James W. Pichert

Diabetes patient education: a meta-analysis and meta-regression

Diabetes education has largely been accepted in diabetes care. The effect of diabetes education on glycemic control and the components of education responsible for such an effect are uncertain. We performed a meta-analysis of randomized controlled trials of diabetes patient education published between 1990 and December 2000 to quantitatively assess and characterize the effect of patient education on glycated hemoglobin (HbA(1c)). Additionally, we used meta-regression to analyze which variables within an education intervention that best explained variance in glycemic control. Twenty-eight educational interventions (n=2439) were included in the analysis. The net glycemic change was 0.320% lower in the intervention group than in the control group. Meta-regression revealed that interventions which included a face-to-face delivery, cognitive reframing teaching method, and exercise content were more likely to improve glycemic control. Those three areas collectively explained 44% of the variance in glycemic control. Current patient education interventions modestly improve glycemic control in adults with diabetes. We highlight three potential components of educational interventions that may predict an increased likelihood of success in ameliorating glycemic control.

A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors.

Vanderbilt University School of Medicine (VUSM) employs several strategies for teaching professionalism. This article, however, reviews VUSM’s alternative, complementary approach: identifying, measuring, and addressing unprofessional behaviors. The key to this alternative approach is a supportive infrastructure that includes VUSM leadership’s commitment to addressing unprofessional/disruptive behaviors, a model to guide intervention, supportive institutional policies, surveillance tools for capturing patients’ and staff members’ allegations, review processes, multilevel training, and resources for addressing disruptive behavior. Our model for addressing disruptive behavior focuses on four graduated interventions: informal conversations for single incidents, nonpunitive “awareness” interventions when data reveal patterns, leader-developed action plans if patterns persist, and imposition of disciplinary processes if the plans fail. Every physician needs skills for conducting informal interventions with peers; therefore, these are taught throughout VUSM’s curriculum. Physician leaders receive skills training for conducting higher-level interventions. No single strategy fits every situation, so we teach a balance beam approach to understanding and weighing the pros and cons of alternative intervention-related communications. Understanding common excuses, rationalizations, denials, and barriers to change prepares physicians to appropriately, consistently, and professionally address the real issues. Failing to address unprofessional behavior simply promotes more of it. Besides being the right thing to do, addressing unprofessional behavior can yield improved staff satisfaction and retention, enhanced reputation, professionals who model the curriculum as taught, improved patient safety and risk-management experience, and better, more productive work environments.

Cause and effect analysis of closed claims in obstetrics and gynecology.

BACKGROUND: Identifying the etiologies of real or perceived adverse clinical events and undesired outcomes is an important step in improving patient safety and reducing malpractice risks. Systematic analysis of obstetrics and gynecology-related risk management files allows a more complete examination of ways that human and systems factors may contribute to adverse events. OBJECTIVE: To learn the medical complaints of patients who experienced apparent adverse events, the general causes of those adverse events, and the significant specific causal factors involved in obstetrics and gynecology-related risk management cases. METHODS: This was a retrospective analysis of 90 consecutive obstetrics and gynecology-related internal review files opened by a medical centers risk managers between 1995 and 2001. Each file was analyzed to identify factors that may have contributed to or caused unanticipated adverse events. The main outcome was the pattern of contributing factors when they were aggregated into categories. RESULTS: Fifty percent of cases were associated with inpatient obstetrics. Factors that may have contributed to adverse events were identified in 78% of cases, and most had more than one contributing factor. Thirty-one percent of adverse events were associated with apparent communication problems. Clinical performance issues were identified in 31% of cases, diagnostic issues in 18% of cases, and patient behavior contributed to 14% of adverse events. CONCLUSION: Diagnostic, therapeutic, and communication issues were the most common factors identified. Although the generalizability of these data are unknown, all obstetrics and gynecology departments face multiple challenges in assuring consistent quality care. Analysis of claims files may help identify opportunities for improvement. LEVEL OF EVIDENCE: II-3

Surgical adverse events, risk management, and malpractice outcome: Morbidity and mortality review is not enough

ObjectiveTo review all admissions (age > 13) to three surgical patient care centers at a single academic medical center between January 1, 1995, and December 6, 1999, for significant surgical adverse events. Summary Background DataLittle data exist on the interrelationships between surgical adverse events, risk management, malpractice claims, and resulting indemnity payments to plaintiffs. The authors hypothesized that examination of this process would identify performance improvement opportunities overlooked by standard medical peer review; the risk of litigation would be constant across the three homogeneous patient care centers; and the risk management process would exceed the performance improvement process. MethodsData collected included patient demographics (age, gender, and employment status), hospital financials (hospital charges, costs, and financial class), and outcome. Outcome categories were medical (disability: <1 month, 1–6 months, permanent/death), legal (no legal action, settlement, summary judgment), financial (indemnity payments, legal fees, write-offs), and cause and effect analysis. Cause and effect analysis attempts to identify system failures contributing to adverse outcomes. This was determined by two independent analysts using the 17 Harvard criteria and subdividing these into subsystem causative factors. ResultsThe study group consisted of 130 patients with surgical adverse events resulting in total liabilities of

Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: a randomized controlled trial.

8.2 million. The incidence of adverse events per 1,000 admissions across the three patient care centers was similar, but indemnity payments per 1,000 admissions varied (cardiothoracic =

Relationship between patient complaints and surgical complications

30, women’s health =

Educational program for physicians to reduce use of non-steroidal anti-inflammatory drugs among community-dwelling elderly persons: a randomized controlled trial.

90, trauma =

A taxonomy for diabetes educational interventions

520). Patient demographics were not predictive of high-risk subgroups for adverse events or litigation. In terms of medical outcome, 51 patients had permanent disability or death, accounting for 98% of the indemnity payments. In terms of legal outcome, 103 patients received no indemnity payments, 15 patients received indemnity payments, four suits remain open, and in eight cases charges were written off (

Situational Obstacles to Adherence for Adolescents with Diabetes

0.121 million). To date, no cases have been adjudicated in court. Cause and effect analysis identified 390 system failures contributing to the adverse events (mean 3.0 failures per adverse event); there were 4.7 failures per adverse event in the 15 indemnity cases. Five categories of causes accounted for 75% of the failures (patient management, n = 104; communication, n = 89; administration, n = 33; documentation, n = 32; behavior, n = 23). The current medical review process would have identified 104 of 390 systems failures (37%). ConclusionsThis study demonstrates no rational link between the tort system and the reduction of adverse events. Sixty-three percent of contributing causes to adverse events were undetected by current medical review processes. Adverse events occur at the interface between different systems or disciplines and result from multiple failures. Indemnity costs per hospital day vary dramatically by patient care center (range

Development of an Early Identification and Response Model of Malpractice Prevention

3.60–97.60 a day). The regionalization of healthcare is in jeopardy from the burden of high indemnity payments.