Thomas O. Staiger

Systematic Review of Antidepressants in the Treatment of Chronic Low Back Pain

Background. Three previous reviews have reached conflicting conclusions regarding the efficacy of antidepressants for patients with back pain. Objectives. To systematically review the efficacy of antidepressants for the treatment of patients with back pain and to determine whether there is evidence that outcomes vary between classes of antidepressants. Materials and Methods. Best evidence synthesis of randomized, placebo-controlled trials of oral antidepressive agents in patients with back pain. Studies were identified by searching MEDLINE, PsycINFO, and the Cochrane Controlled Trials Registry. Two independent reviewers performed data extraction and assessed included studies with a 22-point methodologic quality assessment scale. Effect sizes were calculated if sufficient data were available. Results. Twenty-two trials of antidepressants for the treatment of back pain were identified, of which seven studies of chronic low back pain met inclusion criteria. Among studies using antidepressants that inhibit norepinephrine reuptake (tricyclic or tetracyclic antidepressants), four of five found significant improvement in at least one relevant outcome measure. Assessment of these agents’ impact on functional measures produced mixed results. No benefit in pain relief or functional status was found in three studies of antidepressants that do not inhibit norepinephrine reuptake. Conclusions. Based on a small number of studies, tricyclic and tetracyclic antidepressants appear to produce moderate symptom reductions for patients with chronic low back pain. This benefit appears to be independent of depression status. SSRIs do not appear to be beneficial for patients with chronic low back pain. There is conflicting evidence whether antidepressants improve functional status of patients with chronic low back pain.

BRIEF REPORT: Patient-Physician Agreement as a Predictor of Outcomes in Patients with Back Pain

AbstractOBJECTIVE: To determine whether a patient-physician agreement instrument predicts important health outcomes. DESIGN: Three hundred eighty patients with back pain were enrolled in a comparison of rapid magnetic resonance imaging with standard x-rays. One month later, patients rated agreement with their physician in the following areas: diagnosis, diagnostic plan, and treatment plan. Outcomes included patient satisfaction with care at 1 and 12 months and functional and health status at 12 months. SETTING: Urban academic and community primary care and specialty clinics. MEASUREMENTS AND MAIN RESULTS: Higher agreement at 1 month (using a composite sum of scores on the 3 agreement questions) was correlated in univariate analysis with higher patient satisfaction at 1 month (R=.637, P<.001). In multivariate analysis, controlling for 1-month satisfaction and other potential confounders, higher agreement independently predicted better 12-month patient satisfaction (β=0.188, P=.003), mental health (β=1.080, P<.001), social function (β=1.124, P=.001), and vitality (β=1.190, P<.001). CONCLUSION: Agreement between physicians and patients regarding diagnosis, diagnostic plan, and treatment plan is associated with higher patient satisfaction and better health status outcomes in patients with back pain. Additional research is required to clarify the relationship between physician communication skills, agreement, and patient outcomes.

Relative Impact of Patient and Clinic Factors on Adherence to Primary Care Preventive Service Guidelines: An Exploratory Study

Background.Preventive care service use is commonly compared across health plans, clinics, or individual providers, yet little is known about the influence of the clinic versus patient factors on utilization of these services. Objectives.To measure the relative influence of the facility (clinic) versus patient factors (demographic, behavioral and functional characteristics) on patients’ utilization of mammography, Pap smears, cholesterol screening, and retinal exams for those with diabetes. Research Design. Retrospective analysis, using administrative and patient survey data Subjects.Enrollees in 2 University-based clinics and a county hospital-based clinic serving a predominantly low-income population with limited access to health care. Eligibility for cervical cancer screening, screening mammography, cholesterol screening, or annual retinal exam (diabetes) was defined by age, sex, and diagnosis. Measures.Multivariate models, one using readily available administrative data, and another using detailed health status and behavior data gathered from a clinics-wide survey. Results.Unadjusted screening rates for three of four procedures were significantly and substantially lower at the county hospital based clinic than the two University-based clinics. After adjusting for patient characteristics, utilization of three screening services at the county hospital remained significantly below the University-based clinics (Odds Ratios [95% CI]: mammogram 0.15 [0.06–0.35]; Pap smear 0.32 [0.21–0.50]; cholesterol 0.19 [0.09–0.38]; diabetes retinal exam10.68 [0.93–3.01]). The models with detailed survey data performed only marginally better than the models using only administrative data. Conclusions.Patient characteristics were much less important than the clinic for predicting whether patients received primary care preventive services. Our results suggest that case mix adjustment is unlikely to explain away discrepancies in performance between clinics or provider groups.

