Mohan M. Nadkarni

Patient safety in the ambulatory setting: A clinician-based approach

BACKGROUND: Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis.OBJECTIVES: To determine the feasibility and effectiveness of clinician-based near miss/adverse event voluntary reporting coupled with systems analysis and redesign as a model for continuous quality improvement in the ambulatory setting.DESIGN: We report the initial 1-year experience of voluntary reporting by clinicians in the ambulatory setting, coupled with root cause analysis and system redesign by a patient safety committee made up of clinicians from the practice.SETTING: Internal medicine practice site of a large teaching hospital with 25,000 visits per year.MEASUREMENTS AND MAIN RESULTS: There were 100 reports in the 1-year period, increased from 5 in the previous year. Faculty physicians reported 44% of the events versus 22% by residents, 31% by nurses, and 3% by managers. Eighty-three percent were near misses and 17% were adverse events. Errors involved medication (47%), lab or x-rays (22%), office administration (21%), and communication (10%) processes. Seventy-two interventions were recommended with 75% implemented during the study period.CONCLUSION: This model of clinician-based voluntary reporting, systems analysis, and redesign was effective in increasing error reporting, particularly among physicians, and in promoting system changes to improve care and prevent errors. This process can be a powerful tool for incorporating error reporting and analysis into the culture of medicine.

Determinants of physician use of an ambulatory prescription expert system

PURPOSE To determine whether physician experience with and attitude towards computers is associated with adoption of a voluntary ambulatory prescription writing expert system. METHODS A prescription expert system was implemented in an academic internal medicine residency training clinic and physician utilization was tracked electronically. A physician attitude and behavior survey (response rate=89%) was conducted six months after implementation. RESULTS There was wide variability in system adoption and degree of usage, though 72% of physicians reported predominant usage (> or =50% of prescriptions) of the expert system six months after implementation. Self-reported and measured technology usage were strongly correlated (r=0.70, p<0.0001). Variation in use was strongly associated with physician attitude toward issues of system efficiency and effect on quality, but not with prior computer experience, level of training, or satisfaction with their primary care practice. Non-adopters felt that electronic prescribing was more time consuming and also more likely to believe that their patients preferred hand-written prescriptions. CONCLUSION A voluntary electronic prescription system was readily adopted by a majority of physicians who believed it would have a positive impact on the quality and efficiency of care. However, dissatisfaction with system capabilities among both adopters and non-adopters suggests the importance of user education and expectation management following system selection.

Free clinics: a national survey.

Objectives:To describe the scope and value of services provided by free clinics across the United States. Methods:Mail survey of directors of free clinics registered in the Free Clinic Directory of the Free Clinic Foundation of America, November 2001, concerning the calendar year 2001. Results:Eighty two percent (281/355) of clinics responded. Seventy five percent of clinics described their target population as the “uninsured” and 23% as “low income”. Fifty five percent had income based eligibility criteria of 200% Federal poverty level or less. Clinics provided a mean of 5,989 patient visits/year and 11,202 prescriptions/year to 2,311 unique patients. 61.8% of patients were female, 80.4% between ages 19 to 64, 55.1% white, 21.8% black, and 18.7% Hispanic. Clinics were open 29.7 hours/week, 4.1 days/week, and 32.9% had a licensed pharmacy. The mean annual budget was

The Clinical Health Economics System Simulation (CHESS): a teaching tool for systems- and practice-based learning.

458,028 and clinics were staffed by 156.7 volunteers and 6.9 paid employees per clinic. Conclusions:Free clinics have become an established part of the safety net for the uninsured. The differences among the clinics are striking, supporting the conclusion that a variety of approaches to the care of the underserved can be used. However, despite their efforts, the responding free clinics manage to provide care to only 650,000 of the nation’s 41 million uninsured.

