Chart Audit Of Patients Research Articles

Evaluation and Management of the Nursing Home Resident With Respiratory Symptoms and an Equivocal Chest X-Ray Report

ObjectivesPneumonia is a leading cause of morbidity and mortality in nursing home (NH) residents. Chest x-ray evidence is considered a key diagnostic criterion for pneumonia by the Infectious Disease Society of America (IDSA) diagnostic guidelines, the modified McGeer diagnostic criteria, and the Loeb criteria for initiating antibiotics; however, x-ray interpretation is often equivocal. We conducted chart audits of patients in NHs who had chest x-rays for new respiratory symptoms to determine the degree of ambiguity in the radiology reports and their relationship to antibiotic prescription decisions. DesignCross-sectional study. SettingThirty-one NHs in North Carolina. ParticipantsTwo hundred twenty-six NH residents who had a chest x-ray. MethodsMedical charts were abstracted to record (1) the patient's clinical presentation when a chest x-ray was ordered, (2) the verbatim report of the chest x-ray, and (3) the patient's course during the subsequent 7 days. To standardize the radiologist reports, a seven-category coding system was developed, which was further aggregated into three groups based on the radiologist's description of the likelihood of pneumonia. ResultsOf the 226 chest x-rays, 118 (52%) identified a very low likelihood of pneumonia, 67 (30%) indicated that pneumonia was present or highly likely, and the remaining 41 (18%) used a variety of terms to describe uncertainty regarding the presence of pneumonia. NH medical providers tended to treat ambiguous chest x-ray reports similarly to positive x-ray reports, prescribing antibiotic therapy to 71% of patients with ambiguous reports and 78% of positive reports. Also notable is that 40 (34%) of the 118 patients with a very low likelihood of pneumonia based on chest x-ray results were prescribed antibiotics, the majority of whom failed to meet criteria for a clinical diagnosis of pneumonia or chronic obstructive pulmonary disease exacerbation. ConclusionThe moderate rate of ambiguous x-ray interpretations in NH residents is likely a combination of the poor quality of portable x-rays, a high prevalence of chronic lung conditions, and conservative (ie, cautious) decision making by radiologists whose interpretation is based on little clinical information and a suboptimal quality film. As a result, data suggest that chest x-rays obtained in NHs may unnecessarily encourage antibiotic prescribing because a majority of readings are ambiguous or show a low likelihood of pneumonia, yet more than half of the patients are still treated. From an antibiotic stewardship standpoint, the apparent solution is to more closely rely on clinical signs and symptoms for diagnosis of pneumonia and to place less emphasis on the role of the chest x-ray given the high number of unclear readings.

The safety climate in primary care (SAP-C) study: study protocol for a randomised controlled feasibility study.

BackgroundResearch on patient safety has focused largely on secondary care settings, and there is a dearth of knowledge relating to safety culture or climate, and safety climate improvement strategies, in the context of primary care. This is problematic given the high rates of usage of primary care services and the myriad of opportunities for clinical errors daily. The current research programme aimed to assess the effectiveness of an intervention derived from the Scottish Patient Safety Programme in Primary Care. The intervention consists of safety climate measurement and feedback and patient chart audit using the trigger review method. The purpose of this paper is to describe the background to this research and to present the methodology of this feasibility study in preparation for a future definitive RCT.MethodsThe SAP-C study is a feasibility study employing a randomised controlled pretest-posttest design that will be conducted in 10 general practices in the Republic of Ireland and Northern Ireland. Five practices will receive the safety climate intervention over a 9-month period. The five practices in the control group will continue care as usual but will complete the GP-SafeQuest safety climate questionnaire at baseline (month 1) and at the terminus of the intervention (month 9). The outcomes of the study include process evaluation metrics (i.e. rates of participant recruitment and retention, rates of completion of safety climate measures, qualitative data regarding participants’ perceptions of the intervention’s potential efficacy, acceptability, and sustainability), patient safety culture in intervention and control group practices at posttest, and instances of undetected patient harm identified through patient chart audit using the trigger review method.DiscussionThe planned study investigates an intervention to improve safety climate in Irish primary care settings. The resulting data may inform our knowledge of the frequency of undetected patient safety incidents in primary care, may contribute to improved patient safety practices in primary care settings, and may inform future research on patient safety improvement initiatives.Electronic supplementary materialThe online version of this article (doi:10.1186/s40814-016-0096-5) contains supplementary material, which is available to authorized users.

