Eric Henley

A Quality Improvement Curriculum for Medical Students

BACKGROUND Despite frequent recommendations that quality improvement (QI) be incorporated into medical education, reports of this activity are few. A pilot project to develop and implement a curriculum on QI into a family medicine clerkship was conducted in the 1999-2000 academic year. INTERVENTION A five-part curriculum was developed and implemented on successive weeks of a family medicine clerkship. The curriculum involved students working alone and in small groups. After an orientation to QI principles, students performed a series of chart audits of diabetes care. They then met with QI coordinators from a local health system to review their results. Improvement recommendations were developed and presented to the clinic director. Evaluation included completion of the module, assessment of student knowledge and opinion, and interviews with the QI coordinators. EVALUATION Two clinic sites and 30 third-year medical (M3) students participated. Each student conducted at least two chart audits, met with the QI coordinators, and developed at least one improvement recommendation. The QI coordinators felt that students were interested in the subject but needed more training in QI principles and more faculty development. Students assessed the curriculum as being moderately effective and useful. DISCUSSION A curriculum in QI that involved active learning strategies was successfully implemented during a family medicine clerkship. Students viewed the curriculum as being appropriate to their learning. Future efforts should include more work on faculty development and role modeling of QI activity.

Morinda Citrifolia (Noni) Reduces Cancer Risk in Current Smokers by Decreasing Aromatic DNA Adducts

Quantitative determination of aromatic DNA adducts in peripheral blood lymphocytes (PBLs) of current smokers is an useful surrogate biomarker for the evaluation of environmental carcinogen exposure or chemopreventive intervention. In this study, we examined the impact of Tahitian Noni Juice (TNJ) on the aromatic DNA adducts of PBLs, before and after a 1-mo intervention, using 32P postlabeling assay. Of 283 enrolled, 203 smokers completed the trial. Aromatic DNA adducts levels in all participants were significantly reduced by 44.9% (P < 0.001) after drinking 1 to 4 oz of TNJ for 1 mo. Dose-dependent analyses of aromatic DNA adduct levels showed reductions of 49.7% (P < 0.001) in the 1-oz TNJ group and 37.6% (P < 0.001) in the 4-oz TNJ group. Gender-specific analyses resulted in no significant differences in the 4-oz TNJ groups. Interestingly, the 1-oz TNJ group showed a reduction of 43.1% (P < 0.001) in females compared with 56.1% (P < 0.001) in males. The results suggest that drinking 1 to 4 oz of TNJ daily may reduce the cancer risk in heavy cigarette smokers by blocking carcinogen-DNA binding or excising DNA adducts from genomic DNA.

Individualized Risk Communication and Outreach for Primary Cardiovascular Disease Prevention in Community Health Centers: Randomized Trial

Background—Many eligible primary cardiovascular disease prevention candidates are not treated with statins. Electronic health record data can identify patients with increased cardiovascular disease risk. Methods and Results—We performed a pragmatic randomized controlled trial at community health centers in 2 states. Participants were men aged ≥35 years and women ≥45 years, without cardiovascular disease or diabetes mellitus, and with a 10-year risk of coronary heart disease of at least 10%. The intervention group received telephone and mailed outreach, individualized based on patients’ cardiovascular disease risk and uncontrolled risk factors, provided by lay health workers. Main outcomes included: documented discussion of medication treatment for cholesterol with a primary care clinician, receipt of statin prescription within 6 months, and low-density lipoprotein (LDL)-cholesterol repeated and at least 30 mg/dL lower than baseline within 1 year. Six hundred forty-six participants (328 and 318 in the intervention and control groups, respectively) were included. At 6 months, 26.8% of intervention and 11.6% of control patients had discussed cholesterol treatment with a primary care clinician (odds ratio, 2.79; [95% confidence interval, 2.25–3.46]). Statin prescribing occurred for 10.1% in the intervention group and 6.0% in the control group (odds ratio, 1.76; [95% confidence interval, 0.90–3.45]). The cholesterol outcome did not differ, and the majority of patients did not repeat lipid levels during follow-up. Conclusions—Risk communication and lay outreach increased cholesterol treatment discussions with primary care clinicians. However, most discussions did not result in statin prescribing. For outreach to be successful, it should be combined with interventions to encourage clinicians to follow contemporary risk-based cholesterol treatment guidelines. Clinical Trial Registration—URL: http://www.clincialtrials.gov. Unique identifier: NCT01610609.

Colorectal Cancer Screening Rates at Community Health Centers that Use Electronic Health Records: A Cross Sectional Study

Background. This study was conducted to validate use of electronic health record (EHR) data for measuring colorectal cancer (CRC) screening rates at community health centers (CHCs). Methods. Electronic health records were queried to assess screening via colonoscopy, flexible sigmoidoscopy, or fecal occult blood testing (FOBT) in 2011. Results. Multiple iterations were required to maximize query accuracy. Manual chart reviews, stratified by screening modality, confirmed query results for 112 of 113 (99.1%) reviewed colonoscopies, 110 of 110 (100%) reviewed FOBTs, and 111 of 120 (92.5%) unscreened patients. At participating CHCs, CRC screening rates ranged from 9.7% to 67.2% (median, 30.6%). Adherence to annual FOBT ranged from 3.3% to 59.0% (median, 18.6%). Most screening was done by colonoscopy. Conclusions. Colorectal cancer screening varies substantially across CHCs. Electronic health record data can validly measure CRC screening, but repeated assessments of programming accuracy are required. Community health centers may need support to measure quality using EHR data and increase screening.