Education-based Intervention Research Articles

Improving PHQ9 Utilization Rates in a Primary Care-Mental Health Integration Setting.

INTRODUCTION: Measurement-based care (MBC) uses standardized measurement to systematically monitor treatment response over time. Although MBC is underutilized in mental health settings, primary care-mental health integration (PC-MHI) settings are expected to provide MBC. This article describes a quality improvement (QI) process to increase Patient Health Questionnaire-9 (PHQ9) utilization within a PC-MHI setting. AIMS: Pre-intervention, rates of baseline and follow-up PHQ9 administration for veterans with a depressive disorder were 76% and 35%, respectively. This article describes a QI process to increase PHQ9 utilization rates within a PC-MHI setting, with the goal to improve provider PHQ9 utilization rates at baseline and within 4-week follow-up to 90%. METHOD: An educational intervention and weekly motivational enhancement sessions were implemented in 2017. Chart review data compared PHQ9 utilization rates from fall 2016 and 2017. RESULTS: Following intervention, provider PHQ9 utilization rates increased to 98% and 88% at baseline and follow-up. CONCLUSIONS: These findings demonstrate that a brief education-based intervention can increase clinician use of MBC within a PC-MHI setting. Meaningful use of MBC to inform treatment was not evaluated in this QI project and is an area for future investigation.

Effect of Education on Impaired Hypoglycemia Awareness and Glycemic Variability in Children and Adolescents with Type 1 Diabetes Mellitus

Objective:The aim of this study was to determine the prevalence of impaired hypoglycemia awareness (IHA) in children and adolescents with type 1 diabetes mellitus using a professional continuous glucose monitoring (CGM) system and to show the effect of structured education on glycemic variability (GV) in children and adolescents with IHA.Methods:Forty type 1 diabetic children and adolescents with a diabetes duration of at least five years were eligible for inclusion in this prospective, quantitative study. All subjects were asked about their history of being aware of the symptoms of hypoglycemia using a questionnaire. Professional CGM was conducted in all of the patients for six days. The frequency of IHA detected by comparison of CGM and logbook reports were analyzed. Patients with identified IHA underwent a structured training program. After three months, CGM was re-applied to patients with IHA.Results:The study was completed by 37 diabetic children and adolescents. After the initial CGM, nine patients (24.3%) were found to have had episodes of IHA. Area under the curve (AUC) for hypoglycemia and number of low excursions were; 1.81±0.95 and 8.33±3.60 for the IHA group at the beginning of the study. AUC for hypoglycemia was 0.43±0.47 after three months of structured education the IHA patients (p=0.01). Coefficient of variation which shows primary GV decreased significantly although unstable at the end of education in IHA patients (p=0.03).Conclusion:CGM is a valuable tool to diagnose IHA. IHA, GV and time in range can be improved by education-based intervention.

A literature review of interventions to reduce stress in doctors.

Stress is prevalent among doctors, and interventions are offered, often as part of their continuing professional development, to help doctors learn in the workplace about the recognition, prevention and management of the harmful effects of stress. The aim of this review was to examine existing research to ascertain the features of successful educational interventions with practising doctors and any factors that may affect outcomes. We searched key databases for papers published between 1990 and 2017 on the themes of stress that included an education-based intervention and practising doctors. Using an inclusive approach to the review, a broad evaluation was made of the primary research using both quantitative and/or qualitative evidence where the study reported a positive outcome in terms of stress management. Review criteria were met in 31 studies of 1,356 originally retrieved. Three broad categories of interventions emerged from the coding process: mindfulness-type (n = 12), coping and solutions focused (CSF) (n = 12) and reflective groups (n = 7). There is evidence that these interventions can be successful to help doctors deal with stress. Based on the results from this review, an original guide is advanced to help educators choose an educational intervention. Although evidence for some interventions may be 'hierarchically stronger', it is misleading to assume that interventions can be imported as successfully into any context. Factors such as medical specialty and health care systems may affect which intervention can be used. The guide offers an evidence base on which further research can be built.

