Michael D. Hagen

Survival After In-Hospital Cardiopulmonary Resuscitation: A Meta-Analysis

OBJECTIVE: To determine the rates of immediate survival and survival to discharge for adult patients undergoing in-hospital cardiopulmonary resuscitation, and to identify demographic and clinical variables associated with these outcomes.MEASUREMENTS AND MAIN RESULTS: The MEDLARS database of the National Library of Medicine was searched. In addition, the authors’ extensive personal files and the bibliography of each identified study were searched for further studies. Two sets of inclusion criteria were used, minimal (any study of adults undergoing in-hospital cardiopulmonary resuscitation) and strict (included only patients from general ward and intensive care units, and adequately defined cardiopulmonary arrest and resuscitation). Each study was independently reviewed and abstracted in a nonblinded fashion by two reviewers. The data abstracted were compared, and any discrepancies were resolved by consensus discussion. For the subset of studies meeting the strict criteria, the overall rate of immediate survival was 40.7% and the rate of survival to discharge was 13.4%. The following variables were associated with failure to survive to discharge: sepsis on the day prior to resuscitation (odds ratio [OR] 31.3; 95% confidence interval [CI] 1.9, 515), metastatic cancer (OR 3.9; 95% CI 1.2, 12.6), dementia (OR 3.1; 95% CI 1.1, 8.8), African-American race (OR 2.8; 95% CI 1.4, 5.6), serum creatinine level at a cutpoint of 1.5 mg/dL (OR 2.2; 95% CI 1.2, 3.8), cancer (OR 1.9; 95% CI 1.2, 3.0), coronary artery disease (OR 0.55; 95% CI 0.4, 0.8), and location of resuscitation in the intensive care unit (OR 0.51; 95% CI 0.4, 0.8).CONCLUSIONS: When talking with patients, physicians can describe the overall likelihood of surviving discharge as 1 in 8 for patients who undergo cardiopulmonary resuscitation and 1 in 3 for patients who survive cardiopulmonary resuscitation.

Streptococcal diagnostic testing and antibiotics prescribed for pediatric tonsillopharyngitis.

BACKGROUND This study examined a 1-year cross-sectional sample of Kentucky Medicaid claims for the use of streptococcal diagnostic tests for pediatric tonsillopharyngitis and the empiric use of antibiotics. METHODS Subjects were individuals older than 3 and younger than 18 years old seen in an ambulatory setting for tonsillopharyngitis; 3478 individuals accounted for the 5067 separate outpatient and emergency room encounters for pediatric tonsillopharyngitis; 849 encounters coded as streptococcal sore throat were also examined. RESULTS Diagnostic tests for group A streptococcal tonsillopharyngitis were performed in only 22% (n = 1130) of the tonsillopharyngitis encounters and 36% (n = 306) of the streptococcal sore throat encounters. Urban physicians were more likely than rural physicians to use a diagnostic test (P = 0.0001). Emergency room encounters and outpatient encounters were not significantly different in the likelihood of having a diagnostic test (P = 0.16). In encounters for tonsillopharyngitis antibiotics were prescribed in 72% of the total encounters and in 73% of the encounters without a diagnostic streptococcal test. In encounters for streptococcal sore throat, antibiotics were prescribed for 68% of the total encounters and 69% of the encounters without a diagnostic streptococcal test. CONCLUSIONS Current practices in the Kentucky Medicaid program do not follow the American Academy of Pediatrics guidelines for streptococcal tonsillopharyngitis.

Physician Satisfaction With and Practice Changes Resulting From American Board of Family Medicine Maintenance of Certification Performance in Practice Modules.

Introduction: Physician payment in the United States will be increasingly tied to quality measurement and performance. Whether participation in quality improvement (QI) through Maintenance of Certification for Family Physicians Performance in Practice Modules (PPMs) is useful and results in practice change remains unknown. Methods: All PPM feedback data from inception to April 2014 were analyzed using descriptive statistics by year, topic, and number of PPMs completed. Qualitative content analysis was applied to analyze responses to open-ended questions on practice changes. Results: Of note, 29,755 diplomates completed 38,201 PPMs; median 1 interquartile range (1, 1). Nearly two-thirds (65.8%, n = 25,150) of PPMs had completed feedback surveys. Of note, 78.7% of respondents indicated that they would change patient care and 90.2% indicated that they would continue QI activities after completing the PPM. Respondents endorsed high relevance to practice (90.5%), high currency of clinical information (86.4%), and high usefulness of clinical information (80.5%). When feedback was analyzed by the number of PPMs completed, respondents were less likely to change care but reported increased usefulness to practice and stable intention to continue QI efforts with more PPMs completed. Of note, 86.0% of respondents who said that they would change care provided examples: these varied by PPM topic but “doing more,” focusing on patients, and education were common. Discussion: These findings suggest that QI completed through the PPMs may assist family physicians in improving the care they provide. Furthermore, ratings by the number of PPMs completed suggest that repeated exposure to QI efforts produce continued relevance and usefulness, even when changes in practice decline.