Postintubation Hypotension in General Anesthesia

Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department endotracheal intubations. Study objective was to determine the incidence of PIH and its impact on outcomes following tracheal intubation in a general anesthesia population. Structured chart audit of adult patients intubated for a vascular surgery procedure at a tertiary care center over a 3-year period. Outcomes included in-hospital mortality, extended intensive care unit length of stay (ICU LOS), and requirement for postoperative (postop) hemodialysis or mechanical ventilation. Incidence of PIH was 60% (837 of 1395). Patients who developed PIH had increased mortality (8.8% PIH vs 5.2% no-PIH; P = .014), extended ICU LOS (7.9% PIH vs 2.0% no-PIH; P < .001), and postop mechanical ventilation requirement (20.7% PIH vs 3.8% no-PIH; P < .001). When controlling for confounding factors, PIH was associated with extended ICU LOS (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.01-6.62, P = .049), postop ventilation (OR 2.43, 95% CI 1.27-4.74, P = .008), and a composite end point (OR 1.72, 95% CI 1.02-2.92, P = .043). Development of PIH occurs in 60% of patients undergoing intubation for vascular surgery and was associated with adverse outcomes including extended ICU LOS and postop ventilation requirement.

Improving care coordination for community-dwelling older Australians: a longitudinal qualitative study.

Objective The aim of the present study was to describe the care transition experiences of older people who transfer between subacute and primary care, and to identify factors that influence these experiences. A further aim of the study was to identify ways to enhance the Geriatric Evaluation and Management (GEM) model of care and improve local coordination of services for older people. Methods The present study was an exploratory, longitudinal case study involving repeat interviews with 19 patients and carers, patient chart audits and three focus groups with service providers. Interview transcripts were coded and synthesised to identify recurring themes. Results Patients and carers experienced care transitions as dislocating and unpredictable within a complex and turbulent service context. The experience was characterised by precarious self-management in the community, floundering with unmet needs and holistic care within the GEM service. Patient and carer attitudes to seeking help, quality and timeliness of communication and information exchange, and system pressure affected care transition experiences. Conclusion Further policy and practice attention, including embedding early intervention and prevention, strengthening links between levels of care by building on existing programs and educative and self-help initiatives for patients and carers is recommended to improve care transition experiences and optimise the impact of the GEM model of care. What is known about the topic? Older people with complex care needs experience frequent care transitions because of fluctuating health and fragmentation of aged care services in Australia. The GEM model of care promotes multidisciplinary, coordinated care to improve care transitions and outcomes for older people with complex care needs. What does this paper add? The present study highlights the crucial role of the GEM service, but found there is a lack of systemised linkages within and across levels of care that disrupts coordinated care and affects care transition experiences. There are underutilised opportunities for early intervention and prevention across the system, including the emergency department and general practice. What are the implications for practitioners? Comprehensive screening, assessment and intervention in primary and acute care, formalised transition processes and enhanced support for patients and carers to access timely, appropriate care is required to achieve quality, coordinated care transitions for older people.

P058: Improving patient safety and streamlining care at a community hospital through spread and scale of a trauma care bundle: a quality improvement pilot project

Introduction: Non-trauma centers (NTC) and community hospitals commonly deliver medical care during the “golden hour” of trauma, which has significant implications on the health outcomes of patients. The Niagara Health System (NHS) and its 3 community NTC hospitals provide trauma care to over 100 patients annually during this critical period. NTCs lack standardized resources commonly found in trauma centers. Checklists and bundles have been effective in streamlining process to ensure health care providers provide the right care, at the right time and address critical points during patient care. A trauma care bundle was designed and implemented in the NHS as a means to improve trauma care and patient outcomes. Methods: A quality improvement (QI) approach was used to design, implement and evaluate a trauma care bundle at one of the NHS’s community hospitals. These interventions were adapted and modified for community trauma care purposes. We piloted the trauma care bundle using rapid cycle improvements, known as Plan-Do-Study-Act (PDSA) cycles. We assessed outcome and process measures through a chart audit of all trauma care patients in the NHS from July 2015-December 2015. A safety attitudes questionnaire (SAQ) was administered to health system staff who were involved in the pilot to assess balancing measures. Results: Improvements to the bundle and its implementation from 4 PDSA cycles resulted in increased utilization. This continuous monitoring of the bundle and ongoing, conscious efforts to improve the intervention were used to spread and scale across all 3 sites of the NHS. 30% of patients received the trauma care bundle during phase 1 of the pilot from July 1- October 31, 2015. We are presently analyzing preliminary data to understand how the trauma care bundle impacts health outcomes and process and will present a comparative analysis between patient groups. Conclusion: Trauma care bundles may foster safer and more efficient patient care in community hospitals where the golden hour of trauma often occurs. This community trauma care bundle shows promising results for streamlining the care process to ensure patients receive appropriate care during the golden hour. Spread and scale of this bundle across other community hospitals will likely yield similar improvements in patient care.