Interventions to Promote Oral Medication Adherence in the Pediatric Chronic Illness Population: A Systematic Review From the Children's Oncology Group.

Pediatric oncology protocols frequently include multiple oral medications administered at varied dosing schedules, often for prolonged periods of time. Nonadherence to protocol-directed oral medications may place patients at increased risk for morbidity and mortality. The purpose of this systematic review was to evaluate the existing body of evidence to determine best-practice recommendations regarding interventions for oral medication adherence in children and adolescents with cancer. Twenty-four articles were systematically reviewed and evaluated according to the Grading of Recommendations, Assessment, Development, and Evaluation criteria; 2 studies focused on the pediatric oncology population, and the remaining 22 studies focused on other chronic illnesses of childhood. A variety of interventions to increase oral medication adherence in children were identified, including pill swallowing, technology, incentivization, education-based intervention, psychosocial support-based intervention, and combination intervention. Most interventions were shown to have some benefit in pediatrics, most in the non-oncology setting. The overall synthesis of the literature indicates that nonadherence to oral medications is a prevalent problem in pediatrics, and much work is needed to address this problem, particularly in pediatric oncology.

Educational-based intervention on food labeling: results of the Project “Eat slowly and well and move yourself 2017”

Objective: Currently, childhood obesity is a worldwide growing public health problem. Three of the major factors that contribute to this pandemic are unhealthy eating habits/sedentary, the lack of information on nutrition value of food, and the availability of caloric dense food with poor nutritional content. In this context, health promotion through nutritional education for school-age children is of major relevance. The objective of this study was to evaluate the impact of an education-based intervention on food labeling in children of five different schools in the municipality of Lisbon. Material and methods: This was a community trial. The target population was children enrolled at the 4th grade of elementary school in the 2016/2017 of five schools in the municipality of Lisbon, covered by the project “Eat slowly and well, and move yourself”. This is a 4 years public health project leaded by Direção Geral da Saúde, intended to monitor childhood obesity and to promote healthy habits in school aged children in articulation with public Schools and Health Centers. The interventions based in educational materials were directed to 4th grade children and performed and presented by a nutritionist. In 2017 the core theme of educational sessions was food labeling and nutritional value of packaged foods. Materials included PowerPoint presentations and sample food labels to touch and read. Knowledge was assessed before and after nutritional education sessions through a 15 multiple-choice test designed for the project. The final 6 questions were about two yogurt labels presented. Results: 188 children of the 4th grade of 5 schools in Lisbon were enrolled. After intervention, it was observed knowledge improvement mainly on the following categories of questions: definition of a food label, importance of food labels, habit of reading labels, and understanding of label information (Figure 1). Regarding the labels presented, a higher percentage of correct answers was observed for all schools after intervention. Conclusions: It was possible to conclude that educational-based interventions in community nutrition are fundamental for the acquisition of skills and knowledge, promoting healthy habits and lifestyles. Thus, the figure of the School Nutritionist can play an important role in supporting schools and families in the task of nutritional education of the youngest. Figure 1. Effect of educational-based intervention on food label knowledge and behaviour. Answers with major improvement are presented.

Implementation and evaluation of a driving cessation intervention to improve community mobility and wellbeing outcomes for people living with dementia: study protocol of the \u2018CarFreeMe\u2019 for people with dementia program

