David T. Liss

Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission

BackgroundThis study was designed to determine risk factors and potential harm associated with medication errors at hospital admission.MethodsStudy pharmacist and hospital-physician medication histories were compared with medication orders to identify unexplained history and order discrepancies in 651 adult medicine service inpatients with 5,701 prescription medications. Discrepancies resulting in order changes were considered errors. Logistic regression was used to analyze the association of patient demographic and clinical characteristics including patients’ number of pre-admission prescription medications, pharmacies, prescribing physicians and medication changes; and presentation of medication bottles or lists. These factors were tested after controlling for patient demographics, admitting service and severity of illness.ResultsOver one-third of study patients (35.9%) experienced 309 order errors; 85% of patients had errors originate in medication histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful. In logistic regression analysis, patient’s age ≥65 [odds ratio (OR), 2.17; 95% confidence interval (CI), 1.09–4.30] and number of prescription medications (OR, 1.21; 95% CI, 1.14–1.29) were significantly associated with errors potentially requiring monitoring or causing harm. Presenting a medication list (OR, 0.35; 95% CI, 0.19–0.63) or bottles (OR, 0.55; 95% CI, 0.27–1.10) at admission was beneficial.ConclusionOver one-third of the patients in our study had a medication error at admission, and of these patients, 85% had errors originate in their medication histories. Attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications. Primary care physicians and other clinicians should help patients utilize and maintain complete, accurate and understandable medication lists.

Understanding Current Racial/Ethnic Disparities in Colorectal Cancer Screening in the United States: The Contribution of Socioeconomic Status and Access to Care

BACKGROUND Prior studies have shown racial/ethnic disparities in colorectal cancer (CRC) screening but have not provided a full national picture of disparities across all major racial/ethnic groups. PURPOSE To provide a more complete, up-to-date picture of racial/ethnic disparities in CRC screening and contributing socioeconomic and access barriers. METHODS Behavioral Risk Factor Surveillance System data from 2010 were analyzed in 2013. Hispanic/Latino participants were stratified by preferred language (Hispanic-English versus Hispanic-Spanish). Non-Hispanics were categorized as White, Black, Asian, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native. Sequential regression models estimated adjusted relative risks (RRs) and the degree to which SES and access to care explained disparities. RESULTS Overall, 59.6% reported being up-to-date on CRC screening. Self-reported CRC screening was highest in the White (62.0%) racial/ethnic group; followed by Black (59.0%); Native Hawaiian/Pacific Islander (54.6%); Hispanic-English (52.5%); American Indian/Alaska Native (49.5%); Asian (47.2%); and Hispanic-Spanish (30.6%) groups. Adjustment for SES and access partially explained disparities between Whites and Hispanic-Spanish (final relative risk [RR]=0.76, 95% CI=0.69, 0.83); Hispanic-English (RR=0.94, 95% CI=0.91, 0.98); and American Indian/Alaska Native (RR=0.91, 95% CI=0.85, 0.97) groups. The RR of screening among Asians was unchanged after adjustment for SES and access (0.78, p<0.001). After full adjustment, screening rates were not significantly different among Whites, Blacks, or Native Hawaiian/Pacific Islanders. CONCLUSIONS Large racial/ethnic disparities in CRC screening persist, including substantial differences between English-speaking versus Spanish-speaking Hispanics. Disparities are only partially explained by SES and access to care. Future studies should explore the low rate of screening among Asians and how it varies by racial/ethnic subgroup and language.