Abstract A22: Programmatic implementation of hepatocellular carcinoma prevention through hepatitis C testing, secondary prevention, and treatment for a medically and minority underserved population

Abstract This study assessed the programmatic implementation of a multi-disciplinary program to prevent hepatocellular carcinoma through hepatitis C (HCV) testing, secondary prevention among diagnosed individuals (defined as interventions that prevent further progression of liver disease), and treatment within a medically and minority underserved clinic. The Lewis Cancer &amp; Research Pavilion (LCRP) at St. Joseph's/Candler Health System is a Community Cancer Center and regional destination for cancer care in coastal Georgia. LCRP disparities efforts focus on cancer prevention, screening, and facilitating access to cancer care at two clinics for underserved and uninsured, low-income, predominately African American and Hispanic populations. Because the primary cause of hepatocellular carcinoma is cirrhosis from chronic hepatitis infection, in 2014 the LCRP began implementing Centers for Disease Control and Prevention (CDC) recommendations for HCV testing as a cancer prevention activity at the clinics. As HCV patients were identified, it became clear that disease specific protocols needed to be developed in order to improve nurse practitioners' clinical practice. Barriers identified and addressed during program implementation included: 1) perception that expensive HCV treatment is inaccessible for uninsured patients, 2) lack of knowledge of CDC clinical testing guidelines resulting in inaccurate HCV diagnosis 3) lack of knowledge of secondary prevention and treatment leading to inappropriate clinical care for HCV+ patients, and 4) under-utilization of Electronic Medical Record (EMR) and other data tracking tools to enhance clinical care. The LCRP and clinical team identified available community and statewide resources, physician champions, and education resources. A multi-disciplinary team developed protocols for secondary prevention activities while a clinical team implemented clinical testing and treatment algorithms using CDC, American Association for the Study of Liver Diseases (AASLD), and Infectious Diseases Society of American (IDSA) guidelines. These initiatives are consistent with CDC efforts to move HCV management to community-based health-care providers within primary care with supportive training and supervision by HCV care specialists. The clinic conducted a baseline chart audit of patients with HCV documented in their medical record. At baseline, CDC testing algorithms to confirm diagnosis were followed in 14% of patients who received the initial HCV+ antibody test. Six months after implementation of testing algorithms and other clinical and programmatic improvements, 44% of birth cohort patients (patients born between 1945 and 1964) were screened in compliance with CDC guidelines. Average age of HCV+ patients was 51, 58% were African American, 41% Caucasian, 62% female, and 38% male. Secondary prevention activities including hepatitis A &amp; B vaccines, referral for alcohol and/or substance abuse counseling, depression and mental health screening, and identification of prevention and/or treatment barriers were initiated during the first six months of 2014 with 34% of HCV+ patients. Prevention activities conducted concurrently with treatment planning. Nurse practitioners at the clinic obtained co-management HCV treatment support from an internal medicine and primary care physician. This cancer prevention program demonstrated improvement in HCV testing, prevention, and treatment within a primary-care nurse-managed community clinic. The inter-disciplinary approach outlined in this model utilized evidence based guidelines and diagnostic algorithms. Application of secondary prevention activities and effective data tracking increased overall programmatic success, and ultimately contributes to the prevention of hepatocellular carcinoma among disparate populations. Citation Format: Sarah E. Dobra, Nidsa Baker, Lesley Miller, Lauren Stokes. Programmatic implementation of hepatocellular carcinoma prevention through hepatitis C testing, secondary prevention, and treatment for a medically and minority underserved population. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A22.

Genetic testing of aetiology of intellectual disability in a dedicated physical healthcare outpatient clinic for adults with intellectual disability.

