Physician Audit Research Articles

Evaluating a Physician Audit and Feedback Intervention to Increase Clinical Trial Enrollment in Radiation Oncology in a Multisite Tertiary Cancer Center: A Randomized Study

Clinical trial participation continues to be low, slowing new cancer therapy development. Few strategies have been prospectively tested to address barriers to enrollment. We investigated the effectiveness of a physician audit and feedback report to improve clinical trial enrollment. We conducted a randomized quality improvement study among radiation oncologists at a multisite tertiary cancer network. Physicians in the intervention group received quarterly audit and feedback reports comparing the physician's trial enrollments with those of their peers. The primary outcome was trial enrollments. Among physicians randomized to receive the feedback report (n = 30), the median proportion of patients enrolled during the study period increased to 6.1% (IQR, 2.6%-9.3%) from 3.2% (IQR, 1.1%-10%) at baseline. Among those not receiving the feedback report (n = 29), the median proportion of patients enrolled increased to 4.1% (IQR, 1.3%-7.6%) from 1.6% (IQR, 0%-4.1%) at baseline. There was a nonsignificant change in the proportion of enrollments associated with receiving the feedback report (-0.6%; 95% CI, -3.0% to 1.8%; P = .6). Notably, there was an interaction between baseline trial accrual and receipt of feedback reports (P = .005), with enrollment declining among high accruers. There was an increase in enrollment throughout the study, regardless of study group (P = .001). In this study, a positive effect of physician audit and feedback on clinical trial enrollment was not observed. Future efforts should avoid disincentivizing high accruers and might consider pairing feedback with other patient- or physician-level strategies. The increase in trial enrollment in both groups over time highlights the importance of including a comparison group in quality improvement studies to reduce confounding from secular trends.

Change Management Accompanying Implementation of Decision Support for Prevention of Acute Kidney Injury in Cardiac Catheterization Units: Program Report.

Different models exist to guide successful implementation of electronic health tools into clinical practice. The Contrast Reducing Injury Sustained by Kidneys (Contrast RISK) initiative introduced an electronic decision support tool with physician audit and feedback into all of the cardiac catheterization facilities in Alberta, Canada, with the goal of preventing contrast-associated acute kidney injury (CA-AKI) following coronary angiography and intervention. This report describes the change management approaches used by the initiative and end-user's feedback on these processes. The Canada Health Infoway Change Management model was used to address 6 activities relevant to project implementation: governance and leadership, stakeholder engagement, communications, workflow analysis and integration, training and education, and monitoring and evaluation. Health care providers and invasive cardiologists from all sites completed preimplementation, usability, and postimplementation surveys to assess integration and change success. Prior to implementation, 67% of health providers were less than satisfied with processes to determine appropriate contrast dye volumes, 47% were less than satisfied with processes for administering adequate intravenous fluids, and 68% were less than satisfied with processes to ensure follow-up of high-risk patients. 48% of invasive cardiologists were less than satisfied with preprocedural identification of patients at risk of acute kidney injury (AKI). Following implementation, there were significant increases among health providers in the odds of satisfaction with processes for identifying those at high risk of AKI (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.36-6.66, P = .007), quantifying the appropriate level of contrast dye for each patient (OR 6.98, 95% CI 3.06-15.91, P < .001), determining the optimal amount of IV fluid for each patient (OR 1.86, 95% CI 0.88-3.91, P = .102), and following up of kidney function of high risk patients (OR 5.49, 95%CI 2.45-12.30, P < .001). There were also significant increases among physicians in the odds of satisfaction with processes for identifying those at high risk of AKI (OR 19.53, 95% CI 3.21-118.76, P = .001), quantifying the appropriate level of contrast dye for each patient (OR 26.35, 95% CI 4.28-162.27, P < .001), and for following-up kidney function of high-risk patients (OR 7.72, 95% CI 1.62-36.84.30, P = .010). Eighty-nine percent of staff perceived the initiative as being successful in changing clinical practices to reduce the risk of CA-AKI. Physicians uniformly agreed that the system was well-integrated into existing workflows, while 42% of health providers also agreed. The Canada Health Infoway Change Management model was an effective framework for guiding implementation of an electronic decision support tool and audit and feedback intervention to improve processes for AKI prevention within cardiac catheterization units.

