Elisha M. Friesema

Changes in Performance After Implementation of a Multifaceted Electronic-Health-Record-Based Quality Improvement System

Background:Electronic health record (EHR) systems have the potential to revolutionize quality improvement (QI) methods by enhancing quality measurement and integrating multiple proven QI strategies. Objectives:To implement and evaluate a multifaceted QI intervention using EHR tools to improve quality measurement (including capture of contraindications and patient refusals), make point-of-care reminders more accurate, and provide more valid and responsive clinician feedback (including lists of patients not receiving essential medications) for 16 chronic disease and preventive service measures. Design:Time series analysis at a large internal medicine practice using a commercial EHR. Subjects:All adult patients eligible for each measure (range approximately 100–7500). Measures:The proportion of eligible patients who satisfied each measure after removing those with exceptions from the denominator. Results:During the year before the intervention, performance improved significantly for 8 measures. During the year after the intervention, performance improved significantly for 14 measures. For 9 measures, the primary outcome improved more rapidly during the intervention year than during the previous year (P < 0.001 for 8 measures, P = 0.02 for 1). Four other measures improved at rates that were not significantly different from the previous year. Improvements resulted from increases in patients receiving the service, documentation of exceptions, or a combination of both. For 5 drug-prescribing measures, more than half of physicians achieved 100% performance. Conclusions:Implementation of a multifaceted QI intervention using EHR tools to improve quality measurement and the accuracy and timeliness of clinician feedback improved performance and/or accelerated the rate of improvement for multiple measures simultaneously.

Penetrance of Hemochromatosis in HFE Genotypes Resulting in p.Cys282Tyr and p.[Cys282Tyr];[His63Asp] in the eMERGE Network

Hereditary hemochromatosis (HH) is a common autosomal-recessive disorder associated with pathogenic HFE variants, most commonly those resulting in p.Cys282Tyr and p.His63Asp. Recommendations on returning incidental findings of HFE variants in individuals undergoing genome-scale sequencing should be informed by penetrance estimates of HH in unselected samples. We used the eMERGE Network, a multicenter cohort with genotype data linked to electronic medical records, to estimate the diagnostic rate and clinical penetrance of HH in 98 individuals homozygous for the variant coding for HFE p.Cys282Tyr and 397 compound heterozygotes with variants resulting in p.[His63Asp];[Cys282Tyr]. The diagnostic rate of HH in males was 24.4% for p.Cys282Tyr homozygotes and 3.5% for compound heterozygotes (p < 0.001); in females, it was 14.0% for p.Cys282Tyr homozygotes and 2.3% for compound heterozygotes (p < 0.001). Only males showed differences across genotypes in transferrin saturation levels (100% of homozygotes versus 37.5% of compound heterozygotes with transferrin saturation > 50%; p = 0.003), serum ferritin levels (77.8% versus 33.3% with serum ferritin > 300 ng/ml; p = 0.006), and diabetes (44.7% versus 28.0%; p = 0.03). No differences were found in the prevalence of heart disease, arthritis, or liver disease, except for the rate of liver biopsy (10.9% versus 1.8% [p = 0.013] in males; 9.1% versus 2% [p = 0.035] in females). Given the higher rate of HH diagnosis than in prior studies, the high penetrance of iron overload, and the frequency of at-risk genotypes, in addition to other suggested actionable adult-onset genetic conditions, opportunistic screening should be considered for p.[Cys282Tyr];[Cys282Tyr] individuals with existing genomic data.