No guidelines exist for assessment of aetiology of intellectual disability in adults with intellectual disability by adult physicians, although robust guidelines exist for paediatric populations. It was speculated that the paediatric guidelines would also be suitable for adults. In rural/regional setting with limited clinical genetics, to perform a quality assurance evaluation on genetics assessment of aetiology of developmental disability in adults attending a dedicated healthcare clinic for adults with intellectual disability, compared results with paediatric standards, speculates if these seem appropriate for adults and speculates on a role for clinical genetics services. Retrospective chart audit of eligible patients looking at genetic clinical assessment, tests selected (molecular karyotype, G banding, metabolics), and yields of positive results. The results were compared with the recommended paediatric guidelines. Of 117 eligible adult patients, ideal genetic history was incomplete for 40% of patients without Down syndrome because of physician cause and lack of information. The number of abnormal genetic results increased from 46% to 66%, mainly from the molecular karyotype, though not all may have been clinically relevant. The improved yield from this test was similar to that in paediatric studies. Use of G banding and metabolic testing could be refined. Improvement can be made in clinical genetic assessment, but results generally support use of molecular karyotyping as first tier testing of cause of unknown intellectual disability in adults, as in the case for paediatric populations. The study highlights a necessary complementary role for clinical geneticists to interpret abnormal results.

Incidence of testosterone escape with LHRH agonists in patients receiving radiotherapy for prostate cancer.

24 Background: LHRH agonists (LHRHa) are commonly combined with radiotherapy in the neoadjuvant, concurrent, and adjuvant setting. Testosterone escape (TTE) (&gt;1.74 nmol/L or &gt;50 ng/dL) during therapy with LHRHa has been described, but the incidence and impact of TTE on outcome in this patient group needs to be characterized further. Methods: We performed a retrospective review of a database used for clinical outcomes and research ethics board approved studies, including chart audit of select patients (pts) where information was missing. To be included in the study, there had to be information on: 1) type of LHRHa, date of initiation, date of cessation, or duration of therapy and 2) radiotherapy information, with at least 6 months of follow-up after radiotherapy, 3) had to have radiotherapy to the prostate or prostate bed, and 4) had to have a least one testosterone- (TT) and prostatic-specific antigen (PSA) measurement. Results: 670 pts had a start date for androgen deprivation therapy (ADT) in the database. 630 pts had received an LHRHa, 560 pts had a start date for radiotherapy. 375 pts had sufficient information on ADT, radiotherapy, TT, and PSA levels, and 361 of these patients had information regarding their LHRHa. Median follow-up of patients still alive is 4.7 years. The median duration of LHRHa was 2.02 years. The median number of testosterone measurements per patient was 6. The incidence of TTE per patient course of treatment was: buserelin 9.3%; goserelin 10.5%; leuprolide IM 11.5%; leuprolide sc 23.9%; triptorelin 6.7% (p=0.02). Biochemical failure was defined as per the "nadir +2" definition, or at a value &gt; 0.2 in those patients having had previous radical prostatectomy. There was no significant difference in either biochemical failure-free survival or overall survival in patients who experienced TTE versus those who did not. The most common PSA level during a TTE was an undetectable PSA. Conclusions: Even though there appears to be no impact of TTE on either biochemical relapse-free survival or overall survival, this study demonstrates that a rising PSA does not rule out TTE. Longer-term follow-up is planned.

Development and adaptation of a Canadian clinical practice guideline for the rehabilitation of adults with moderate-to-severe traumatic brain injury (tbi)

A clinical practice guideline (CPG) for traumatic brain injury (TBI) rehabilitation is under development in Ontario and Québec, Canada. Multiple stakeholders (clinicians/managers, physicians, researchers, and decision-makers) were consulted regarding their perceptions about their needs and the CPG content/format and implementation and participated as experts in a meeting to achieve consensus on the main recommendations to include in the CPG; to modify recommendations requiring adaptation, and to identify performance indicators to measure practice related to the recommendations. To report on the consensus process results. Sixty TBI experts (i.e. clinicians from multiple disciplines, researchers, managers, decision-makers and community associations) participated. Using prepared lists of recommendations based on scientific evidence and existing guidelines about the organization of rehabilitation services (e.g. case management) and the rehabilitation of specific brain injury-related impairments (e.g. fatigue and sleep disorders), experts assembled in 6 working groups produced a preliminary set of recommendations. For the organization of services, 39 new recommendations were added to the 71 existing recommendations; 78 new recommendations were added to the 142 related to impairments, for a total of 330 recommendations. Examples of performance indicators included patient satisfaction and chart audit (presence/absence of recommended assessment/intervention). A first set of guidelines was produced and they will be refined through further consultation with the experts who will prioritise the recommendations for the final version of the CPG.