Using the Medical Audit to Improve Practice Performance.

Feedback to physicians on their clinical performance is critical to continuous learning and maintenance of skills as well as maintaining patient safety. However, it is fraught with challenges around both implementation and acceptance. Additionally, rewarding of performance improvement is not often done, putting into question the efficacy of the process. Physician audit and feedback have been studied extensively and shown to be beneficial in many fields of medicine. Documenting physician performance and sharing individual and group data have been positively linked to changing physician behavior, ultimately leading to improved patient outcomes. Although casual review of one's own performance is often the easiest approach, it is frequently over- or underestimated by self-evaluation. Objective measures are therefore important to provide concrete data on which physicians can act. A fundamental question remains in mammography: Is reporting the information to the physician and accreditation bodies enough, or should there be consequences for the radiologist and/or facility if there is outlier behavior?

Improving Isotonic Maintenance Intravenous Fluid Use in the Emergency Department.

Maintenance intravenous fluids (IVFs) are commonly used in the hospital setting. Hypotonic IVFs are commonly used in pediatrics despite concerns about high incidence of hyponatremia. We aimed to increase isotonic maintenance IVF use in children admitted from the emergency department (ED) from a baseline of 20% in 2018 to >80% by December 2019. We included patients aged 28 days to 18 years receiving maintenance IVFs (rate >10 mL/hour) at the time of admission. Patients with active chronic medical problems were excluded. Interventions included institutional discussions on isotonic IVF based on literature review, education on isotonic IVF use per the American Academy of Pediatrics guideline (isotonic IVF use with appropriate potassium chloride and dextrose), electronic medical record changes to encourage isotonic IVF use, and group practice review with individual physician audit and feedback. Balancing measures were the frequency of serum electrolyte checks within 24 hours of ED admission and occurrence of hypernatremia. Data were analyzed by using statistical process control charts. Isotonic maintenance IVF use improved, with special cause observed twice; the 80% goal was met and sustained. No difference was noted in serum electrolyte checks within 24 hours of admission (P > .05). There was no increase in occurrence of hypernatremia among patients who received isotonic IVF compared with those who received hypotonic IVF (P > .05). The application of improvement methods resulted in improved isotonic IVF use in ED patients admitted to the inpatient setting. Institutional readiness for change at the time of the American Academy of Pediatrics guideline release and hardwiring of preferred fluids via electronic medical record changes were critical to success.

Improving influenza and pneumococcal vaccination uptake among incident peritoneal dialysis patients: a quality improvement initiative.

Influenza and pneumococcal vaccination rates among peritoneal dialysis (PD) patients remain suboptimal, despite availability of vaccinations and health recommendations. The primary aim was to improve influenza and pneumococcal vaccination rates among incident PD patients at our center to 80%. A secondary aim was to develop a sustainable workflow for vaccination in PD patients. A quality improvement (QI) initiative to increase vaccination rate among incident PD patients was conducted in a tertiary care hospital in Singapore from Jul 2017 to Dec 2018. Key drivers and barriers to success were identified through root cause analysis. Change ideas focusing on improving opportunities, access and enhancement of reminder systems were implemented using Plan-Do-Study-Act methodology. Vaccination rates were monitored at 3-month intervals. Total of 249 patients were eligible for vaccination. The baseline vaccination rate for influenza, pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) were 63%, 54% and 14%, respectively. Root-cause analyses revealed several practice-related barriers, including lack of physician recommendation, time constraints and ineffective reminder systems. Multifaceted interventions, such as the provision of vaccination at non-traditional clinical settings, physician audit and feedback, utilisation of reminder tools, successfully increased influenza, PCV13 and PPSV23 vaccination rates to 86%, 85% and 63%, respectively. A robust influenza and pneumococcal vaccination program implemented using a standardized QI methodology and multidisciplinary approach is effective in improving and sustaining influenza and pneumococcal vaccination uptake among PD patients.

