Brook Watts

Effective Antimicrobial Stewardship in a Long-Term Care Facility through an Infectious Disease Consultation Service: Keeping a LID on Antibiotic Use

DESIGN We introduced a long-term care facility (LTCF) infectious disease (ID) consultation service (LID service) that provides on-site consultations to residents of a Veterans Affairs (VA) LTCF. We determined the impact of the LID service on antimicrobial use and Clostridium difficile infections at the LTCF. SETTING A 160-bed VA LTCF. METHODS Systemic antimicrobial use and positive C. difficile tests at the LTCF were compared for the 36 months before and the 18 months after the initiation of the ID consultation service through segmented regression analysis of an interrupted time series. RESULTS Relative to that in the preintervention period, total systemic antibiotic administration decreased by 30% (P<.001), with significant reductions in both oral (32%; P<.001) and intravenous (25%; P=.008) agents. The greatest reductions were seen for tetracyclines (64%; P<.001), clindamycin (61%; P<.001), sulfamethoxazole/trimethoprim (38%; P<.001), fluoroquinolones (38%; P<.001), and β-lactam/β-lactamase inhibitor combinations (28%; P<.001). The rate of positive C. difficile tests at the LTCF declined in the postintervention period relative to preintervention rates (P=.04). CONCLUSIONS Implementation of an LTCF ID service led to a significant reduction in total antimicrobial use. Bringing providers with ID expertise to the LTCF represents a new and effective means to achieve antimicrobial stewardship.

Impact of a chronic kidney disease registry and provider education on guideline adherence – a cluster randomized controlled trial

BackgroundLow adherence to chronic kidney disease (CKD) guidelines may be due to unrecognized CKD and lack of guideline awareness on the part of providers. The goal of this study was to evaluate the impact of provider education and access to a CKD registry on guideline adherence.MethodsWe conducted a cluster randomized controlled trial at the Louis Stokes Cleveland VAMC. One of two primary care clinics was randomized to intervention. Providers from both clinics received a lecture on CKD guidelines at study initiation. Providers in the intervention clinic were given access to and shown how to use a CKD registry, which identifies patients with CKD and is automatically updated daily. Eligible patients had at least one primary care visit in the last year, had CKD based on eGFR, and had not received renal replacement therapy. The primary outcome was parathyroid hormone (PTH) adherence, defined by at least one PTH measurement during the 12 month study. Secondary outcomes were measurement of phosphorus, hemoglobin, proteinuria, achievement of goal blood pressure, and treatment with a diuretic or renin-angiotensin system blocker.ResultsThere were 418 and 363 eligible patients seen during the study in the control and intervention clinics, respectively. Compared to pre-intervention, measurement of PTH increased in both clinics (control clinic: 16% to 23%; intervention clinic: 13% to 28%). Patients in the intervention clinic were more likely to have a PTH measured during the study (adjusted odds ratio = 1.53; 95% CI (1.01, 2.30); P = 0.04). However, the intervention was not associated with a consistent improvement in secondary outcomes. Only 5 of the 37 providers in the intervention clinic accessed the registry.ConclusionsAn intervention that included education on CKD guidelines and access to a CKD patient registry marginally improved guideline adherence over education alone. Adherence to the primary process measure improved in both clinics, but no improvement was seen in intermediate clinical outcomes. Improving the care of patients with CKD will likely require a multifaceted approach including system redesign.ClinicalTrials.Gov registration numberNCT00921687

A pharmacist based intervention to improve the care of patients with CKD: a pragmatic, randomized, controlled trial