O22.1 Australian hiv/hepatitis c co-infected patients fall behind hiv mono-infected patients in move towards early hiv treatment initiation

Introduction One in eight people living with HIV (PLHIV) in Australia are estimated to be co-infected with Hepatitis C (HCV). In the light of clinical guideline changes with regard to antiretroviral therapy (ART) initiation, we examine the impact of co-infection status on uptake of treatment, and highlight population-specific differences relative to HIV mono-infected patients. Methods Ipsos Healthcare’s HIV Therapy Monitor is a patient chart audit study, which monitors trends in the treatment of PLHIV in Australia. Demographic and treatment data are collected bi-annually from a panel of 25+ HIV-treating clinicians. The data in this report is based on a sample of 4331 patient records collected between 2008- 2014, of which 412 were co-infected with HCV. Results While the proportion of HIV mono-infected patients receiving ART has steadily increased from 67% in 2008 to 84% in 2014 (p Conclusion Increasing evidence is now available to support early initiation of ART, both in terms of clinical benefits as well as in preventing disease transmission. However, despite encouraging results among HIV mono-infected patients, outcomes for the HIV/HCV co-infected population reveal a growing disparity between these groups in Australia. The increasing delay to treatment supports the need to consider this patient group a priority population, and indicates that further action is required to address the complications involved in treating these patients. Disclosure of interest statement There are no conflicts of interest to declare.

To Retreat or Not to Retreat? That is the Question

It is widely accepted that approximately half of all patients with a cancer diagnosis will require radiation therapy but, perhaps, less commonly known is that, of this 50%, approximately one-fifth of patients require a second or subsequent line of radiotherapy at some point along their disease trajectory. This may occur in the setting of persistent or recurrent disease in the previously treated volume; local/distant metastases arising subsequent to radical treatment; or when patients previously treated palliatively require additional radiation treatment. Curative dose and fractionation schemes may have delivered significant doses (near or at tolerance) to organs at risk (OARs) making retreatment difficult from both a technological and a clinical standpoint. Palliative doses, although typically lower, can still result in complexity for retreatment as the daily doses are often higher and structures like the spinal cord often have to be re-irradiated on multiple occasions. Factors like previous dose, interval between subsequent treatments, tumour histology, normal tissue tolerance, life expectancy, and response to prior radiotherapy need to be considered. A chart audit of palliative patients treated between January and December of 2013 was conducted at the Carlo Fidani Regional Cancer Centre (CFRCC) to determine local radiotherapy retreatment patterns. The number of retreatment episodes, first and subsequent radiotherapy dose/fractionation schemes, time interval between initial treatment and subsequent courses, diagnoses, and whether or not the same volume was retreated was determined using data extracted from the Aria™ software. This information was then analyzed to identify trends and to calculate averages and means. 1095 patients were treated with a palliative intent and 1784 courses of palliative treatment were delivered during the time period examined. 142, or 13%, of those patients treated palliatively in 2013 had received previous courses of treatment at our centre. 9% received treatment to the same/overlapping treatment volume. 30% of these patients had a lung diagnosis, 24% were breast, 22% were prostate, and the other 24% was made up of a variety of diagnoses. The average interval between subsequent courses was 11 months with a range of between 1 and 77 months. Dose prescriptions varied greatly between practitioners. A significant proportion of the patients treated with palliative radiation in the CFRCC have a prior history of radiation treatment and many have received more than one course of treatment to the same area resulting in more complex decision making for the radiation oncologist. As anti-neoplastic therapies improve, these numbers may increase further due to the ever more chronic nature of the disease. As a result, techniques like SRS and SBRT may prove more useful in the palliative setting in order to spare normal tissues that have been treated previously.