A Randomized Comparative Effectiveness Trial for Preventing Type 2 Diabetes

OBJECTIVES We evaluated the weight loss effectiveness of a YMCA model for the Diabetes Prevention Program (DPP) lifestyle intervention. METHODS Between July 2008 and November 2010, we individually randomized 509 overweight or obese, low-income, nondiabetic adults with elevated blood glucose in Indianapolis, Indiana, to receive standard care plus brief lifestyle counseling or be offered a group-based YMCA adaptation of the DPP (YDPP). Primary outcome was mean weight loss difference at 12 months. In our intention-to-treat analyses, we used longitudinal linear or logistic regression, multiply imputing missing observations. We used instrumental variables regression to estimate weight loss effectiveness among participants completing 9 or more intervention lessons. RESULTS In the YDPP arm, 161 (62.6%) participants attended ≥ 1 lesson and 103 (40.0%) completed 9 or more lessons. In intention-to-treat analysis, mean 12-month weight loss was 2.3 kilograms (95% confidence interval [CI] = 1.1, 3.4 kg) more for the YDPP arm than for standard care participants. In instrumental variable analyses, persons attending 9 or more lessons had a 5.3-kilogram (95% CI = 2.8, 7.9 kg) greater weight loss than did those with standard care alone. CONCLUSIONS The YMCA model for DPP delivery achieves meaningful weight loss at 12 months among low-income adults.

Spreading a Medical Home Redesign: Effects on Emergency Department Use and Hospital Admissions

PURPOSE The patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy. METHODS We used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices. RESULTS After accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care office visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically significant changes were found for hospital admissions. CONCLUSIONS The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and sufficient resources and supports.

Patient-Reported Care Coordination: Associations With Primary Care Continuity and Specialty Care Use

PURPOSE Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use. METHODS We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use. RESULTS Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77). CONCLUSIONS High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.

Incorporating patient decision aids into standard clinical practice in an integrated delivery system

Background. Randomized controlled trials show that patient decision aids (DAs) can promote shared decision making and improve decision quality. Despite this evidence, integration of DAs into routine clinical practice has proceeded slowly. Objective. To identify factors that promote or impede integrating DAs into clinical practice in a large health care delivery system. Design. Mixed-methods case study. Setting and Patients. Group Health, an integrated health plan and care delivery system in Washington state. Intervention. The project was carried out in 6 specialty service lines using 12 video-based DAs for preference-sensitive conditions related to elective surgical procedures. Measurements. Process data, site visits, meeting observations, and in-depth interviews conducted with clinical staff, project staff, and health plan leaders in 2009 and 2010. Results. The project established systemwide and clinic-specific processes that facilitated the distribution of approximately 10,000 DAs over 2 years. Several factors were identified as important for success in this implementation, including strong support from senior leaders, establishing a system for previsit ordering and providing timely feedback to teams about distribution rates, engaging providers and staff in development of the implementation process, and finding ways to address concerns about conditions that were perceived as life-threatening and/or time sensitive. Limitations. Limitations included lack of data on patient perspectives, an implementation setting with salaried providers, and frontline provider interviews conducted in only selected service lines. Conclusions. With strong leadership, financial support, and a well-defined implementation strategy, 12 video-based DAs in 6 specialty service lines were integrated into routine practice over 2 years. Findings from this demonstration may advance the ability of other organizations to use DAs effectively and promote widespread adoption of shared decision making in routine patient care.

Impact on Seniors of the Patient-Centered Medical Home: Evidence From a Pilot Study

PURPOSE To assess the impact on health care cost and quality among seniors of a patient-centered medical home (PCMH) pilot at Group Health Cooperative, an integrated health care system in Washington State. DESIGN AND METHODS A prospective before-and-after evaluation of the experience of seniors receiving primary care services at 1 pilot clinic compared with seniors enrolled at the remaining 19 primary care clinics owned and operated by Group Health. Analyses of secondary data on quality and cost were conducted for 1,947 seniors in the PCMH clinic and 39,396 seniors in the 19 control clinics. Patient experience with care was based on survey data collected from 487 seniors in the PCMH clinic and of 668 in 2 specific control clinics that were selected for their similarities in organization and patient composition to the pilot clinic. RESULTS After adjusting for baseline, seniors in the PCMH clinic reported higher ratings than controls on 3 of 7 patient experience scales. Seniors in the PCMH clinic had significantly greater quality outcomes over time, but this difference was not significant relative to control. PCMH patients used more e-mail, phone, and specialist visits but fewer emergency services and inpatient admissions for ambulatory care sensitive conditions. At 1 and 2 years, the PCMH and control clinics did not differ significantly in overall costs. IMPLICATIONS A PCMH redesign can be associated with improvements in patient experience and quality without increasing overall cost.

