Physician Educational Intervention Research Articles

Impact of Low-Dose Computed Tomography and Physician Education on Referral for Head Shape.

Imaging before specialist evaluation of abnormal head shape is associated with a delay in evaluation and an increase in radiation exposure. A retrospective cohort study was performed to identify referral patterns before and after the implementation of a low-dose computed tomography (LDCT) protocol and physician education to examine the intervention's impact on time to evaluation and radiation exposure. Six hundred sixty-nine patients with an abnormal head shape diagnosis at a single academic medical center between July 1, 2014 and December 1, 2019 were reviewed. Demographics, referral information, diagnostic testing, diagnoses, and timeline of clinical evaluation were recorded. Before and after the LDCT and physician education intervention, the average ages at initial specialist appointments were 8.82 and 7.75 months, respectively ( P = 0.125). Children referred after our intervention were less likely to have prereferral imaging than children referred prior (odds ratio: 0.59, CI: 0.39-0.91, P = 0.015). Average radiation exposure per patient before referral decreased from 14.66 mGy to 8.17 mGy ( P = 0.021). Prereferral imaging, referral by a non-pediatrician, and non-Caucasian race were associated with older age at the initial specialist appointment. Widespread craniofacial center adoption of an LDCT protocol and improved clinician knowledge may lead to a reduction in late referrals and radiation exposure in pediatric patients with an abnormal head shape diagnosis.

Engaging Physicians and Systems to Improve Hepatitis C Virus Testing in Baby Boomers.

Approximately three million people in the United States have been exposed to the hepatitis C virus (HCV), with two-thirds of these having chronic HCV infection. Baby boomers (those born 1945-1965) have nearly five times the prevalence of HCV infection compared with other age groups. Despite clinical practice guidelines that recommend HCV testing in baby boomers, the testing rates remain low. We developed and tested a multilevel intervention to increase orders for HCV testing that included integrated clinical decision support within the electronic health record (EHR) and a physician education session to improve HCV physician knowledge in one Florida academic health system. In the year prior to the intervention, test order rates for encounters with baby boomers was 11.9%. During the intervention period (August 2019-July 2020) for providers that viewed a best practice alert (BPA), the ordering increased to 59.2% in Family Medicine and 64.6% in Internal Medicine. The brief physician education intervention improved total HCV knowledge and increased self-efficacy in knowledge of HCV risk factors. These findings suggest that interventions at the system and physician levels hold promise for increasing HCV testing rates. Future studies are needed to evaluate this intervention in additional clinical settings and to test the benefit of adding additional intervention components that are directed at patients.

Sacrum magnetic resonance imaging for low back and tail bone pain: A quality initiative to evaluate and improve imaging utility.

As quality and cost effectiveness become essential in clinical practice, an evidence-based evaluation of the utility of imaging orders becomes an important consideration for radiology’s value in patient care. We report an institutional quality improvement project including a retrospective review of utility of sacrum magnetic resonance (MR) imaging for low back pain at our institution over a four-year period and follow-up results after physician education intervention. Sacral MR imaging for low back pain and tailbone pain were only positive for major findings in 2/98 (2%) cases, and no major changes in patient management related to imaging findings occurred over this period, resulting in almost $500000 cost without significant patient benefit. We distributed these results to the Family Medicine department and clinics that frequently placed this order. An approximately 83% drop in ordering rate occurred over the ensuing 3 mo follow-up period. Sacrum MR imaging for low back pain and tail bone pain has not been a cost-effective diagnostic tool at our institution. Physician education was a useful tool in reducing overutilization of this study, with a remarkable drop in such studies after sharing these findings with primary care physicians at the institution. In conclusion, sacrum MR imaging rarely elucidates the cause of low back/tail pain diagnosed in a primary care setting and is even less likely to result in major changes in management. The practice can be adopted in other institutions for the benefit of their patients and improve cost efficiency.

The effect of physician educational intervention on venous thromboembolism pharmacological prophylaxis in medical inpatients from the respiratory department: a retrospective cohort study.

Venous thromboembolism (VTE) is a serious health problem for which pharmacological prophylaxis has been proven to be effective. However, there are significant gaps between the guidelines and clinical practice. This study is to evaluate the effect of physician educational intervention (PEI) on VTE pharmacological prophylaxis in medical inpatients from the respiratory department. Medical inpatients from the respiratory department between February 2014 and December 2016 were recruited in this retrospective cohort study. They were assigned to the PEI group or the control group according to whether their physicians undertook a quality improvement (QI) project carried out in hospital to raise physician awareness of pharmacological thromboprophylaxis by educational intervention. Any and appropriate pharmacological VTE prophylaxis rates, the use of appropriate anticoagulants, and the occurrence of VTE events in the two groups were calculated and compared using a chi-square test and continuity correction. Poisson regression analysis was used to evaluate the relative risk (RR) of PEI on the occurrence of VTE events. The any pharmacological VTE prophylaxis rate (11.3% vs. 5.9%, P=0.048) and appropriate pharmacological VTE prophylaxis rate (9.3% vs. 5.5%, P=0.036) in high-risk patients without high major bleeding risk were both significantly higher than the control group. Compared with the control group, appropriate anticoagulants in the PEI group took up a larger proportion of all used anticoagulants (90.3% vs. 78.7%, P=0.007). In anticoagulants used for high-risk patients without high major bleeding, appropriate anticoagulants show no statistical difference between the two groups (93.8% vs. 77.8%, P=0.153). There was no difference in the occurrence of VTE events between the two study groups in overall patients (0.5% vs. 0.6%, P=0.913), and among those with high VTE risk (1.7% vs. 1.0%, P=0.554). PEI had no association with the probability of VTE event occurrence (RR, 1.246; 95% CI, 0.478-2.188, P=0.954). Educational intervention effectively increased physician awareness of VTE prophylaxis in the respiratory department. Further interventions are still necessary since the guidelines were implemented to a relatively low degree.