BackgroundGiving up driving is a pivotal life event and universal challenge for people living with dementia and their families, and a complex area of clinical practice for health professionals who monitor driving cessation. The best outcomes are for individuals to plan for and eventually cease driving, however with insufficient support programs in place, many avoid the issue until it is reaches a crisis point. This program of research investigates a comprehensive support- and education-based intervention targeted at people living with dementia and their care partners who are managing driving cessation. The primary aim of this research is to determine the effectiveness of the program through a cluster randomized controlled trial.Methods/designThe intervention (CarFreeMe) is an intensive program delivered by a trained health professional that addresses practical and emotional needs relevant to driving cessation. The seven module program is person-centred, covering awareness raising, adjustment, and practical support that is individualized according to geographic location and the particular goals and preferences of participants. A cluster randomized controlled trial will evaluate the effectiveness of the program. Evaluation will take place pre-intervention, immediately following, and three months post-intervention. Clusters are randomized to either intervention or usual treatment. Participants within clusters will be recruited via primary and secondary care clinics, community agencies, service providers, local media, social media, support groups, and word of mouth. The primary outcome measure for persons with dementia and their care partners is lifespace, collected via (i) smartphone GPS technology and (ii) self-reported number of episodes away from home (during the past week). Secondary outcomes include safe alternative transport status, wellbeing, depression, anxiety, and self-efficacy, which will be collected from dyads. Caregiving strain will be collected from care partner/family member only. A process evaluation of the intervention will also be undertaken.DiscussionThere is an urgent need for therapeutic approaches to supporting people living with dementia and their families to negotiate the complex decision making involved in deciding to change their approach to driving. The driving cessation intervention may fill an important gap in service delivery to people living with dementia who are adjusting to life without driving.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12618000388213, 15 March 2018.

Effectiveness of health education-based conventional intervention method to reduce noncommunicable diseases risk factors among rural population.

Noncommunicable diseases (NCDs) are the major public health challenges that can be averted through prevention and control of behavioral risk factors. The study aimed to assess the effectiveness of health education-based conventional intervention method to reduce NCD risk factors among a selected rural population of Bangladesh. A quasi-experimental study was conducted among 80 adults of Basulia village. Cluster sampling technique was used to grasp the participants. A baseline pre-test was done, followed by health education intervention in terms of awareness creating and warning messages containing leaflets on NCD risk factors. A weekly leaflet was provided to the participants throughout 3 months followed by post-test. World Health Organization STEPS instrument was used for data collection. Paired t-test was done to see the significance of the intervention. Men were dominator (60%), and the mean age of the participants was 37.1±13.8 years. Significant pre- and post-test differences were found for decreasing the number of smoking tobacco sticks daily (11.1±5.9 and 7.4±2.9; P=0.016) along with the frequency of smokeless tobacco use daily (6.7±3.6 and 4.3±1.7; P=0.005), increasing the servings of fruit and vegetables intake daily (3.3±0.8 and 4.9±1.1; P=0.046), decreasing the amount of added salt intake daily (1.2±0.5 and 0.8±0.5 teaspoon; P<0.001), and also increasing the total weekly metabolic equivalent (MET) of physical activity (3,756±4,094 and 4,002±4,249; P=0.046). In terms of percentage of the risk factors, all were reduced except tobacco use. A fair positive interventional effect of health education messages using conventional method has been evinced for all NCD risk factors.

Cost and cost-effectiveness of voluntary medical male circumcision in street-connected youth: findings from an education-based pilot intervention in Eldoret, Kenya

BackgroundVoluntary medical male circumcision (VMMC) is a critical component of HIV prevention. VMMC policies have achieved initial targets in adult men yet continue to fall short in reaching younger men and adolescents.SettingWe present the cost and scale-up implications of an education-based, VMMC intervention for adolescent street-connected males, for whom the street has become their home and/or source of livelihood. The intervention was piloted as part of the Engaging Street Youth in HIV Interventions Project in Eldoret, Kenya.MethodsWe used a micro-costing approach to estimate the average cost of a VMMC intervention in 116 street-connected youth. Average cost was estimated per individual and per cohort by dividing total cost per intervention by number of clients accessing the intervention over a 30-day period. Total average costs included direct and support procedure costs, educational costs, and direct research costs. Cost-effectiveness was measured in cost per DALYs averted over a 5 and 10-year period.ResultsThe total cost of the intervention was $12,526 over the 30-day period, with an average cost per individual of $108. The direct VMMC procedure cost was approximately $9 per individual. Personnel costs contributed the greatest percentage to the total intervention cost (38.2%), with mentors and social workers representing the highest wage earners. Retreat-related and education costs contributed 51% and 13% respectively to the total average cost, with surgical equipment costs contributing less than 1%. At a cost of $108 per individual, the intervention averted 60166 DALYs in 5 years resulting in a cost per DALY averted of $267.ConclusionThe VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to reach SCY. Further scale-up may be warranted to effectively apply this intervention in comparable populations.