A Collaborative, Systems-Level Approach to Eliminating Healthcare-Associated MRSA, Central-Line-Associated Bloodstream Infections, Ventilator-Associated Pneumonia, and Respiratory Virus Infections

&NA; To achieve sustainable reductions in healthcare‐associated infections (HAIs), the University of Washington Medical Center (UWMC) deployed a collaborative, systems‐level initiative. With the sponsorship of senior leadership, multidisciplinary teams were established to address healthcare‐associated methicillin‐resistant Staphylococcus aureus (MRSA), central‐line–associated bloodstream infections (CLABSI), ventilator‐associated pneumonia (VAP), and respiratory virus infections. The goal of the initiative was to eliminate these four HAIs among medical center inpatients by 2012. In the first 24 months of the project, the number of healthcare‐associated MRSA cases decreased 58%; CLABSI cases decreased 54%. Staff and provider compliance with infection prevention measures improved and remained strong, for example, 96% compliance with hand hygiene, 98% compliance with the recommended influenza vaccination program, and 100% compliance with the VAP bundle. Achieving these results required an array of coordinated, systems‐level interventions. Critical project success factors were believed to include creating organizational alignment by declaring eliminating HAIs as an organizational breakthrough goal, having the organizations executive leadership highly engaged in the project, coordination by an experienced and effective project leader and manager, collaboration by multidisciplinary project teams, and promoting transparency of results across the organization.

The role of quality improvement and patient safety in academic promotion: results of a survey of chairs of departments of internal medicine in North America.

The Association of Professors of Medicine (APM) is the national organization of departments of internal medicine at the US medicalschools and numerous affiliated teaching hospitals as represented by chairs and appointed leaders. As the official sponsor of TheAmerican Journal of Medicine, the association invites authors to publish commentaries on issues concerning academic internalmedicine.For the latest information about departments of internal medicine, please visit APM’s website at www.im.org/APM.

A multidisciplinary care pathway significantly increases the number of early morning discharges in a large academic medical center.

In an environment where there is increased demand for hospital beds, it is important that inpatient flow from admission to treatment to discharge is optimized. Among the many drivers that impact efficient patient throughput is an effective and timely discharge process. Early morning discharge helps align inpatient capacity with clinical demand, thereby avoiding gridlock that adversely affects scheduled surgical procedures, diagnostic procedures, and therapies. At our large, academic medical center, we hypothesized that an interdisciplinary approach to scheduled discharge order entry would increase the percentage of discharges occurring before 11:00 AM and improve overall discharge time. The pilot study involved moving rate-limiting steps to earlier in the discharge process, specifically medication reconciliation to the night before discharge and “discharge to home” order entry before 9:00 AM the morning of discharge. The baseline rate of discharges before 11:00 AM was 8% and significantly increased to 11% after the intervention (P = .02). Moreover, in the subset of patients (21%) for whom early medication reconciliation and discharge to home order entry were both executed, the percentage of patient discharges occurring before 11:00 AM increased to 29.7%, with an associated average discharge time of more than 3 hours earlier. No patient harm events were associated with this pilot project. There was no significant change in length of stay, and 30-day readmission rate improved significantly from 13.8% to 10.3% (P = .002). Our study demonstrates that a multidisciplinary approach using prescribed order entry and medication reconciliation is a low cost, safe, and effective way to increase early morning discharges and improve patient flow for large hospitals with high volumes of scheduled patient admissions.

A case-based approach to outpatient evaluation and management service coding.