Practice Patterns for Peptic Ulcer Disease: Are Family Physicians Testing for H. pylori?

Background. Peptic ulcer disease (PUD) is a problem common in family medicine. Recent evidence of Helicobacter pylori as an etiological agent of PUD has led to National Institutes of Health recommendations for treatment to eradicate H. pylori through antibiotic therapy. The purpose of this study is to examine practice patterns of family physicians in treating PUD, their use of H. pylori testing, and knowledge of current recommendations for PUD.

Physician Perceptions of Performance Feedback in a Quality Improvement Activity.

Physician performance and peer comparison feedback can affect physician care quality and patient outcomes. This study aimed to understand family physician perspectives of the value of performance feedback in quality improvement (QI) activities. This study analyzed American Board of Family Medicine open-ended survey data collected between 2004 and 2014 from physicians who completed a QI module that provided pre- and post-QI project individual performance data and peer comparisons. Physicians made 3480 comments in response to a question about this performance feedback, which were generally positive in nature (86%). Main themes that emerged were importance of accurate feedback data, enhanced detail in the content of feedback, and ability to customize peer comparison groups to compare performance to peers with similar patient populations or practice characteristics. Meaningful and tailored performance feedback may be an important tool for physicians to improve their care quality and should be considered an integral part of QI project design.

A pocket calculator program for using Pozen's formula

Pozens formula has been shown to improve diagnostic accuracy in patients with acute chest pain. This paper describes a short program for the HP-41CV calculator which reliably calculates acute ischemic heart disease probabilities using Pozens formula.

Improving Performance Improvement

Since 2005, the American Board of Family Medicine (ABFM) has provided Diplomates with quality improvement tools for meeting the continuing certification Performance in Practice requirement. These tools took the form of Performance in Practice Modules (PPMs) based on the Deming model for quality improvement. The ABFM focused on common disorders frequently encountered by family physicians: diabetes, hypertension, asthma, depression, coronary artery disease, and heart failure. The ABFM also created a “comprehensive” PPM that provided diplomates with a broader set of measure options based on the Ambulatory Quality Alliance Starter Set. Since inception of the PPMs, Diplomates have completed 98,000 quality improvement activities (ABFM internal report, accessed February 20, 2017; available upon request.) As Diplomates have gained experience and familiarity with quality improvement methodology, ABFM has received a growing number of requests for more flexible and varied options for meeting Performance in Practice requirements. In addition, with the development of the PRIME registry, ABFM needed a vehicle for accepting electronic clinical quality measures (eCQMs) for use in diplomates’ performance improvement activities as well other reporting needs (eg, Physicians Quality Reporting System, Merit-Based Incentive Payment System). Briefly, the PRIME registry system includes several components: an extraction tool that derives data directly from electronic health records, a data warehouse in which to store these data, and the registry itself, which holds the eCQMs in order to support performance improvement and reporting. Enter ABFM’s revised Performance Improvement Activity (PIA) platform! Working with its vendor, FIGmd, ABFM has reworked the existing PPM product to support a broader spectrum of quality domains. In addition, instructional materials regarding quality improvement methods have been incorporated (another aspect of functionality requested by many diplomates over the years). We worked with consultants from Case Western Reserve University to develop these materials, and we have integrated them into the product to provide contextually appropriate guidance throughout. The platform provides tools and resources for identifying performance gaps, developing and implementing quality improvement plans, and accomplishing the reporting needs described earlier. Although we designed the system to support direct population of quality data from PRIME, the system also supports manual data entry for those Diplomates who do not yet participate in the registry. The PIA platform currently supports 49 eCQMs, as defined in the measures codes that the Center for Medicare & Medicaid Services maintains for Physicians Quality Reporting System reporting. In addition, ABFM physician staff have identified and vetted (for validity and to remain free from commercial influence), for each measure, examples of web-based resources for implementing improvement plans. The platform organizes these resources by the categories included in the Chronic Care Model: clinical information systems, decision support, delivery system design, self-management support, and community resources and policies. Upon entering the system, Diplomates will see a dashboard that displays their performance on the 49 measures compared with that of their peers (Figure 1). They then select the measures for which they wish to create a performance improvement project, and develop an intervention plan using the Chronic Care Model–based resources provided (or custom actions that diplomates develop locally.) (Figure 2). FIGmd and ABFM development staff anticipate deployment in the late second quarter or early third quarter of 2017. In addition, ABFM has contracted with collaborators at the University of Missouri–Columbia to create Conflict of interest: The author is an employee of the ABFM.

“The End of the Beginning” for Clinical Simulation in the ABFM Self-Assessment Modules (SAMs)

“Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”[1][1] With these words, Winston Churchill marked the Allied victory of Second El Alamein that represented a major turning point in the struggle against the Axis powers in World War

ABFM's self-assessment module (SAM) revision process.