EHR-Based Medication Support and Nurse-Led Medication Therapy Management: Rationale and Design for a Three-Arm Clinic Randomized Trial

Background Patients with chronic conditions often use complex medical regimens. A nurse‐led strategy to support medication therapy management incorporated into primary care teams may lead to improved use of medications for disease control. Electronic health record (EHR) tools may offer a lower‐cost, less intensive approach to improving medication management. Methods and Results The Northwestern and Access Community Health Network Medication Education Study is a health center–level cluster‐randomized trial being conducted within a network of federally qualified community health centers. Health centers have been enrolled in groups of 3 and randomized to (1) usual care, (2) EHR‐based medication management tools alone, or (3) EHR tools plus nurse‐led medication therapy management. Patients with uncontrolled hypertension who are prescribed ≥3 medications of any kind are recruited from the centers. EHR tools include a printed medication list to prompt review at each visit and automated plain‐language medication information within the after‐visit summary to encourage proper medication use. In the nurse‐led intervention, patients receive one‐on‐one counseling about their medication regimens to clarify medication discrepancies and identify drug‐related concerns, safety issues, and nonadherence. Nurses also provide follow‐up telephone calls following new prescriptions and periodically to perform medication review. The primary study outcome is systolic blood pressure after 1 year. Secondary outcomes include measures of understanding of dosing instructions, discrepancies between patient‐reported medications and the medical record, adherence, and intervention costs. Conclusions The Northwestern and Access Community Health Network Medication Education Study will assess the effects of 2 approaches to support outpatient medication management among patients with uncontrolled hypertension in federally qualified health center settings. Clinical Trial Registration URL: clinicaltrials.gov. Unique identifier: NCT01578577.

Hiring and Screening Practices of Agencies Supplying Paid Caregivers to Older Adults

To assess what screening practices agencies use in hiring caregivers and how caregiver competency is measured before assigning responsibilities in caring for older adults.

Unnecessary complexity of home medication regimens among seniors

OBJECTIVE To determine whether seniors consolidate their home medications or if there is evidence of unnecessary regimen complexity. METHODS Face-to-face interviews were conducted with 200 community-dwelling seniors >70 years in their homes. Subjects demonstrated how they took their medications in a typical day and the number of times a day patients would take medications was calculated. A pharmacist and physician blinded to patient characteristics examined medication regimens and determined the fewest number of times a day they could be taken by subjects. RESULTS Home medication regimens could be simplified for 85 (42.5%) subjects. Of those subjects not optimally consolidating their medications, 53 (26.5%) could have had the number of times a day medications were taken reduced by one time per day; 32 (16.0%) reduced by two times or more. The three most common causes of overcomplexity were (1) misunderstanding medication instructions, (2) concern over drug absorption (i.e. before meals), and (3) perceived drug-drug interactions. CONCLUSION Almost half of seniors had medication regimens that were unnecessarily complicated and could be simplified. This lack of consolidation potentially impedes medication adherence. PRACTICE IMPLICATIONS Health care providers should ask patients to explicitly detail when medication consumption occurs in the home.

Paid caregiver motivation, work conditions, and falls among senior clients

The purpose of this study was to determine the motivation of paid non-familial caregivers of seniors, understand more about their work conditions, and identify any links to negative outcomes among their senior clients. Ninety-eight paid caregivers (eighty-five female and thirteen male), recruited from multiple sites (i.e. senior centers, shopping malls, local parks, lobbies of senior apartments, caregiver agency meetings) completed face-to-face questionnaires and semi-structured interviews. We found that 60.7% of participants chose to become a caregiver because they enjoyed being with seniors while 31.7% were unable to obtain other work, and 8.2% stated it was a prerequisite to a different health related occupation. Caregivers stated that the most challenging conditions of their work were physical lifting (24.5%), behavioral and psychological symptoms of dementia (24.5%), senior depression/mood changes (18.4%), attachment with impending death (8.2%), missing injuries to client (5.1%), lack of sleep (4.1%), and lack of connection with outside world (3.1%). Caregivers who reported that the best part of their job was the salary, flexible hours, and ease of work were significantly more likely to have clients who fell and fractured a bone than those who enjoyed being with seniors (job characteristics, 62.5% vs. senior enjoyment, 25.6%; p<0.004). We concluded that in pursuing their occupation, paid caregivers are motivated commonly by their love of seniors and also by their lack of other job opportunities. Paid caregivers frequently face challenging work conditions. When seeking a caregiver for a senior, motivation of the caregiver should be considered when hiring.