Can Prescription Refill Feedback to Physicians Improve Patient Adherence

Academic medical centers face barriers to training physicians in systems- and practice-based learning competencies needed to function in the changing health care environment. To address these problems, at the University of Virginia School of Medicine the authors developed the Clinical Health Economics System Simulation (CHESS), a computerized team-based quasi-competitive simulator to teach the principles and practical application of health economics. CHESS simulates treatment costs to patients and society as well as physician reimbursement. It is scenario based with residents grouped into three teams, each team playing CHESS using differing (fee-for-service or capitated) reimbursement models. Teams view scenarios and select from two or three treatment options that are medically justifiable yet have different potential cost implications. CHESS displays physician reimbursement and patient and societal costs for each scenario as well as costs and income summarized across all scenarios extrapolated to a physicians entire patient panel. The learners are asked to explain these findings and may change treatment options and other variables such as panel size and case mix to conduct sensitivity analyses in real time. Evaluations completed in 2003 by 68 (94%) CHESS resident and faculty participants at 19 U.S. residency programs preferred CHESS to a traditional lecture-and-discussion format to learn about medical decision making, physician reimbursement, patient costs, and societal costs. Ninety-eight percent reported increased knowledge of health economics after viewing the simulation. CHESS demonstrates the potential of computer simulation to teach health economics and other key elements of practice- and systems-based competencies.

The Effect of Physician Feedback and an Action Checklist on Diabetes Care Measures

Background: Although adherence to long‐term drug therapy is an important issue, the means to facilitate its assessment and improvement in clinical practice remain a challenge. Objective: To evaluate the impact of prescription refill feedback and adherence education provided to primary care physicians. Methods: We provided 83 resident and attending physicians at a university‐based general internal medicine practice with refill adherence reports on each of 340 diabetic patients. An educational session on adherence assessment and improvement techniques was held, and all physicians received a written outline on this topic. Physician attitude toward the intervention and 6‐month change in refill adherence (doses filled/doses prescribed) of their patient panels were assessed. A nonrandomized comparison group of patients receiving hypertension medications for whom the physicians did not receive feedback was also evaluated. Results: The overall improvement in mean refill adherence was not significant (83.9% vs 86.0%, P = 0.18). The educational session was attended by 53% of the physicians. The patient refill adherence of physicians attending the educational session improved by 5.0% (P < 0.0009) with no significant change among patients of physicians not attending the session. There was no adherence change among patients for whom physicians did not receive refill feedback data, regardless of educational session attendance. Conclusions: Patients of physicians that received refill feedback and attended an educational session improved their refill adherence. After replication of these results in a randomized trial, broad implementation of this approach could have substantial impact from a public health perspective, given the ubiquity of prescription claims data.

The Natural History of Smoking Cessation Among Medical Patients in a Smoke-Free Hospital

The objective was to evaluate whether physician feed-back accompanied by an action checklist improved diabetes care process measures. Eighty-three physicians in an academic general medicine clinic were provided a single feedback report on the most recent date and result of diabetes care measures (glycosylated hemoglobin [Alc, urine microalbumin, serum creatinine, lipid levels, retinal examination) as well as recent diabetes medication refills with calculated dosing and adherence on 789 patients. An educational session regarding the feedback and adherence information was provided. The physicians were asked to complete a checklist accompanying the feedback on each of their patients, indicating requested actions with respect to follow-up, testing, and counseling. The physicians completed 82% of patient checklists, requesting actions consistent with patient needs on the basis of the feedback. Of the physicians, 93% felt the patient information and intervention format to be useful. The odds of urine microalbumin testing, serum creatinine, lipid profile, Alc, and retinal examination increased in the 6 months after the feedback. The increase was sustained at 1 year only for microalbumin and retinal exams. There was no significant change in refill adherence for the group overall after the feedback, although adherence did improve among patients of physicians attending the educational session. No significant change was noted in lipid or Alc levels during the study period. In conclusion, a simple physician feedback tool with action checklist can be both helpful and popular for improving rates of diabetes care guideline adherence. More complex interventions are likely required to improve diabetes outcomes.