The impact of a nurse led rapid response system on adverse, major adverse events and activation of the medical emergency team

To identify the relationship between one example of a rapid response system (RRS), specifically, an after-hours Clinical Team Co-Ordinator (CTC), and the incidence of Medical Emergency Team (MET) activations and, adverse and major adverse events in medical patients. A retrospective chart audit of patients' medical records was undertaken. The intervention group consisted of 150 randomly selected medical patients admitted during three months after the introduction of the CTC after-hours service. The control group consisted of 150 randomly selected medical patients admitted before the introduction of the after-hours CTC service. Multiple logistic regression was used to determine which of the potential predictors, along with the after-hours CTC service, were associated with adverse and major adverse events. A total of 130 patients (n=63, 42% control; n=67, 45% intervention) exhibited physiological abnormalities that should have activated the MET yet it was only activated five times. In total there were 69 adverse events (n=32, 21% control; n=36, 25% intervention) and 25 major adverse events (n=7, 5% control; n=18, 12% intervention). There were more adverse and major adverse events identified after the introduction of the CTC after-hours service. Changes in heart rate and reduction in Glasgow Coma Scores (GCS) were significant predictors of an adverse event. A low urine output and a drop of two or more in the GCS were significant predictors of a major adverse event. The introduction of an after-hours CTC service in a specific clinical site was associated with an increase in the identification of adverse and major adverse events in medical patients. Further exploration of nurse-led rapid response systems should be undertaken in different clinical settings.

Improving the Assessment of Overweight/Obesity in Asthmatic Pediatric Patients in a Quality Improvement Project

S A T U R D A Y 152 Improving the Assessment of Overweight/Obesity in Asthmatic Pediatric Patients in a Quality Improvement Project Anthony P. Nguyen, DO, Jennifer A. Shih, MD; Children’s Healthcare of Atlanta, Atlanta, GA, Emory University, Atlanta, GA. RATIONALE: Overweight/obesity is a known co-morbid condition with asthma. Overweight asthmatic children have increased risk of developing asthma exacerbations versus those of average weight. Objective: The aim of this quality improvement project was to facilitate the identification of overweight/obesity in asthmatic pediatric patients. METHODS: Consecutive patients presenting to an academic-based pediatric allergy clinic in Southeastern United States were included. This clinic was not electronic medical record based. Exclusion criteria included inability to obtain weight. Initially, a random chart audit of asthmatic patients for body mass index (BMI, a marker of overweight/obesity) assessment was performed. Providers and nursing staff were educated about BMI, overweight/obesity, and asthma and asked to record these assessments on checklists. Checklists were collected in 4 phases (1-2 weeks/phase) from June August 2014. Before proceeding to the next phase, modifications were implemented to facilitate the recording of BMI, overweight/obesity, and asthma. RESULTS: In the audit period, 4% of patients had their BMI assessed. In phase 1, after education of staff and implementation of checklists, BMI assessments increased to 43%. BMI assessments increased to 44% after repeat education in phase 2. BMI assessments increased to 79% after checklist modification in phase 3. By the end of the monitoring period phase 4, BMI assessments increased from 4% to 83% overall. CONCLUSIONS: Assessment of an asthmatic pediatric patient’s BMI, to identify those with the co-morbid condition of obesity, is paramount to the optimal care of this chronic disease. Incorporating this specific data in a patient’s chart increases the likelihood of addressing this important issue.

Oral oncolytics: Patient-monitoring improvements in private practice.

215 Background: The use of oral oncolytics is becoming more common. These drugs have their own unique challenges in managing patient initiation, monitoring side effects and adherence. Methods: We conducted a baseline chart audit of patients prescribed oral oncolytics in our private oncology practice followed by a quality improvement program and subsequent reassessment. Information obtained included: prescription date, actual start date and any documented problems with the oral therapy. The baseline audit included patients from may of 2011 to July 2013. Subsequently we joined the Michigan oncology quality consortium’s oral chemotherapy collaborative and initiated the following: office procedures for identification of all patients on oral therapy, use of the Edmonton Symptoms assessment system (ESAS), and a self-care management education program including patient self-monitoring of symptoms with recommended initial treatments. A postintervention audit was conducted from August 2013 to March 2014. Results: We identified 25 patients in the first time period and 13 in the second. In the first time period we found only 13 of the 25 patients had an actual start date documented, and of these 13, 10 had a &gt;/=4 week delay prior to starting therapy, with 3/13 having a 2-4 week delay prior to start of therapy. 12 of the 25 patients discontinued their drug within the first month due to side effects without consulting their physician. After participating in the quality initiative, we identified only one patient without a documented start date, only 1/13 that had a &gt; 4 week delay from prescription date to starting the drug, with 12/13 having a less than 2 week lapse. We also found that there were no patients who discontinued the drug and only one dose reduction as directed by the physician. Conclusions: The introduction of new office procedures to easily identify all patients on oral therapy and improved patient management of symptoms at home with the use of self-care guidelines, and in the office with use of ESAS contributed to greater adherence to oral chemotherapy regimens.