Feasibility of a quality improvement project to increase adherence to evidence-based pulmonary embolism diagnosis in the emergency department

BackgroundMany evidence-based clinical decision tools are available for the diagnosis of pulmonary embolism (PE). However, these clinical decision tools have had suboptimal uptake in the everyday clinical practice in emergency departments (EDs), despite numerous implementation efforts. We aimed to test the feasibility of a multi-faceted intervention to implement an evidence-based PE diagnosis protocol.MethodsWe conducted an interrupted time series study in three EDs in Ontario, Canada. We enrolled consecutive adult patients accessing the ED with suspected PE from January 1, 2018, to February 28, 2020. Components of the intervention were as follows: clinical leadership endorsement, a new pathway for PE testing, physician education, personalized confidential physician feedback, and collection of patient outcome information. The intervention was implemented in November 2019. We identified six criteria for defining the feasibility outcome: successful implementation of the intervention in at least two of the three sites, capturing data on ≥ 80% of all CTPAs ordered in the EDs, timely access to electronic data, rapid manual data extraction with feedback preparation before the end of the month ≥ 80% of the time, and time required for manual data extraction and feedback preparation ≤ 2 days per week in total.ResultsThe intervention was successfully implemented in two out of three sites. A total of 5094 and 899 patients were tested for PE in the period before and after the intervention, respectively. We captured data from 90% of CTPAs ordered in the EDs, and we accessed the required electronic data. The manual data extraction and individual emergency physician audit and feedback were consistently finalized before the end of each month. The time required for manual data extraction and feedback preparation was ≤ 2 days per week (14 h).ConclusionsWe proved the feasibility of implementing an evidence-based PE diagnosis protocol in two EDs. We were not successful implementing the protocol in the third ED.RegistrationThe study was not registered.

Regional needs assessment for emergency physician audit and feedback.

Audit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region. We conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups. A total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners. This study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.

An Overview of Strategies Targeting Inappropriate Advanced Diagnostic Imaging in the Setting of Acute Uncomplicated Low Back Pain

The aims of this article are to review the driving forces for increased utilization of imaging within the US and to review the strategies currently being implemented to curtail the use of inappropriate advanced diagnostic imaging (ADI) in the setting of acute uncomplicated low back pain. Strategies aimed at reducing inappropriate ADI in the setting of uncomplicated low back pain, including guideline dissemination, clinical decision support (CDS), audit and feedback, prior authorization, and prior notification. Increasing utilization of inappropriate ADI is a multifactorial problem, and the solution is complex. Like many problems in medicine, it is unlikely that we will be able to identify a single intervention as a solution. Instead, a concerted effort grounded in physician education, CDS, and audit and feedback may be our best tool against inappropriate ADI in the setting of acute uncomplicated low back pain.

Predictors and variability of antibiotic prescribing amongst family physicians

Rising rates of antimicrobial resistance are driven by overuse of antibiotics. Characterizing physician antibiotic prescribing variability can inform interventions to optimize antibiotic use. To describe predictors of overall antibiotic prescribing as well as the inter-physician variability in antibiotic prescribing amongst family physicians. We conducted a 5 year cohort study of antibiotic prescribing rates by family physicians in Ontario, Canada using a repository of electronic medical records. Using multilevel logistic regression models fitted with random intercepts for physicians, we evaluated the association of patient-, physician- and clinic-level characteristics with antibiotic prescribing rates. We included 3956921 physician-patient encounters, 322129 unique patients and 313 physicians from 41 family medicine clinics. Physicians prescribed a median of 54 (interdecile range 28-95) antibiotics per 1000 encounters. Female children aged 3-5 years were most likely to receive antibiotics compared with men ≥65 years (OR 4.01, 95% CI 3.89-4.13). The only significant physician-level predictor was median daily patient visits of ≥20 compared with <10 (OR 1.28, 95% CI 1.06-1.55). The median ORs without and with patient characteristics were 1.68 and 1.69, respectively. Thus, the odds of receiving an antibiotic varied by 1.7-fold for the same patient simply by virtue of encountering two different physicians. We observed substantial inter-physician variability in antibiotic prescribing that could not be explained by sociodemographic and clinical patient differences, suggesting that risk adjustment of antibiotic prescribing practices may not be required for audit and feedback of family physicians working in similar practice settings.