Effect of Education-Based Intervention Using Group Discussion on the Knowledge, Attitude, and Practice of Postmenopausal Women about Osteoporosis Preventive Behaviors

Effect of Education-Based Intervention Using Group Discussion on the Knowledge, Attitude, and Practice of Postmenopausal Women about Osteoporosis Preventive Behaviors

Programmatic Comparison and Dissemination of an Audit of Single-fraction Radiation Therapy Prescribing Practices for Bone Metastases is Associated with a Meaningful and Lasting Change in Practice on a Population Level

There is ample evidence that single-fraction radiation therapy (SFRT) is as efficacious as more costly and morbid multifraction regimens. We previously demonstrated that an audit-based intervention increased the use of SFRT in all regional cancer centers the following year. However, other investigators have demonstrated that interventions were only associated with a transient 1-year change in prescribing practices. We sought to determine whether our intervention resulted in a more lasting impact. In 2012, we performed an audit of the prescribing practices of individual physicians, which was then presented to leaders and oncologists as an intervention to increase SFRT. We compared the use of SFRT between 2007 to 2011 (preintervention) and 2013 to 2016 (postintervention) in all 31,192 patients treated in our provincial program. The use of SFRT increased from 49.2% to 58.9% postintervention (P < .001). Rates from 2007 to 2011 were 51%, 51%, 48%, 49%, and 48%, respectively, whereas the postintervention rates from 2013 to 2016 were 60%, 62%, 59%, and 56%, respectively. Postintervention, half of the centers prescribed SFRT in a relatively narrow range (55%-58%). However, across all centers, there was still a broad range, with the lowest and highest users at 35% and 81%, respectively, although the lowest-using center still showed a significant increase (26% to 35%; P < .001). Our audit and education-based intervention resulted in a lasting and meaningful 10% change in practice. Our provincial rate is similar to that of a previously recommended benchmark rate of 60%, but we continue to see significant variation by center, suggesting further room for improvement in provincial standardization. With emerging evidence in support of ablative radiation therapy for select populations of patients with bone metastases, future benchmark rates of SFRT should be readdressed. However, our data suggest that programmatic comparison and dissemination of SFRT prescribing practices can achieve a population-based SFRT utilization rate near 60%.

Pilot randomised controlled trial to improve hand hygiene through mindful moments

BackgroundTo evaluate the effectiveness of a brief mindfulness intervention on hand hygiene performance and mindful attention for inpatient physician teams.DesignA pilot, pre-test/post-test randomised controlled mixed methods trial.SettingOne academic medical centre...

Improving prenatal care in pregnant women in Iranshahr, Iran: Applying Health Belief Model

ABSTRACTTo determine the effect of an education-based intervention on receiving adequate prenatal care. This randomized, controlled trial was conducted on 90 primiparous pregnant women, referred in Iranshahr, Iran for prenatal care (intervention = 45, control group = 45). The data were collected from February to June 2016 using a questionnaire developed based on the Health Belief Model (HBM). The intervention group received three intervention sessions during the second trimester of pregnancy, and 3 months after intervention, both groups completed a questionnaire. Data were analyzed using independent sample t-tests, chi-squared tests, paired t-test, Pearson and multivariate regression. Unlike the control group, in the intervention group’s mean scores for knowledge, variables from the HBM model and frequency of prenatal care significantly differed from pre- to post-intervention (pre-intervention mean = 12.62 ± 2.63, post-intervention mean = 17.71 ± 1.56, (p ˂ 0.05). Self-efficacy was positively correlated with knowledge (r = 0.304, p = 0.02) and adequate prenatal care (r = 0.583, p ˂ 0.001). The constructs of the HBM explained 75% of the variance in frequency of prenatal care in multivariable models. Developing an educational program based on the HBM was effective in the adoptation of prenatal care. Additionally, considering social, economic, and educational follow-up while implementing these programs is recommended.