Teaching Medication Reconciliation Through Simulation: A Patient Safety Initiative for Second Year Medical Students

Errors in medication reconciliation constitute a large area of potential injury to patients. Medication reconciliation is rarely incorporated into medical school curriculums so students learn primarily from observing clinical care. To design and implement an interactive learning exercise to teach second year medical students about medication reconciliation Northwestern University Feinberg School of Medicine, Chicago, IL The Medication Reconciliation Simulation teaches medical students how to elicit information from active real-world sources to reconcile a medication history. At the conclusion of the session, students completed a Likert scale survey rating the level of improvement in their knowledge and comfort in obtaining medication histories. Students rated their knowledge level as having increased by 27% and their comfort level as having increased by 20%. A full 91% of the 158 students felt that it should be performed again for the following medical student class. The Medication Reconciliation Simulation is the first to specifically target medication reconciliation as a curriculum topic for medical students. Students praised the entertaining simulation and felt it provided a very meaningful experience on the patient safety topic. This simulation is generalizable to other institutions interested in teaching medication reconciliation and improving medication safety.IntroductionErrors in medication reconciliation constitute a large area of potential injury to patients. Medication reconciliation is rarely incorporated into medical school curriculums so students learn primarily from observing clinical care.AimTo design and implement an interactive learning exercise to teach second year medical students about medication reconciliationSettingNorthwestern University Feinberg School of Medicine, Chicago, ILProgram DescriptionThe Medication Reconciliation Simulation teaches medical students how to elicit information from active real-world sources to reconcile a medication history.Program EvaluationAt the conclusion of the session, students completed a Likert scale survey rating the level of improvement in their knowledge and comfort in obtaining medication histories. Students rated their knowledge level as having increased by 27% and their comfort level as having increased by 20%. A full 91% of the 158 students felt that it should be performed again for the following medical student class.DiscussionThe Medication Reconciliation Simulation is the first to specifically target medication reconciliation as a curriculum topic for medical students. Students praised the entertaining simulation and felt it provided a very meaningful experience on the patient safety topic. This simulation is generalizable to other institutions interested in teaching medication reconciliation and improving medication safety.

Predictors of 1‐Year Change in Patient Activation in Older Adults with Diabetes Mellitus and Heart Disease

To identify patterns and predictors of 1‐year change in patient activation in chronically ill older adults.

Changes in Office Visit Use Associated With Electronic Messaging and Telephone Encounters Among Patients With Diabetes in the PCMH

PURPOSE Telephone- and Internet-based communication are increasingly common in primary care, yet there is uncertainty about how these forms of communication affect demand for in-person office visits. We assessed whether use of copay-free secure messaging and telephone encounters was associated with office visit use in a population with diabetes. METHODS We used an interrupted time series design with a patient-quarter unit of analysis. Secondary data from 2008–2011 spanned 3 periods before, during, and after a patient-centered medical home (PCMH) redesign in an integrated health care delivery system. We used linear regression models to estimate proportional changes in the use of primary care office visits associated with proportional increases in secure messaging and telephone encounters. RESULTS The study included 18,486 adults with diabetes. The mean quarterly number of primary care contacts increased by 28% between the pre-PCMH baseline and the postimplementation periods, largely driven by increased secure messaging; quarterly office visit use declined by 8%. In adjusted regression analysis, 10% increases in secure message threads and telephone encounters were associated with increases of 1.25% (95% CI, 1.21%–1.29%) and 2.74% (95% CI, 2.70%–2.77%) in office visits, respectively. In an interaction model, proportional increases in secure messaging and telephone encounters remained associated with increased office visit use for all study periods and patient subpopulations (P <.001). CONCLUSIONS Before and after a medical home redesign, proportional increases in secure messaging and telephone encounters were associated with additional primary care office visits for individuals with diabetes. Our findings provide evidence on how new forms of patient-clinician communication may affect demand for office visits.