BackgroundPrimary care providers do not routinely follow guidelines for the care of patients with chronic kidney disease (CKD). Multidisciplinary efforts may improve care for patients with chronic disease. Pharmacist based interventions have effectively improved management of hypertension. We performed a pragmatic, randomized, controlled trial to evaluate the effect of a pharmacist based quality improvement program on 1) outcomes for patients with CKD and 2) adherence to CKD guidelines in the primary care setting.MethodsPatients with moderate to severe CKD receiving primary care services at one of thirteen community-based Veterans Affairs outpatient clinics were randomized to a multifactorial intervention that included a phone-based pharmacist intervention, pharmacist-physician collaboration, patient education, and a CKD registry (n = 1070) or usual care (n = 1129). The primary process outcome was measurement of parathyroid hormone (PTH) during the one year study period. The primary clinical outcome was blood pressure (BP) control in subjects with poorly controlled hypertension at baseline.ResultsAmong those with poorly controlled baseline BP, there was no difference in the last recorded BP or the percent at goal BP during the study period (42.0% vs. 41.2% in the control arm). Subjects in the intervention arm were more likely to have a PTH measured during the study period (46.9% vs. 16.1% in the control arm, P <0.001) and were on more classes of antihypertensive medications at the end of the study (P = 0.02).ConclusionsA one-time pharmacist based intervention proved feasible in patients with CKD. While the intervention did not improve BP control, it did improve guideline adherence and increased the number of antihypertensive medications prescribed to subjects with poorly controlled BP. These findings can inform the design of quality improvement programs and future studies which are needed to improve care of patients with CKD.Trial registrationClinicalTrials.gov: NCT01290614.

Implementation of quality improvement skills by primary care teams: case study of a large academic practice.

Background: Continuous quality improvement (QI) is important to primary care in general, and is emphasized as a key tenet of the primary care patient-centered medical home (PCMH) model. While team-based QI activities within the PCMH model are expected, concerns exist as to how successful efforts have been at implementing team-driven QI projects. Objective: To (a) identify opportunities and challenges to QI efforts in a large primary care practice in order to (b) develop action plans to facilitate QI work into primary care teams. Design: We obtained qualitative and quantitative information about existing primary care team QI initiatives. Participants: Eleven interdisciplinary primary care teams and 4 facilitators/coaches. Methods: We conducted unstructured interviews and gathered documentation from primary care team members about QI efforts to (a) characterize team-based QI progress and (b) identify barriers and facilitators. Results: In the 18 months since local leadership prioritized conducting team-based QI projects, team members described multiple exposures to QI training, coaching resources, and data/analysis support. No team developed a formal aim statement. Six of the 11 teams completed any steps beyond the initial team discussion. Four teams attempted to apply an intervention. Challenges included team time and competing demands/priorities; 3 of the 4 teams attempting to implement a project credited a data/informatics facilitator for their progress. Conclusions: In this large academic primary care clinic setting, interdisciplinary team training in QI, support for data collection, and dedicated coaching resources produced few sustainable continuous QI initiatives. Several potentially modifiable barriers to initiation, completion, and sustainability of QI initiatives by primary care teams were identified.

Specialty Care Delivery: Bringing Infectious Disease Expertise to the Residents of a Veterans Affairs Long‐Term Care Facility

To initiate a long‐term care facility (LTCF) infectious disease (LID) service that provides on‐site consultations to LTCF residents to improve the care of residents with possible infections.

Teaching quality improvement in the midst of performance measurement pressures: mixed messages?

Background While the importance of teaching quality improvement (QI) is recognized, formal opportunities to teach it are limited and are not always successful at getting physician trainee buy-in. We summarize findings that emerged from a QI curriculum designed to promote physician trainee insights into the evaluation and improvement of quality of care. Methods Grounded-theory approaches to thematic coding of responses from 24 trainees to open-ended items about aspects of a QI curriculum. The 24 trainees were subsequently divided into 9 teams that provided group responses to open-ended items about assessing quality care. Coding was also informed by notes from group discussions. Results Successes associated with QI projects reflected several aspects of optimizing care such as approaches to improving processes and enabling providers. Counterproductive themes included aspects of compromising care such as creating blinders and complicating care delivery. Themes about assessing care included absolute versus process trade-offs, time frame, documentation completeness, and the underrecognized role of the patient/provider dynamic. Conclusions Our mapping of the themes provides a useful summary of issues and ways to approach the potential lack of buy-in from physician trainees about the value of QI and the “mixed-messages” regarding inconsistencies in the application of presumed objective performance measures.

Understanding the Health Needs and Barriers to Seeking Health Care of Veteran Students in the Community.