Effects of health empowerment intervention on resilience of adolescents in a tribal area: A study using the Solomon four-groups design

RationaleResilience prevents the emergence of stress-related mental health problems among adolescents. Adolescents in tribal areas of India are more prone to develop such problems. ObjectivesThe primary objective was to determine the effect of combined life skills-based health empowerment intervention on the resilience of school-going adolescents in a tribal area. The secondary objectives were to determine the effect of the intervention on internal health locus of control and self-determination and to compare the effect of intervention on resilience between non-tribal and tribal adolescents. MethodsWe conducted this quasi-experimental study using a Solomon four-group design among 742 adolescents in two schools of Purulia, West Bengal, India. Students of the pretested group were examined for resilience using the Child Youth Resilience Measurement scale. A life skills education-based health empowerment intervention was administered among students of the experimental group. Post-test data on resilience, self-determination, internal health locus of control and pathological behaviour was obtained 3 months after the completion of intervention. A multi-level general linear mixed model was constructed to determine the effect of intervention on resilience. ResultsResilience was less among tribal adolescents at baseline. The intervention significantly improved resilience [βAdjusted = 11.19 (95% CI = 10.55, 11.83], with a greater increase for tribal adolescents [βtribal-nontribal = 1.53 (95% CI = 0.03, 3.03)]. The intervention also significantly improved internal health locus of control (marginal mean increment 1.38 ± 0.05), self-determination (marginal mean increment 3.71 ± 0.09) and reduced pathological behaviour of the adolescents. ConclusionOur study informed the current health policy that the existing life skills education-based programme should be reviewed and modified to include generic life skills, and the life skills education-based programme should be coupled with developmental interventions aimed at improving adult education and family climate for optimum effect on mental health and health behaviour of adolescents.

Plasma REST: a novel candidate biomarker of Alzheimer\u2019s disease is modified by psychological intervention in an at-risk population

The repressor element 1-silencing transcription (REST) factor is a key regulator of the aging brain’s stress response. It is reduced in conditions of stress and Alzheimer’s disease (AD), which suggests that increasing REST may be neuroprotective. REST can be measured peripherally in blood plasma. Our study aimed to (1) examine plasma REST levels in relation to clinical and biological markers of neurodegeneration and (2) alter plasma REST levels through a stress-reduction intervention—mindfulness training. In study 1, REST levels were compared across the following four well-characterized groups: healthy elderly (n=65), mild cognitive impairment who remained stable (stable MCI, n=36), MCI who later converted to dementia (converter MCI, n=29) and AD (n=65) from the AddNeuroMed cohort. REST levels declined with increasing severity of risk and impairment (healthy elderly>stable MCI>converter MCI>AD, F=6.35, P<0.001). REST levels were also positively associated with magnetic resonance imaging-based hippocampal and entorhinal atrophy and other putative blood-based biomarkers of AD (Ps<0.05). In study 2, REST was measured in 81 older adults with psychiatric risk factors for AD before and after a mindfulness-based stress reduction intervention or an education-based placebo intervention. Mindfulness-based training caused an increase in REST compared with the placebo intervention (F=8.57, P=0.006), and increased REST was associated with a reduction in psychiatric symptoms associated with stress and AD risk (Ps<0.02). Our data confirm plasma REST associations with clinical severity and neurodegeneration, and originally, that REST is modifiable by a psychological intervention with clinical benefit.

Education and process change to improve skin health in a residential aged care facility.

We report on an intervention and evaluation in relation to changes in staff knowledge, time spent on healing and wound prevention and proportion of wounds in the facilities before and after. A rapid review of recent peer-reviewed literature (2006-2016) found 14 education-based intervention articles and provided the background and context for this intervention. A cohort of 164 nurses and personal care workers and 261 residents at two aged care-approved facilities contributed to this intervention on the effect of education, mentoring and practice change on staff knowledge and wound prevalence between 2015 and 2016. There was a significant decrease in pressure injury prevalence and an increase in the early identification of potential wounds between phase 1 and 3 across the two facilities. Overall, registered nurses and enrolled nurses showed significant increase in mean knowledge scores. There was a reorganisation of time spent on various wound care and prevention strategies that better represented education and knowledge. Wound management or prevention education alone is not enough; this study, using an educational intervention in conjunction with resident engagement, practice change, mentorship, onsite champions for healthy skin and product choice suggestions, supported by an organisation that focuses on a healthy ageing approach, showed improvement across two residential sites.