Effect of Electronic Health Record–Based Medication Support and Nurse-Led Medication Therapy Management on Hypertension and Medication Self-management: A Randomized Clinical Trial

Importance Complex medication regimens pose self-management challenges, particularly among populations with low levels of health literacy. Objective To test medication management tools delivered through a commercial electronic health record (EHR) with and without a nurse-led education intervention. Design, Setting, and Participants This 3-group cluster randomized clinical trial was performed in community health centers in Chicago, Illinois. Participants included 794 patients with hypertension who self-reported using 3 or more medications concurrently (for any purpose). Data were collected from April 30, 2012, through February 29, 2016, and analyzed by intention to treat. Interventions Clinics were randomly assigned to to groups: electronic health record–based medication management tools (medication review sheets at visit check-in, lay medication information sheets printed after visits; EHR-alone group), EHR-based tools plus nurse-led medication management support (EHR plus education group), or usual care. Main Outcomes and Measures Outcomes at 12 months included systolic blood pressure (primary outcome), medication reconciliation, knowledge of drug indications, understanding of medication instructions and dosing, and self-reported medication adherence. Medication outcomes were assessed for all hypertension prescriptions, all prescriptions to treat chronic disease, and all medications. Results Among the 794 participants (68.6% women; mean [SD] age, 52.7 [9.6] years), systolic blood pressure at 12 months was greater in the EHR-alone group compared with the usual care group by 3.6 mm Hg (95% CI, 0.3 to 6.9 mm Hg). Systolic blood pressure in the EHR plus education group was not significantly lower compared with the usual care group (difference, −2.0 mm Hg; 95% CI, −5.2 to 1.3 mm Hg) but was lower compared with the EHR-alone group (−5.6 mm Hg; 95% CI, −8.8 to −2.4 mm Hg). At 12 months, hypertension medication reconciliation was improved in the EHR-alone group (adjusted odds ratio [OR], 1.8; 95% CI, 1.1 to 2.9) and the EHR plus education group (adjusted odds ratio [OR], 2.0; 95% CI, 1.3 to 3.3) compared with usual care. Understanding of medication instructions and dosing was greater in the EHR plus education group than the usual care group for hypertension medications (OR, 2.3; 95% CI, 1.1 to 4.8) and all medications combined (OR, 1.7; 95% CI, 1.0 to 2.8). Compared with usual care, the EHR tools alone and EHR plus education interventions did not improve hypertension medication adherence (OR, 0.9; 95% CI, 0.6-1.4 for both) or knowledge of chronic drug indications (OR for EHR tools alone, 1.0 [95% CI, 0.6 to 1.5] and OR for EHR plus education, 1.1 [95% CI, 0.7-1.7]). Conclusions and Relevance The study found that EHR tools in isolation improved medication reconciliation but worsened blood pressure. Combining these tools with nurse-led support suggested improved understanding of medication instructions and dosing but did not lower blood pressure compared with usual care. Trial Registration ClinicalTrials.gov identifier: NCT01578577

Changes in Care After Implementing a Multifaceted Intervention to Improve Preventive Cardiology Practice in Rheumatoid Arthritis

Rheumatoid arthritis (RA) increases cardiovascular disease (CVD) risk. However, CVD risk factor identification and treatment is often inadequate. The authors implemented a multifaceted rheumatology practice intervention to improve CVD risk factor measurement, assessment, and management. The intervention included clinician education, point-of-care decision support, feedback, and care management. The authors measured quality indicators from electronic health records and assessed impact with interrupted time series. Following the intervention, more RA patients had all major CVD risk factors assessed (53% vs 72.2%), and the rate of increase was greater during the intervention period than baseline (difference of 0.74% per month, P = .0016). Moderate- or high-intensity statin prescribing increased (21.6% to 28.2%), but the rate of change was not different from baseline. Several other quality measures did not increase. Although CVD risk factor assessment improved, the intervention did not affect risk factor management and control. Other strategies are needed to optimize CVD prevention in RA.