Objectives Access to care at Veterans Affairs facilities may be limited by long wait times; however, additional barriers may prevent US military veterans from seeking help at all. We sought to understand the health needs of veterans in the community to identify possible barriers to health-seeking behavior. Methods Focus groups were conducted with veteran students at a community college until thematic saturation was reached. Qualitative data analysis involved both an inductive content analysis approach and deductive elements. Results A total of 17 veteran students participated in 6 separate focus groups. Health needs affecting health-seeking behavior were identified. Themes included lack of motivation to improve health, concern about social exclusion and stigma, social interactions and behavior, limited access to affordable and convenient health care, unmet basic needs for self and family, and academics competing with health needs. Conclusions Veterans face a range of personal, societal, and logistical barriers to accessing care. In addition to decreasing wait times for appointments, efforts to improve the transition to civilian life; reduce stigma; and offer assistance related to work, housing, and convenient access to health care may improve health in veteran students.

Quality of care by a hypertension expert: A cautionary tale for pay-for-performance approaches

Context Pay-for-performance programs may be widely implemented, but gaps remain in our understanding of the implementation of performance measurement approaches. Objectives To compare 3 approaches to hypertension quality measurement as applied to high-quality care delivered by a hypertension expert. Methods Care of 23 patients treated by a single hypertension expert was assessed by 3 measurement approaches: (1) outcome, (2) a multicomponent process, and (3) “outcome-linked” process. Exemplary case studies were identified to illustrate additional challenges to applying the approaches. Results Forty-four percent of patients (n = 10) had complete concordance between the outcome and outcome-linked process approaches, 22% of patients (n = 5) had complete concordance between the outcome and multicomponent process approaches, 52% of patients (n = 12) had complete concordance between outcome-linked process and multicomponent process approaches, and 22% of patients (n = 5) had uniform agreement among all 3 approaches. Case studies revealed numerous opportunities for misinterpretation or gaming by providers. Conclusions Currently available measurement approaches resulted in a varied assessment of provider performance under optimal hypertension care conditions suggesting that caution is required before their use for provider compensation.

Development and Implementation of Team-Based Panel Management Tools: Filling the Gap between Patient and Population Information Systems

Effective team-based models of care, such as the Patient-Centered Medical Home, require electronic tools to support proactive population management strategies that emphasize care coordination and quality improvement. Despite the spread of electronic health records (EHRs) and vendors marketing population health tools, clinical practices still may lack the ability to have: (1) local control over types of data collected/reports generated, (2) timely data (eg, up-to-date data, not several months old), and accordingly (3) the ability to efficiently monitor and improve patient outcomes. This article describes a quality improvement project at the hospital system level to develop and implement a flexible panel management (PM) tool to improve care of subpopulations of patients (eg, panels of patients with diabetes) by clinical teams. An in-depth case analysis approach is used to explore barriers and facilitators in building a PM registry tool for team-based management needs using standard data elements (eg, laboratory values, pharmacy records) found in EHRs. Also described are factors that may contribute to sustainability; to date the tool has been adapted to 6 disease-focused subpopulations encompassing more than 200,000 patients. Two key lessons emerged from this initiative: (1) though challenging, team-based clinical end users and information technology needed to work together consistently to refine the product, and (2) locally developed population management tools can provide efficient data tracking for frontline clinical teams and leadership. The preliminary work identified critical gaps that were successfully addressed by building local PM registry tools from EHR-derived data and offers lessons learned for others engaged in similar work. (Population Health Management 2016;19:232-239).

Access to and utilization of healthcare: the provider’s role

Access to and utilization of healthcare are distinct, yet related, concepts that serve as a focus for health policy and quality improvement. This article identifies their similarities and differences, calling on previous research and reviews to elaborate on a current understanding of factors that influence both, with a particular focus on those related to the healthcare provider. Access describes an individual’s ability to position oneself to receive healthcare services. Utilization presumes access and includes the formulation of a healthcare plan during a healthcare encounter and its subsequent implementation. We present a framework that envisions access and utilization as aspects of healthcare delivery that may be affected by the context within which services are delivered, the structure of the practice that delivers them and other processes leading to outcomes experienced by the healthcare consumer. Based on current trends, we anticipate that research and policy related to access and utilization over the next 5 years will be primarily driven by a focus on quality improvement. Providers are positioned to use their collective authority to exercise influence on access and quality at the individual, institutional and policy levels.