Indicators of Pediatric Malnutrition in a Tertiary Care Hospital.

This study was conducted to determine the prevalence of malnutrition at a Canadian children's hospital based on medical records and to identify gaps in current practices and rates/reasons for dietitian consult. A retrospective chart audit of patients admitted during a winter season was completed. Patients with length of stay <4 days were excluded, as were those with fluid retention diseases. Outcome variables included anthropometrics, diet order, rates and reasons for dietitian consult, and biochemical data. Of the 83 charts reviewed (mean ± SD age 7.3 ± 5.6 years of age), weights were recorded less frequently than recommended (45% of patients ≤2 years of age and 85% of patients >2 years of age met or exceeded recommendations). Twenty-nine (36%) patients were identified at potential increased nutrition risk for overweight, 10 (12%) for underweight, and 31 (38%) patients had nutrition-related chart notes. Only 23 patients (28%) received a dietitian consult and, of those, 21 had a nutrition related chart note. Consultation occurred an average 5.4 ± 4.96 days after admission. These data emphasize the need for development of standardized screening and assessment tools to better identify pediatric patients at risk for malnutrition and to improve access to optimal nutrition care.

Cell cycle progression score and treatment decisions in prostate cancer: results from an ongoing registry

Objective:The cell cycle progression (CCP) test (Prolaris) is a novel prognostic assay that provides accurate risk of prostate cancer-specific disease progression and disease specific mortality when combined with standard clinicopathologic parameters. This prospective study evaluated the impact of the CCP report on physician treatment recommendations for prostate cancer.Methods:Physicians ordering the CCP test in clinical practice completed surveys regarding treatment recommendations before and after they received and discussed the test results with patients. Clinicians also rated the influence of the test result on treatment decisions. Treatment selections were confirmed via third-party audit of patient charts following final survey responses.Results:Overall, 65% of cases showed a change between intended treatment pre- and post-CCP test reporting. Pre-CCP testing, 164 of 305 cases received a recommendation for interventional treatment. Post-CCP test, interventional therapy was recommended for 103 of these cases, a reduction of 37.2%. Conversely, 141 of 305 cases were recommended pre-CCP testing for non-interventional treatment; 108 of these remained with non-interventional treatment while 33 shifted to interventional options, a 23.4% increase. There was a 49.5% reduction in surgical interventions and a 29.6% reduction in radiation treatment. A third-party audit identified 80.2% concordance between the post-CCP testing treatment recommendation and actual treatment. Re-assignment to intervention or non-intervention generally correlated with the result of the CCP report. Study limitations included physician selection of patients for testing, no evaluation of patient input in therapeutic choice, and other potential treatment decision factors not queried by the survey.Conclusion:Based on responses of ordering physicians, the CCP report adds meaningful new information to risk assessment for localized prostate cancer patients. Test results led to changes in treatment with reductions and increases in interventional treatment that were directionally aligned with prostate cancer risk specified by the test.

Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings.

BackgroundAlthough dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence.Methods/DesignGuided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines—staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers’ tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence.DiscussionWe hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings will improve knowledge pertinent to the implementation, dissemination, and sustained utilization of evidence-based tobacco use treatment in dental practices.Trial registrationNCT01615237.

Comparative Effectiveness of Audit-Feedback Versus Additional Physician Communication Training to Improve Cancer Screening for Patients with Limited Health Literacy

We designed a continuing medical education (CME) program to teach primary care physicians (PCP) how to engage in cancer risk communication and shared decision making with patients who have limited health literacy (HL). We evaluated whether training PCPs, in addition to audit-feedback, improves their communication behaviors and increases cancer screening among patients with limited HL to a greater extent than only providing clinical performance feedback. Four-year cluster randomized controlled trial. Eighteen PCPs and 168 patients with limited HL who were overdue for colorectal/breast/cervical cancer screening. Communication intervention PCPs received skills training that included standardized patient (SP) feedback on counseling behaviors. All PCPs underwent chart audits of patients' screening status semiannually up to 24 months and received two annual performance feedback reports. PCPs experienced three unannounced SP encounters during which SPs rated PCP communication behaviors. We examined between-group differences in changes in SP ratings and patient knowledge of cancer screening guidelines over 12 months; and changes in patient cancer screening rates over 24 months. There were no group differences in SP ratings of physician communication at baseline. At follow-up, communication intervention PCPs were rated higher in general communication about cancer risks and shared decision making related to colorectal cancer screening compared to PCPs who only received performance feedback. Screening rates increased among patients of PCPs in both groups; however, there were no between-group differences in screening rates except for mammography. The communication intervention did not improve patient cancer screening knowledge. Compared to audit and feedback alone, including PCP communication training increases PCP patient-centered counseling behaviors, but not cancer screening among patients with limited HL. Larger studies must be conducted to determine whether lack of changes in cancer screening were due to clinic/patient sample size versus ineffectiveness of communication training to change outcomes.