MP11: A quality improvement initiative to decrease the rate of solitary blood cultures in the emergency department

Introduction: Best practice guidelines recommend that at least two sets of blood cultures be sent when blood cultures are required. However, high rates of solitary blood cultures are still common in the emergency department. The aim of this study was to evaluate the efficacy of different quality improvement initiatives aimed at reducing the rate of solitary blood cultures being sent to the lab on patients ultimately discharged from our emergency department. Methods: This was a multi-centre, multi-phase, prospective study evaluating a comprehensive education-based intervention and a second intervention that combined a computerized forcing function along with a brief education-based intervention. The results were analyzed using segmented regression analysis, as well as statistical process control charts. Results: The baseline rate of solitary sets of blood cultures was 41.1%. The education intervention reduced this rate to 30.3%. The introduction of a forcing function with a brief educational intervention further reduced the rate to 11.6%. This represents an absolute reduction of 29.5% from baseline (relative reduction of 71.8%). According to segmental regression analyses, the education intervention alone did not produce a statistically significant change when factoring possible background time-related trends (P=0.071). However, the forcing function produced a statistically significant improvement (P &amp;lt; 0.0005), which was maintained for 6 months. Conclusion: The combination of a brief education-based intervention and a computerized forcing function was more effective than education alone in reducing solitary blood culture collection in our emergency department in this time series study. Forcing functions can be a powerful tool in modifying behaviours and processes in the clinical setting.

Nurses’ knowledge and perception of delirium screening and assessment in the intensive care unit: Long-term effectiveness of an education-based knowledge translation intervention

ObjectivesTo determine the impact of education on nurses’ knowledge of delirium, knowledge and perception of a validated screening tool, and delirium screening in the ICU. MethodsA quasi-experimental single group pretest-post-test design. SettingA 16 bed ICU in a Canadian urban tertiary care centre. Main outcome measuresNursing knowledge and perception were measured at baseline, 3-month and 18-month periods. Delirium screening was then assessed over 24-months. ResultsDuring the study period, 197 surveys were returned; 84 at baseline, 53 at 3-months post education, and 60 at the final assessment period 18-months post intervention. The significant improvements in mean knowledge scores at 3-months post intervention (7.2, SD 1.3) were not maintained at 18-months (5.3, SD 1.1). Screening tool perception scores remained unchanged. Improvements in the perception of utility were significant at both time periods (p=0.03, 0.02 respectively). Physician value significantly improved at 18-months (p=0.01). Delirium screening frequency improved after education (p<0.001) demonstrating a positive correlation over time (p<0.01). ConclusionMultifaceted education is effective in improving delirium knowledge and screening; however, without sustained effort, progress is transient. Education improved perceived tool utility and over time utility perception and physician value improved.

A Quality Improvement Initiative to Decrease the Rate of Solitary Blood Cultures in the Emergency Department.

Best practice guidelines recommend that at least two sets of blood cultures (BCs) be sent when blood cultures are required. However, high rates of solitary BCs are still common in the emergency department (ED). The aim of this study was to evaluate the efficacy of different quality improvement initiatives aimed at reducing the rate of solitary blood cultures being sent to the laboratory on patients ultimately discharged from our ED. This was a multicenter, multiphase, prospective study evaluating a comprehensive education-based intervention and a second intervention that combined a computerized forcing function (FF) along with a brief education-based intervention. The results were analyzed using segmented regression analysis, as well as statistical process control charts. The baseline rate of solitary sets of BCs was 41.1%. The education intervention reduced this rate to 30.3%. The introduction of a FF with a brief educational intervention further reduced the rate to 11.6%. This represents an absolute reduction of 29.5% from baseline (relative reduction of 71.8%). According to segmental regression analyses, the education intervention alone did not produce a statistically significant change when factoring possible background time-related trends (p = 0.071). However, the FF produced a statistically significant improvement (p < 0.0005), which was maintained for 6 months. The combination of a brief education-based intervention and a computerized FF was more effective than education alone in reducing solitary BC collection in our ED in this time series study. FFs can be a powerful tool in modifying behaviors and processes in the clinical setting.