A centrally generated primary care physician audit report does not improve colonoscopy uptake after a positive result on a fecal occult blood test in Ontario's ColonCancerCheck program.

Timely follow-up of fecal occult blood screening with colonoscopy is essential for achieving colorectal cancer mortality reduction. In the present study, we evaluated the effectiveness of centrally generated, physician-targeted audit and feedback to improve colonoscopy uptake after a positive fecal occult blood test (fobt) result within Ontario's population-wide ColonCancerCheck Program. This prospective cohort study used data sets from Ontario's ColonCancerCheck Program (2008-2011) that were linked to provincial administrative health databases. Cox proportional hazards regression was used to estimate the effect of centralized, physician-targeted audit and feedback on colonoscopy uptake in an Ontario-wide fobt-positive cohort. A mailed physician audit and feedback report identifying individuals outstanding for colonoscopy for 3 or more months after a positive fobt result did not increase the likelihood of colonoscopy uptake (hazard ratio: 0.95; 95% confidence interval: 0.79 to 1.13). Duration of positive fobt status was strongly inversely associated with the hazard of follow-up colonoscopy (p for linear trend: <0.001). In a large population-wide setting, centralized tracking in the form of physician-targeted mailed audit and feedback reports does not improve colonoscopy uptake for screening participants with a positive fobt result outstanding for 3 or more months. Mailed physician-targeted screening audit and feedback reports alone are unlikely to improve compliance with follow-up colonoscopy in Ontario. Other interventions such as physician audits or automatic referrals, demonstrated to be effective in other jurisdictions, might be warranted.

Effectiveness of Quality Improvement Interventions at Reducing Inappropriate Cardiac Imaging: A Systematic Review and Meta-Analysis.

Between 5% and 25% of cardiac imaging tests are performed for inappropriate indications. Studies have examined the impact of appropriate use criteria-based quality improvement initiatives on inappropriate testing, but they have not been systematically evaluated. We performed a systematic review of studies evaluating quality improvement initiatives aimed at reducing inappropriate cardiac imaging. The primary outcome was the proportion of inappropriate tests based on appropriate use criteria. Studies were analyzed using a random effects meta-analysis model, and heterogeneity was examined using subgroup analyses. We identified 6 observational studies and 1 randomized control trial. Most interventions (n=6) had a formal education component, and 5 included a mechanism for physician audit and feedback. Although these interventions were associated with lower odds of inappropriate testing (odds ratio, 0.44 [95% confidence interval, 0.32-0.61]; P<0.001), significant heterogeneity was observed (I(2)=70%), which was best explained by the utilization of physician audit and feedback. Interventions that employed physician audit and feedback were associated with significantly lower odds of inappropriate testing (odds ratio, 0.36 [95% confidence interval, 0.31-0.41]; P<0.001; I(2)=0%), whereas those that did not had no effect (odds ratio, 0.89 [95% confidence interval, 0.61-1.29]; P=0.51; I(2)=0%; P value for difference <0.001). All studies had potential sources of bias that could have affected the observed estimates. Interventions using physician audit and feedback are associated with lower odds of inappropriate cardiac testing. Further research is needed to evaluate a greater diversity of intervention types, with improved study designs.

The use of an automated notification system to identify and address early readmissions by a university hospitalist service

Objectives. To examine the association of an automated physician feedback system prompting physician review of early readmissions with a change in overall readmission rates. Methods. The University of Utah Internal Medicine Hospitalist Service created an automated system to alert discharging providers to any patient readmitted within 30 days. For any 7-day readmission, the physician was asked to complete a survey to describe the admission and discharge and to identify contributing factors to the readmission. Using the University HealthSystem Consortium database, readmission rates were compared prior to and following this intervention. Results. Following the intervention, 30-day readmission rates significantly decreased from 13.93% to 11.99% (p = 0.0298). The 7-day readmission rates decreased as well but the findings were not statistically significant. The discharging physician deemed 45% of the readmissions preventable or probably preventable. Conclusion. Readmissions are common, costly and potentially preventable. This tool for physician audit and feedback and identification of defects contributing to readmissions was associated with a statistically significant decrease in 30-day readmissions. Further investigation is needed to verify these results and evaluate the best mechanism of application.