In 2004, the first self-assessment modules (SAMs) went online as a resource for fulfilling the part II requirement of Maintenance of Certification for Family Physicians (MC-FP). As time has gone by, Diplomates have occasionally asked about the process the American Board of Family Medicine (ABFM) uses for revising and updating the content of the SAMs. Given the pace of change in medical knowledge, ABFM staff has found it necessary to employ multiple strategies to keep the SAMs current. In an effort to obtain automated summaries of knowledge updates, our information specialist has worked with a physician to identify sets of search terms, called hedges, for use in the MedLINE/PubMed My NCBI tool available at the National Library of Medicine’s PubMed website (http://www.ncbi.nlm.nih.gov/myncbi/). This site allows users to create and store literature search strategies that will run on a periodic basis to retrieve recent information on a given topic. These searches have been developed for every SAM item, and the staff reviews the results on a regular basis to identify significant new content or changes to existing information. A second strategy is to have a member of the knowledge team that developed the SAM review the complete set of questions. Those that are no longer accurate or current are modified or replaced accordingly. In addition, some questions are removed to make room for new ones that reflect important developments. Since Diplomates are permitted to repeat a SAM for MC-FP credits after 5 years have elapsed, a more in-depth review of the SAM is performed every 5 years by members of the original development team, as well as by new additions to the group, with a goal of replacing at least one-third of the questions. Finally, the commenting feature accessible to Diplomates after completing the SAM questions has also proven to be a helpful tool for keeping SAMs up to date. As with the hedges, staff members review this feedback on a regular basis. In addition to providing input regarding ambiguous or controversial content, these comments can also alert our staff to content that has become outdated because of new recommendations or studies. After a physician has revised or replaced a question, the changes go to the Content Development department. The new or revised content is then edited and incorporated into the department’s database. From there, the new content is exported to the IT department, where it is moved into another database. The editors then review the questions once more in the format used on the Web., Cnce approved, the changes are deployed to our website. While complex and labor-intensive, these strategies have served to keep the SAMs current and assure our Diplomates that the content remains dynamically responsive to the changing field of family medicine!

ABFM’S HEART FAILURE SELF-ASSESSMENT MODULE SIMULATION ACTIONS VIS-À-VIS GUIDELINE RECOMMENDATIONS

The American Board of Family Medicine (ABFM) introduced Maintenance of Certification for Family Physicians (MC-FP) in 2004 in response to policy adopted by the American Board of Medical Specialties (ABMS.)1 ABFM reported in 2006 the initial Diplomate experiences with MC-FP.2 At that time, ABFM had Self-Assessment Modules (SAMs), consisting of a 60-item knowledge assessment followed by a virtual patient clinical simulation available only for hypertension, type 2 diabetes mellitus, asthma, and depression. Since that time, ABFM has deployed modules for coronary artery disease, chronic heart failure, well child care, maternity care, preventive care, care of the vulnerable elderly, pain management, early childhood illness, cerebrovascular disease, and health behavior. Each of the SAMs includes a Diplomate assessment of both the knowledge assessment and the simulation components. In addition to the Diplomates’ subjective assessments of the SAMs, ABFM captures the actions taken during each simulation, including the action itself, the simulated date and time of the action, and the simulated patient’s current health state. This information is captured in an action log, which serves as a persistent record of the Diplomate’s traversal through the simulation scenario. ABFM introduced the chronic heart failure (CHF) SAM and associated simulation in 2006. We present in Figure 1 a graphical summary of simulation actions taken in the CHF SAM, as extracted from the simulation action logs from 2006 to 2011. We present the results as percentage of simulations in which given actions occurred. Figure 1 Chronic heart failure Self-Assessment Module simulations including indicated actions. The results indicate overall high use of angiotensin converting inhibitors (ACEInhibitors), ACE inhibitors and/or angiotensin receptor blockers (ACEInhibitor-sARBS), but surprisingly low use of beta-adrenergic blocking agents (BetaBlockers.) Digitalis preparations (DigitalisPrep) demonstrated very low use. The majority of Diplomates also did a formal assessment of left ventricular function (Echocardiogram.) The CHF simulations generally present scenarios representing patients with stage C heart failure, as defined in the 2009 ACCF/AHA heart failure guideline.3 According to that guideline, ACE inhibitors and beta-adrenergic blockers should routinely be used in these patients.3 This discrepancy between recommended therapy and the low percentage of beta-adrenergic blocker prescriptions in the simulations suggests that the knowledge assessments should perhaps place greater emphasis on the use of these agents in class C .heart failure. The current CHF knowledge assessment contains only 7 items that reference beta-blockers, and nearly all of these present a beta-adrenergic agent only as historical information in the clinical stem of the item, rather than as a focus of decision-making in the item. These results suggest that the simulations, although clearly presenting a virtual patient environment, can serve as a useful probe for identifying possible management gaps that should be emphasized in the SAM knowledge assessments.