High complexity chronic heart failure management programmes: Programme characteristics and 12 month patient outcomes

Chronic heart failure management programmes (CHF-MPs) have been developed to improve, clinical outcomes in response to the high burden of disease from chronic heart failure (CHF). Programmes vary in model, duration, complexity of interventions and incorporation of evidence-based guidelines for programme delivery. Few studies have explored patient outcomes at 12 months from enrolment in a CHF. The aim of the current study was to explore the characteristics and clinical outcomes of patients enrolled in four high complexity CHF-MPs at 12 months after initial enrolment. A secondary aim was to explore the adoption of key evidence-based CHF management strategies in these programmes. After ethics approval, a multisite mixed methods design was implemented incorporating survey and chart audit. Programme characteristics and interventions used in four CHF-MPs were surveyed in Stage 1. Stage 2 involved a chart audit of patients enrolled in the programmes (N = 135) on or after the 1/1/07. Primary endpoints were all-cause hospitalisation and/or mortality at 12 months. Data were analysed using descriptive and inferential statistics. All programmes implemented a high complexity of evidence-based interventions consistent with national guidelines. However, documentation of New York Heart Association functional class was rare; limiting quantifiable evaluation of response to therapy throughout programme enrolment. The majority of patients (73%) had severe systolic heart failure with high co-morbidities reflected in a mean Charlson's total co-morbidity score of 3 (± 2.1). The high rate of baseline evidence-based, pharmacothe- rapy (beta-blocker: 86%, n = 112 and ACE inhibitor: 76%, n = 103) was maintained at 12 months (71% and 84% respectively). At 12 months all cause hospitalisation and/or mortality was 57% (n = 77). The CHF-MPs in this study implemented complex evidence-based interventions resulting in high rates of key medication prescription. However, despite the implementation of several evidence-based interventions, over a period of 12 months, more than half of the patients were rehospitalised or died.

P05.04. Essential Hypertension—a Cross-sectional Audit of Naturopathic Management Strategies in a Teaching Clinic

Focus Area: Integrative Approaches to CareA cross-sectional audit of patient charts was conducted in the Robert Schad Naturopathic Clinic (RSNC), the largest naturopathic teaching clinic in North America, to assess the management of essential hypertension (EH) compared to recommendations made by the Canadian Hypertension Education Program (CHEP). Objectives of this study included the assessment of adherence to 2012 CHEP guidelines, a survey of naturopathic modalities and treatments commonly used for EH in the RSNC, an analysis of efficacy of naturopathic interventions to reduce systolic and diastolic blood pressure (SBP and DBP), and the delivery of specific recommendations to improve EH management at the Canadian College of Naturopathic Medicine (CCNM) and the RSNC. Four hundred four patient charts were identified using the ICD-10 code assessment of I10 (Essential Hypertension). Two hundred eighteen files met inclusion criteria. Adherence to CHEP guidelines was measured using categories of (1) blood pressure measurements; (2) correct diagnosis/staging; (3) risk assessment, and (4) objective measures (including physical examination and laboratory investigation). Charts also were assessed for use of naturopathic interventions, for measures of SBP and DBP over time, and for laboratory markers of cardiovascular risk. Results demonstrate that common naturopathic modalities used were dietary interventions, lifestyle interventions, nutritional supplementation, and botanical medicine. Less frequently used modalities for the specific treatment of hypertension included traditional Chinese medicine, physical medicine, homeopathy, hydrotherapy, and counseling. Preliminary analysis indicates that supplementation of omega-3 fatty acids, coenzyme Q10, hibiscus, magnesium, hawthorne, and implementation of diet and exercise recommendations were most closely associated with significant reductions in SBP and DBP. Overall, audit data suggest that the RSNC clinical interns and naturopathic doctors fair well at utilizing and documenting a wide array of evidence-based naturopathic interventions with promising improvements in hypertension.