Increasing NICE compliance in multiple sclerosis and cognition: a service evaluation

Purpose – The purpose of this paper is to increase awareness and compliance of The National Institute for Health and Care Excellence (NICE) Guidance regarding cognitive impairment in multiple sclerosis (MS). Design/methodology/approach – Assessments were offered routinely to consecutive inpatients with MS and to 20 per cent of outpatients. Once consent was gained, a cognitive assessment and subjective measure of cognition was completed with the patient, as well as a disability scale completed by the Medical Consultant. Individually targeted cognitive rehabilitation advice was provided using a bespoke advice leaflet. Afterwards, those who completed the assessment were asked to provide feedback on their experience. Findings – The percentage that were classed as below average cognitively and the pattern of impairment was comparable to previous findings. Memory was rated the most affected by the largest number of MS individuals and a strong relationship was found between objective and subjective measures of attention. The average functional disability level was rated at 6.99. Evaluations for the service provided were positive; over half of the sample was unaware of NICE Guidance on this issue but 100 per cent would recommend this service and provided optimistic quotes. Practical implications – This evaluation has enabled greater numbers to receive the recommended services and provided a useful baseline assessment of cognitive impairment and of patient attitudes towards this service. Resulting from this process, a new service framework has been proposed and presented at a local level. The advice leaflet developed for this process has been well received by patients and colleagues resulting in its submission to become an official NHS leaflet. Originality/value – Developed clinical governance of NHS services to patients with MS in offering improved assessment and management of cognitive problems. This is in contrast to the national trend showing little improvement of MS care and the lack of NICE implementation by the MS Trust and Royal College of Physicians audit. Furthermore, the bespoke advice leaflet developed for patients and carers of MS demonstrates originality of information provided.

Improving Medical Oncology Quality Through Peer-to-Peer Consultation.

This study describes how the use of peer-to-peer (P2P) physician consultation improves medical oncology care quality by preventing non-evidence-based and potentially morbid chemotherapy treatments. New Century Health (NCH) has adapted a physician audit and feedback model to strengthen adherence to clinical guidelines. In the NCH oncology program, P2P consultation complements clinical pathways and an online prior authorization platform. Payers are adopting the use of clinical pathways as a management strategy for managing costs and improving quality. Managing medical oncology is a complex process, because evidence evolves rapidly, and almost one third of chemotherapy is prescribed off label. The use of prior authorization, combined with standardized protocols for patients with specific cancer diagnoses, is one way for payers to reduce unnecessary treatment variation. [Table: see text] Methods: NCH completed a retrospective analysis of the chemotherapy treatment requests (CTRs) submitted by payers' oncologists for prior authorization between January and December 2012. The objectives of the clinical impact analysis were to measure the CTR disposition rate, identify the CTR intervention rate resulting from P2P consultation, and identify the types of drug triggering the interventions. Analysis of the 13,078 CTRs associated with the 1,116 unique Medicare and commercial patients of a national health plan determined that CTRs voluntarily withdrawn or recommended adverse determination (RAD; ie, NCH recommendation to member's health plan to not authorize treatment as requested; after review of health plan policy and compendia, NCH was not able to resolve provider's request through P2P consultation and could not recommend approval of treatment plan as requested, therefore recommending denial of request) by the submitting physician as a result of a P2P consultation with an NCH board-certified oncologist comprised 11.6% of all CTRs. Further analysis identified the types of medication associated with the 1,521 CTRs withdrawn/RAD as a consequence of P2P consultation. Interventions on chemotherapeutic medications and supportive care were evenly distributed at 51.2% and 48.8%, respectively. Interventions on medications that had received US Food and Drug Administration approval within the last 2 years (initial approval or for new indications) represented 12.1%. [Table: see text] Conclusion: Using P2P consultation to complement a pathway-driven prior authorization process improves medical oncology quality. In addition, P2P consultation can be an effective collaborative physician engagement strategy by supporting oncologists with critical clinical information and mitigating concerns about pathway implementation and about payer involvement in drug use management.

