whether literacy mediates the association between education, hypertension knowledge and control.

Methods

In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control.

Results

In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1–8: β = −0.30, 95% CI = −1.44–0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10–2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54–4.70).

Conclusion

Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure.

Practice implications

Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease.     

Chemical agents of terrorism: preparing nurse practitioners

Nurse practitioners must exercise vigilant readiness to properly care for victims of chemical injuries. In this article, appropriate clinical management of each category of chemicals is addressed, including supportive and pharmacologic care. Triage decisions are explained and decontamination concerns are identified. Attention is directed at special populations such as children and the elderly.     

Effect of Peer Benchmarking on Specialist Electronic Consult Performance in a Los Angeles Safety-Net: a Cluster Randomized Trial

BackgroundSince the advent of COVID-19, accelerated adoption of systems that reduce face-to-face encounters has outpaced training and best practices. Electronic consultations (eConsults), structured communications between PCPs and specialists regarding a case, have been effective in reducing face-to-face specialist encounters. As the health system rapidly adapts to multiple new practices and communication tools, new mechanisms to measure and improve performance in this context are needed.ObjectiveTo test whether feedback comparing physicians to top performing peers using co-specialists’ ratings improves performance.DesignCluster-randomized controlled trialParticipantsEighty facility-specialty clusters and 214 cliniciansInterventionProviders in the feedback arms were sent messages that announced their membership in an elite group of “Top Performers” or provided actionable recommendations with feedback for providers that were “Not Top Performers.”Main MeasuresThe primary outcomes were changes in peer ratings in the following performance dimensions after feedback was received: (1) elicitation of information from primary care practitioners; (2) adherence to institutional clinical guidelines; (3) agreement with peer’s medical decision-making; (4) educational value; (5) relationship building.Key ResultsSpecialists showed significant improvements on 3 of the 5 consultation performance dimensions: medical decision-making (odds ratio 1.52, 95% confidence interval 1.08–2.14, p<.05), educational value (1.86, 1.17–2.96) and relationship building (1.63, 1.13–2.35) (both p<.01).ConclusionsThe pandemic has shed light on clinicians’ commitment to professionalism and service as we rapidly adapt to changing paradigms. Interventions that appeal to professional norms can help improve the efficacy of new systems of practice. We show that specialists’ performance can be measured and improved with feedback using aspirational norms.Trial Registrationclinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT03784950","term_id":"NCT03784950"}}NCT03784950Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07002-1.KEY WORDS: behavioral economics, electronic consultation, peer comparison, quality of care, specialty care     

Association of Postoperative Complications with Hospital Costs and Length of Stay in a Tertiary Care Centre

BACKGROUND: Modifications to the National Cholesterol Education Program (NCEP) guidelines lowered optional low-density lipoprotein cholesterol (LDL-C) treatment goals. OBJECTIVE: We evaluated the implications of widely adopting these optional goals in clinical practice. DESIGN AND PARTICIPANTS: We performed a cross-sectional study using 1999 to 2002 data from 3,281 U.S. adults aged 20 to 79 years participating the National Health and Nutrition Examination Survey. MEASUREMENTS: The primary outcomes were the proportions of adults whose fasting LDL-C levels exceeded NCEP recommended and optional targets from 2001 and 2004. We used survey weights to estimate the size of the U.S. population exceeding targets. We examined outcomes for 4 coronary disease risk subgroups described by the NCEP. RESULTS: Low-density lipoprotein cholesterol values exceeded 2001 NCEP goals for 30.0% of adults, and 35.8% had levels above optional 2004 goals. An estimated 24,900,000 individuals (14.2%) exceeded 2001 thresholds for drug therapy, 46,200,000 (26.3%) exceeded optional 2001 thresholds for drug therapy, and 56,500,000 (32.2%) were above the optional 2004 thresholds for drug therapy. For lower, moderate, moderately high, and high-risk groups, 13.4%, 44.2%, 58.8%, and 71.8%, respectively, exceeded 2001 NCEP goals; 13.4%, 15.7%, 87.4%, and 96.0% of these groups exceeded optional 2004 thresholds for drug therapy. CONCLUSIONS: In 1999 to 2002, LDL-C levels commonly exceeded 2001 NCEP goals, especially for moderately high and high-risk individuals, and cholesterol-lowering medications were underused. Optional goals promulgated by the NCEP in 2001 and 2004 moderately increased the number of adults with LDL-C above their goal, and greatly increased the number of low, moderately high, and high-risk adults who exceeded LDL-C thresholds, for cholesterol-lowering medication. Dr. Lloyd-Jones has received honoraria from Pfizer for speaking and for being a member of an advisory board. Presented in part at the Society of General Internal Medicine National Meeting, May 14, 2005. This study was financially supported by the Division of General Internal Medicine funds, Northwestern University.     

The marginal value of pre-visit paper reminders when added to a multifaceted electronic health record based quality improvement system

Objective

We have reported that implementation of an electronic health record (EHR) based quality improvement system that included point-of-care electronic reminders accelerated improvement in performance for multiple measures of chronic disease care and preventive care during a 1-year period. This study examined whether providing pre-visit paper quality reminders could further improve performance, especially for physicians whose performance had not improved much during the first year.

Design

Time-series analysis at a large internal medicine practice using a commercial EHR. All patients eligible for each measure were included (range approximately 100–7500).

Measurements

The proportion of eligible patients in the practice who satisfied each of 15 quality measures after removing those with exceptions from the denominator. To analyze changes in performance for individual physicians, two composite measures were used: prescribing seven essential medications and completion of five preventive services.

Results

During the year after implementing pre-encounter reminders, performance continued to improve for eight measures, remained stable for four, and declined for three. Physicians with the worst performance at the start of the pre-encounter reminders showed little absolute improvement over the next year, and most remained below the median performance for physicians in the practice.

Conclusions

Paper pre-encounter reminders did not appear to improve performance beyond electronic point-of-care reminders in the EHR alone. Lagging performance is likely not due to providers'' EHR workflow alone, and trying to step backwards and use paper reminders in addition to point-of-care reminders in the EHR may not be an effective strategy for engaging slow adopters.