Abstract Understanding Center for Medicare and Medicaid Services (CMS) documentation and coding rules is challenging for most physicians. To accurately bill for clinical services, physicians must learn a system that may initially seem daunting, but is in fact governed by a small number of straightforward rules. The Evaluation and Management (E/M) guidelines for all service codes specify 3 components: history, examination, and medical decision-making, each with a defined set of elements or characteristics. Service coding is based on the level of care supported by the number of history and examination elements and the complexity of decision making. This article will clarify the guidelines for outpatient clinical services and suggest a practical method of selecting appropriate E/M codes. Because physicians must often choose between billing codes 99213 and 99214 for a visit by an established patient, it will particularly focus on the minimum documentation needed to bill a 99214 code.

Anticipation in Complex Systems: Potential Implications for Improving Safety and Quality in Healthcare

The theoretical biologist, Robert Rosen, proposed that a capacity for anticipatory change is a fundamental characteristic of most complex systems, including all living systems. As defined in his Anticipatory Systems: Philosophic, Mathematic, and Methodological Foundations, an anticipatory system contains “a predictive model of itself and/or its environment, which allows it to change state at an instant in accord with the model’s prediction pertaining to a later instant”. In Rosen’s view, two key features which differentiate anticipatory complex systems from “simple” mechanistic systems are: (1) no single formal model or finite set of models are capable of capturing all of the information in a complex system, and (2) anticipatory complex systems are capable of change in the present based on their imperfect models of the future. Change in simple, mechanistic systems occurs only due to forces acting iteratively on the system’s current state, while change in anticipatory complex systems occurs through both iterative state transitions and from the system’s capacity to respond to anticipatory models. If Rosen’s anticipatory theory of complex systems is correct, implications for improving safety in healthcare organizations are likely to include the following: (1) Greater congruence between the models of the current situation and anticipatory models of future states among clinical team members, and among the clinical team, patient, and family increases the likelihood of attaining preferred outcomes; (2) Inputs from the anticipatory models of clinical team members, patients, and families may be useful for identifying and real time mitigation of some clinical situations in which there is an increased risk of a future serious adverse outcome; (3) Significantly discrepant present-state or anticipatory mental models between clinical team members or between team and patients/families may indicate an increased risk for an adverse outcome; (4) Clinical teams that recognize that disagreements regarding the appropriate care of a patient may indicate an increased risk of an adverse outcome may be able to create better shared present-state and anticipatory mental modes which could help mitigate future risks; and (5) Optimal team functioning should encourage anticipatory inputs from all clinical team members and should include encourage identifying significantly discrepant current state and anticipatory models among clinical team members and between clinical team and patients/families, especially in high-risk situations.

A Conceptual Framework for Applying the Anticipatory Theory of Complex Systems to Improve Safety and Quality in Healthcare

Effective anticipation is a fundamental characteristic of highly reliable organizations. In Rosen’s anticipatory theory of complex systems, all living systems and virtually all other complex systems require anticipatory models to maintain an organized state. This paper provides an overview of Rosen’s anticipatory theory of complex systems and presents a conceptual framework for applying this framework to improve safety and quality in healthcare. Organizational interventions based on this theory could include education of clinicians, patients, and families on how anticipatory complex systems function and improve safety in clinical environments, and systems interventions to promote optimal concordance between a team’s model of a clinical situation and the actual clinical situation. Enhanced general understandings of anticipatory complex systems and of their failure modes could help reduce communications failures that are a common cause of serious adverse events.

A Cross-Sectional Analysis of Publication Types in Quality Improvement Journals.

Despite widespread engagement in quality improvement activities, little is known about the designs of studies currently published in quality improvement journals. This study’s goal is to establish the prevalence of the types of research conducted in articles published in journals dedicated to quality improvement. A cross-sectional analysis was performed of 145 research articles published in 11 quality improvement journals in 2011. The majority of study designs were considered pre-experimental (95%), with a small percentage of quasi-experimental and experimental designs. Of the studies that reported the results of an intervention (n = 60), the most common research designs were pre–post studies (33%) and case studies (25%). There were few randomized controlled trials or quasi-experimental study designs (12% of intervention studies). These results suggest that there are opportunities for increased use of quasi-experimental study designs.