Effects of FDA Advisories on the Pharmacologic Treatment of ADHD, 2004–2008

This study assessed the effect of public health advisories issued between 2005 and 2007 by the U.S. Food and Drug Administration (FDA) on treatments of attention-deficit hyperactivity disorder (ADHD) and physician prescribing practices. Data obtained from the IMS Health National Disease and Therapeutic Index, a nationally representative audit of ambulatory physicians, were used to examine trends in office visits by children and adolescents (under age 18) during which ADHD was treated with Adderall, other psychostimulants, or atomoxetine. Segmented time series regressions were conducted to determine changes in use associated with three advisories issued between 2005 and 2007. In 2004, before the first FDA advisory, Adderall accounted for 36% of ADHD pharmacotherapy treatment visits. Other stimulants accounted for 46%, and atomoxetine accounted for 19%. Overall pharmacotherapy treatment rates were stable over the study period, but by 2008 the treatment visits accounted for by Adderall (that is, market share) declined to 24%, and the market share for atomoxetine declined to 8%. The market share for substitute therapies-clonidine, guanfacine, and bupropion-was stable over this period, ranging from 5% to 7%. Despite the declines in the use of Adderall and atomoxetine over the study period, results from the regression models suggest that the advisories did not have a statistically significant effect on ADHD medication prescribing. FDA advisories regarding potential cardiovascular and other risks of ADHD medications had little discernible incremental effect on the use of these medicines in this nationally representative ambulatory audit.

Association between the commercial characteristics of psychotropic drugs and their off-label use.

Off-label prescribing, or the use of a medicine for non-Food and Drug Administration (FDA)-approved indications, is especially common for psychotropic therapies and often lacks scientific support. We quantified the association between 4 commercial characteristics of prescription medicines-product age, therapeutic class age, drug volume, and promotional expenditures-and off-label use of antidepressants, antipsychotics, and mood stabilizers from 1998 through 2009. We linked data from the IMS Health National Disease and Therapeutic Index, a nationally representative audit of office-based physicians, with data from FDA@gov and the drug compendium DrugDex, to derive information regarding off-label use. Our primary outcome was the rate (per 1000 uses) with which a drug was prescribed for non-FDA-approved indications during a given calendar year. We used mixed-effects regression models with random intercepts for each drug, adding measures of commercial characteristics as fixed effects within this model. From 1998 through 2009, the average proportion of all uses that occurred off-label was 23.3% for antidepressants, 60.7% for antipsychotics, and 54.2% for mood stabilizers. There was a positive association between the annual rate of off-label use and drug volume [incidence rate ratio (IRR), 1.41; 95% confidence intervals (CI), 1.32-1.50], although the strength of this association was not uniform across the therapeutic classes examined. There was also a small but statistically significant association between product age (IRR, 0.96; 95% CI, 0.94-0.98) and class age (IRR, 1.03; 95% CI, 1.01-1.06) and the rate of off-label use, also varying across therapeutic class. There was a statistically significant inverse association between promotional expenditures and off-label use (IRR, 0.94; 95% CI, 0.93-0.96) when controlling for our other commercial characteristics. These associations were similar when examining scientifically unsupported rather than all off-label use. Our findings suggest that drug prescription volume, rather than product age or therapeutic class age, should be scrutinized further to identify settings where the public health impact of unsupported off-label prescribing may be particularly important.

Audit of Physicians’ Adherence to the Antibiotic Policy Guidelines in Kuwait

Objective: To audit physicians’ adherence to the local antibiotic policy guidelines in government hospitals in Kuwait. Materials and Methods: The study was a retrospective review of patient records in nine hospitals between July 1 and December 31, 2008. Clinical notes and medication charts of the latest hospital admissions were checked for antibiotic prescribing. On the audit form, aspects of the prescribed antibiotic were benchmarked to the hospital antibiotic policy guidelines to evaluate adherence. Results: Of 2,232 reviewed records, 1,112 (49.8%) patients had 1,528 antibiotic prescriptions. Patients who received antibiotics were significantly younger than those who did not (median age: 26.3 vs. 29.8 years, p < 0.001) and their hospital stay was significantly longer (median: 4 vs. 2 days, p < 0.001). The choice of an antibiotic was appropriate and matched the policy in 806 (52.7%) prescriptions. Of such appropriate antibiotics, adherence to route of administration was observed in 768/806 (95.3%), to dose in 758 (94%), to frequency in 746 (92.6%) and to duration in 608 (75.4%). Full adherence to all aspects of antibiotic choice, dose, route, frequency and duration was achieved in 464 (30.4%) prescriptions. In 382 (25%), the antibiotics administered were not indicated. Conclusion: There was low adherence to the local antibiotic policy guidelines. Physicians’ antibiotic prescribing practices should be optimized. Adherence to, and update of, the policy is recommended.