BRIEF REPORT: Multiprogram Evaluation of Reading Habits of Primary Care Internal Medicine Residents on Ambulatory Rotations

Our purpose was to determine the frequency and predictors of quitting smoking among patients hospitalized on the medical services of a smoke-free hospital. All smokers admitted to the medical services of a single university teaching hospital were eligible and 129 patients were enrolled. A questionnaire detailing demographic information, stages of change, smoking behavior while hospitalized, and intention to remain abstinent on discharge was administered. The primary discharge diagnosis was obtained from the medical record. Patients were followed at 3- and 6-month intervals for continuous abstinence, with expired carbon monoxide confirmation at 6 months. A total of 7% of smoking patients receiving usual medical care were continuously abstinent at 6 months. Of those who relapsed, 45% did so by the time of discharge, 18% within the first week, 20% between 1 week and 3 months, and 10% between 3 and 6 months after discharge. All patients who were abstinent at 6 months had been admitted for coronary artery disease (CAD). Nine of the 38 patients with CAD were abstinent, versus none of 93 with another diagnosis (p <.001). Smokers admitted to a smoke-free hospital had a high rate of relapse, especially early after discharge. Patients admitted for CAD had a greater likelihood of successfully quitting. Designing hospital-based smoking cessation interventions with a focus on early relapse prevention may help improve smoking cessation rates.

Evaluation and treatment of acute bronchitis at an academic teaching clinic.

OBJECTIVE: To assess the reading habits and educational resources of primary care internal medicine residents for their ambulatory medicine education.DESIGN: Cross-sectional, multiprogram survey of primary care internal medicine residents.PARTICIPANTS/SETTING: Second- and third-year residents on ambulatory care rotations at 9 primary care medicine programs (124 eligible residents; 71% response rate).MEASUREMENTS AND MAIN RESULTS: Participants were asked open-ended and 5-point Likert-scaled questions about reading habits: time spent reading, preferred resources, and motivating and inhibiting factors. Participants reported reading medical topics for a mean of 4.3±3.0 SD hours weekly. Online-only sources were the most frequently utilized medical resource (mean Likert response 4.16±0.87). Respondents most commonly cited specific patients’ cases (4.38±0.65) and preparation for talks (4.08±0.89) as motivating factors, and family responsibilities (3.99±0.65) and lack of motivation (3.93±0.81) as inhibiting factors.CONCLUSIONS: To stimulate residents’ reading, residency programs should encourage patient- and case-based learning; require teaching assignments; and provide easy access to online curricula.

Charlottesville Health Access: A Locality-based Model of Health Care Navigation for the Homeless

BackgroundRandomized controlled trials have demonstrated that antibiotics provide no benefit for acute bronchitis, yet 55 to 90% of patients who receive this diagnosis are treated with antibiotics. Given substantial data against antibiotics for acute bronchitis, it could be expected that physicians at academic teaching institutions would be less likely to prescribe antibiotics. However, limited data of antibiotic use for acute bronchitis in this setting has been published. MethodsCharts of patients seen between January 1 and October 25, 2000, who received an ICD-9 diagnosis of acute bronchitis or upper respiratory infection (URI) at the University of Virginia internal medicine clinic were reviewed. Patients were excluded if they had no cough, chronic obstructive pulmonary disease, symptoms for ≥3 weeks, or antibiotics for another reason. ResultsOf the 160 patients included in this study, 105 (66%) received an antibiotic. Multivariate analysis revealed that patients with increasing age (P = 0.002), purulent cough (P = 0.003), abnormal exam (P = 0.003), and comorbidities (P = 0.03) were most likely to receive an antibiotic. Smoking, duration of symptoms, gender, and race did not predict antibiotic use (P > 0.05). Macrolides accounted for 68% of antibiotics. Twenty-two (14%) of all patients received a chest radiograph and 72 (45%) received an inhaler. Of those who had chest radiographs negative for signs of infection, 76% received an antibiotic. ConclusionIn our teaching clinic, antibiotics were overused, whereas chest radiographs and inhalers were underused for the evaluation and treatment of acute bronchitis. Recently published guidelines will help curb use of antibiotics, but a more intensive intervention, including physician and patient education is probably necessary.