Chronic disease management interventions for people with chronic kidney disease in primary care: a systematic review and meta-analysis.

Primary care providers manage the majority of patients with chronic kidney disease (CKD), although the most effective chronic disease management (CDM) strategies for these patients are unknown. We assessed the efficacy of CDM interventions used by primary care providers managing patients with CKD. The Medline, Embase and Cochrane Central databases were systematically searched (inception to November 2014) for randomized controlled trials (RCTs) assessing education-based and computer-assisted CDM interventions targeting primary care providers managing patients with CKD in the community. The efficacy of CDM interventions was assessed using quality indicators [use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), proteinuria measurement and achievement of blood pressure (BP) targets] and clinical outcomes (change in BP and glomerular filtration rate). Two independent reviewers evaluated studies for inclusion, quality and extracted data. Random effects models were used to estimate pooled odds ratios (ORs) and weighted mean differences for outcomes of interest. Five studies (188 clinics; 494 physicians; 42 852 patients with CKD) were included. Two studies compared computer-assisted intervention strategies with usual care, two studies compared education-based intervention strategies with computer-assisted intervention strategies and one study compared both these intervention strategies with usual care. Compared with usual care, computer-assisted CDM interventions did not increase the likelihood of ACEI/ARB use among patients with CKD {pooled OR 1.00 [95% confidence interval (CI) 0.83-1.21]; I2 = 0.0%}. Similarly, education-related CDM interventions did not increase the likelihood of ACEI/ARB use compared with computer-assisted CDM interventions [pooled OR 1.12 (95% CI 0.77-1.64); I2 = 0.0%]. Inconsistencies in reporting methods limited further pooling of data. To date, there have been very few randomized trials testing CDM interventions targeting primary care providers with the goal of improving care of people with CKD. Those conducted to date have shown minimal impact, suggesting that other strategies, or multifaceted interventions, may be required to enhance care for patients with CKD in the community.

$1.8 Million and counting: how volatile agent education has decreased our spending $1000 per day

Study ObjectiveVolatile anesthetic agents comprise a substantial portion of every hospital's pharmacy budget. Challenged with an initiative to lower anesthetic drug expenditures, we developed an education-based intervention focused on reducing volatile anesthetic costs while preserving access to all available volatile anesthetics. When postintervention evaluation demonstrated a dramatic year-over-year reduction in volatile agent acquisition costs, we undertook a retrospective analysis of volatile anesthetic purchasing data using time series analysis to determine the impact of our educational initiative. Design/SettingWe obtained detailed volatile anesthetic purchasing data from the Central Supply of Wake Forest Baptist Health from 2007 to 2014 and integrated these data with the time course of our educational intervention. PatientsAggregate volatile anesthetic purchasing data were analyzed for 7 consecutive fiscal years. InterventionThe educational initiative emphasized tissue partition coefficients of volatile anesthetics in adipose tissue and muscle and their impact on case management. MeasurementsWe used an interrupted time series analysis of monthly cost per unit data using autoregressive integrated moving average modeling, with the monthly cost per unit being the amount spent per bottle of anesthetic agent per month. Main ResultsThe cost per unit decreased significantly after the intervention (t=−6.73, P<.001). The autoregressive integrated moving average model predicted that the average cost per unit decreased $48 after the intervention, with 95% confidence interval of $34 to $62. As evident from the data, the purchasing of desflurane and sevoflurane decreased, whereas that of isoflurane increased. ConclusionsAn educational initiative focused solely on the selection of volatile anesthetic agent per case significantly reduced volatile anesthetic expense at a tertiary medical center. This approach appears promising for application in other hospitals in the rapidly evolving, value-added health care environment. We were able to accomplish this with instruction on tissue partition coefficients and each agent's individual cost per MAC-hour delivered.