Audit of Physicians’ Adherence to a Preprinted Order Set for Community-Acquired Pneumonia

Community-acquired pneumonia is the seventh leading cause of death in Canada. Previous studies have shown reductions in both mortality rate and length of hospital stay with the use of guideline-concordant empiric therapy and standardized preprinted orders. The primary objective was to determine adherence to the preprinted order for community-acquired pneumonia at the University Hospital of Northern British Columbia (UHNBC). The study also had the following secondary objectives: to assess the appropriateness of prescribing of levofloxacin in relation to institutional recommendations; to determine adherence with recent guidelines from the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) for the treatment of community-acquired pneumonia; and to determine all-cause mortality, duration of IV antibiotic therapy, and length of stay for the various regimens reviewed. A retrospective observational chart review was conducted of patients with community-acquired pneumonia who were admitted between November 2007 and February 2008. Exclusion criteria were designed to eliminate patients who did not have this condition. Descriptive statistics were used to assess adherence with the preprinted order. Secondary outcomes were analyzed with the Pearson χ(2) test, t tests, and analysis of variance. In total, the charts for 113 patients were reviewed, and 58 patients were included in the study. The preprinted order for community-acquired pneumonia was used for 25 (43%) of the 58 patients; however, for only 4 (7%) of these admissions were all sections of the preprinted order used correctly. No statistically significant differences in length of stay were found for any of the antibiotic combinations assessed. However, the proportion of patients treated according to the IDSA-ATS guidelines was significantly greater when the preprinted order was used (p = 0.012). In addition, use of the preprinted order encouraged assessment of the patient's pneumococcal vaccination status (9 [25%] of 25 patients versus 3 [9%] of 33 patients) and utilization of the pneumonia severity index (13 [52%] of 25 patients versus 0 [0%] of 33 patients). The preprinted order for community-acquired pneumonia at UHNBC was not being utilized to its fullest. However, when it was used, it increased guideline-concordant empiric therapy and encouraged assessment of patients' pneumococcal vaccination status and pneumonia severity index.

Impact of FDA Black Box Advisory on Antipsychotic Medication Use

In April 2005, the US Food and Drug Administration (FDA) issued an advisory and subsequent black box warning regarding the risks of atypical anti psychotic use among elderly patients with dementia. The impact of these warnings on atypical drug use is unknown. We used quasi-experimental, interrupted time-series analyses to examine nationally representative data from IMS Health's National Disease and Therapeutic Index from January 2003 through December 2008. The primary measurement from this audit of office-based physicians was the use of an atypical antipsychotic agent. We quantified the impact of the advisory on atypical antipsychotic use among all individuals and those 65 years or older with dementia. From January 2003 to March 2005, mentions of total atypical antipsychotic drugs increased at an annual rate of 34%, and among patients with dementia, 16%. In the year prior to the FDA advisory, there were approximately 13.6 million atypical drug mentions, including 0.8 million among those with dementia. In the year following the advisory, atypical drug mentions fell 2% overall and 19% among those with dementia. In 2004, 19% (0.8 of 4.1 million) of drug mentions for dementia were for an atypical agent. By 2008, this proportion decreased to 9% (0.4 of 4.3 million). Atypical drug use slowed for both FDA-approved and off-label indications and declined through 2008 for all populations examined. The FDA advisory was associated with decreases in the use of atypical antipsychotics, especially among elderly patients with dementia.

Bridging the Osteoporosis Quality Chasm

Bridging the Osteoporosis Quality Chasm