Jacquelyn S. Hunt

Provider feedback to improve 5A's tobacco cessation in primary care: a cluster randomized clinical trial.

The electronic health record (EHR) may be an effective tool to help clinicians address tobacco use more consistently. To evaluate the impact of EHR-generated practice feedback on rates of referral to a state-level tobacco quitline, we conducted a cluster randomized clinical trial (feedback versus no feedback) within 19 primary care clinics in Oregon. Intervention clinics received provider-specific monthly feedback reports generated from EHR data. The reports rated provider performance in asking, advising, assessing, and assisting with tobacco cessation compared with a clinic average and an achievable benchmark of care. During 12 months of follow-up, EHR-documented rates of advising, assessing, and assisting were significantly improved in the intervention clinics compared with the control clinics (p<.001). A higher case-mix index and presence of a clinic champion were associated with higher rates of referral to a state-level quitline. EHR-generated provider feedback improved documentation of assistance with tobacco cessation. Connecting physician offices to a state-level quitline was feasible and well accepted.

Impact of Educational Mailing on the Blood Pressure of Primary Care Patients with Mild Hypertension

OBJECTIVE: To assess the effectiveness of mailed hypertension educational materials.DESIGN: Prospective, randomized, controlled single-blind trial.SETTING: Primary care practice-based research network in which 9 clinics located in Portland, Oregon participated.PARTICIPANTS: Patients with mildly uncontrolled hypertension as defined as a last blood pressure of 140 to 159/90 to 99 mmHg from query of an electronic medical record database.INTERVENTIONS: Patients randomized to intervention were mailed 2 educational packets approximately 3 months apart. The first mailer included a letter from each patient’s primary care provider. The mailer included a booklet providing an overview of hypertension and lifestyle modification and a refrigerator magnet noting target blood pressure. The second mailing also included a letter from the patient’s primary care provider, a second educational booklet focused on medication compliance and home blood pressure monitoring, and a blood pressure logbook. The control group consisted of similar patients receiving usual care for hypertension.MEASUREMENTS AND MAIN RESULTS: Patients from each group were randomly selected for invitation to participate in a study visit to measure blood pressure and complete a survey (intervention n=162; control n=150). No significant difference was found in mean blood pressure between intervention and control patients (135/77 mmHg vs 137/77 mmHg; P=.229). Patients in the intervention arm scored higher on a hypertension knowledge quiz (7.48 ± 1.6 vs 7.06 ± 1.6; P=.019), and reported higher satisfaction with several aspects of their care. No significant difference was seen in the prevalence of home blood pressure monitoring ownership or use.CONCLUSIONS: In patients with mildly uncontrolled hypertension, educational mailers did not yield a significant decrease in blood pressure. However, significant improvement in patient knowledge, frequency of home monitoring, and satisfaction with care were demonstrated.

Team-based care approach to cholesterol management in diabetes mellitus: two-year cluster randomized controlled trial.

BACKGROUND Creative, cost-effective interventions to improve the quality of care of chronic illnesses are needed. This study was designed to evaluate the impact of remote physician-pharmacist team-based care on cholesterol levels in patients with diabetes mellitus (DM). METHODS This 2-year prospective, cluster randomized controlled trial was conducted within the Providence Primary Care Research Network in Oregon. Participants at least 18 years of age were identified by a diagnosis of DM. The intervention included remote physician-pharmacist team-based care focused on cholesterol management in DM. All clinicians in the study had access to the health information technology tool CareManager, which provided automated DM-related point-of-care prompts, a Web-based registry, and performance feedback with benchmarking. Study outcomes included the difference in low-density lipoprotein cholesterol (LDL-C) goal attainment, mean LDL-C, prescribed lipid-lowering therapy, and patient satisfaction between the intervention and control arms. RESULTS A total of 6963 patients with DM cared for by 68 physicians in 9 clinics were evaluated. Patients in the intervention arm were more likely to achieve their target LDL-C levels compared with controls (78% vs 50%; P = .003). The mean LDL-C level was 12 mg/dL lower in the intervention arm compared with the control arm (P < .001). The rate of LDL-C testing was significantly higher in the intervention arm compared with the control arm. Patients in the intervention arm were also 15% more likely to receive a prescription for a lipid-lowering medication (P = .008). There was no significant difference in patient satisfaction between study arms (P = .15). CONCLUSION Remotely located physician-pharmacist team-based care resulted in significantly improved LDL-C levels and goal attainment among patients with DM.

Clinical implications of an accurate problem list on heart failure treatment

CONTEXT: The premise of the problem-oriented medical record is that an accurately defined problem list will directly result in more thorough and efficient patient care. However, little empirical evidence exists demonstrating improved patient outcomes as a result of an adequately structured problem list.OBJECTIVE: To determine the impact of problem list documentation of heart failure on the likelihood that evidence-based pharmacotherapy has been prescribed.DESIGN: Cross-sectional study.SETTING: Community-based primary care clinics in Portland, Oregon.SUBJECTS: Active patients in the network with a left ventricular ejection fraction of 40% or less, with and without heart failure, in their structured problem list.MAIN OUTCOME MEASURES: The proportion of patients prescribed medications with known benefits for systolic dysfunction.RESULTS: In this group of patients with known systolic dysfunction, the likelihood of therapy with either an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker was higher in patients who had heart failure listed on their problem list compared to patients who did not (92.2% vs 76.7%; P<.05). This association remained after statistical adjustment for age, gender, and ejection fraction. Patients with accurate problem list entries were also more likely to receive digoxin (61.1% vs 36.7%; P=.001) and spironolactone (26.7% vs 13.3% P=.025). There were no differences in the use of beta-blockers between the 2 groups.CONCLUSION: Accurate documentation of heart failure on the problem list of patients with known systolic dysfunction is associated with a significant increase in the likelihood of being prescribed medications with known clinical benefit.

Effect of patient withdrawal on a study evaluating pharmacist management of hypertension

Study Objectives. To examine potential threats to internal and external study validity caused by differential patient withdrawal from a randomized controlled trial evaluating pharmacist management of hypertension, to compare the characteristics of patients who withdrew with those of patients who completed the study, and to identify characteristics that predispose patients to withdraw from hypertension management.

Female Sexual Dysfunction: Review of the Disorder and Evidence for Available Treatment Alternatives

With the introduction and marketing of sildenafil, national attention has focused on sexual dysfunction in men. However, strides are being made to focus more effort on evaluation and treatment of female sexual disorder (FSD) since a 1999 national survey reported prevalence rates as high as 43% in women. Evaluation and assessment of FSD requires a comprehensive history and physical examination. Understanding of FSD requires knowledge and understanding of sexual anatomy, physiology, and pathophysiology. Nonpharmacologic treatment may include sex therapy or relationship counseling. Pharmacologic treatment of FSD has focused mainly on hormonal therapies, including estrogen and testosterone, with the majority of studies being done in postmenopausal and hysterectomized women. However, recent studies indicate a more prudent and careful use of hormonal therapies. Research is also moving toward evaluation of bupropion and sildenafil as options for women who suffer from FSD. Available evidence for treatment alternatives is scant and in some cases inconclusive.