S0893 Evaluation of Interventions Intended to Increase Vaccination Rates in Inflammatory Bowel Disease: A Systematic Review

INTRODUCTION: Vaccinations in inflammatory bowel disease (IBD) patients are important to reduce the risk of opportunistic infections. Previous studies have shown that vaccination rates in IBD patients are suboptimal, despite guidelines by ACG and ECCO. We aimed to assess the different modalities currently studied to increase vaccination rates in IBD patients. METHODS: With the assistance of a medical librarian, two independent MEDLINE searches were conducted with search words and synonyms that included: “IBD”, “UC”, “Crohns”, “vaccinations”, and “prevention” between the years 1946 and 2020. We performed a systematic review according to the PRISMA guidelines. Inclusion criteria included patients with IBD ≥18 years old, prospective trials with interventions aimed to increase vaccinations or immunizations, and full-length publications in English. Data on population, setting, study design, and outcomes were extracted and synthesized. RESULTS: The searches retrieved 1,403 articles. Six articles met our inclusion criteria. Overall 2,828 patients and 83 gastroenterologists were studied in six countries (United States, Denmark, France, Belgium, UK, and Australia). All studies were completed in GI/IBD based clinics. Five out of the six studies were pre-post test interventions and one study was a RCT. Two of the studies were physician-oriented (i.e. one was an educational intervention and the other used a scribe to allow the GI more time with the patient). One study was solely patient-oriented (i.e., a survey). One study was mixed with both a patient and physician educational interventions and two studies were barrier-oriented with either infectious disease physician (ID) or an IBD nurse acting as a navigator. Five out of the six studies found that the largest increase was in pneumococcal vaccinations (PCV), with the greatest effect occurring in the ID navigation intervention, as PCV increased from 16% to 88% (P < 0.001). CONCLUSION: In our review, many different interventions have shown some degree of benefit in increasing vaccination rates in IBD patients. Similar to other studies in preventative medicine, it is possible that barrier-oriented interventions (i.e., navigation) may have the greatest effect in increasing vaccination rates in IBD, however future high-quality RCTs are needed.

Adherence to osteoporosis therapy after an upper extremity fracture: a pre-specified substudy of the C-STOP randomized controlled trial.

To compare the effectiveness of two interventions on long-term oralbisphosphonate adherence after an upper extremity fragility fracture. Community-dwelling participants 50years or older with upper extremity fragility fractures not previously treated with bisphosphonates were randomized to either a multi-faceted patient and physician educational intervention (the active control arm) vs. a nurse-led case manager (the study arm). Primary outcome was adherence (taking > 80% of prescribed doses) with prescribedoral bisphosphonates at 12months postfracture between groups; secondary outcomes included rates of primary non-adherence and 24-month adherence. We also compared quality of life between adherent and non-adherent patients. By 12months, adherence with the initially prescribed bisphosphonate was similar (p = 0.96) in both groups: 38/48 (79.2%) in the educational intervention group vs. 66/83 (79.5%) in the case manager arm. By 24months, adherence rates were 67% (32/48) in the educational intervention group vs. 53% (43/81) in case managed patients (p = 0.13). Primary non-adherence was 6% (11 patients) in the educational intervention group and 12% (21 patients) in the case managed group (p = 0.07). Prior family history of osteoporosis (aOR 2.1, 95% CI 1.0 to 4.4) and being satisfied with current medical care (aOR 2.3, 95% CI 1.1 to 4.8) were associated with better adherence while lower income (aOR 0.2, 95% CI 0.1 to 0.6, for patients with income < $30,000 per annum) was associated with poorer rates of adherence. There were no differences in health-related quality of life scores at baseline or during follow-up between patients who were adherent and those who were not. While both interventions achieved higher oral bisphosphonate adherence compared to previously reported adherence rates in the general population, primary non-adherence and long-term adherence to bisphosphonates were similar in both arms. Adherence was influenced by family history of osteoporosis, satisfaction with current medical care, and income. ClinicalTrials.gov : NCT01401556.

Correction: Antibiotic resistance rates and physician antibiotic prescription patterns of uncomplicated urinary tract infections in southern Chinese primary care.

[This corrects the article DOI: 10.1371/journal.pone.0177266.].

Effect of a Multimodal Educational Intervention on Use of Urinary Catheters in Hospitalized Individuals

Urinary catheters are frequently used in hospital inpatients despite their association with greater morbidity and mortality. Reducing their unnecessary use can improve patient care. The objective of the current study was to determine the effectiveness of a multimodal nursing and physician education intervention to reduce the unnecessary use of urinary catheters in adult inpatients. Quasi-experimental interrupted time series study. General internal medicine and surgical services of a large urban teaching hospital. Admissions to the services under study during the study period (September 2009 to February 2013) (N = 21,550). A multimodal educational intervention incorporating educational posters, small-group teaching sessions, and changes to the hospital's electronic health records and nursing clinical documentation systems were introduced to nurses and physicians. Mean catheter days per patient (CDPP) and incidence of urinary catheterization, measured at monthly intervals throughout the study period. A decrease in mean CDPP of 5.6 and 6.5 days (P < .001) respectively was observed on the medical and surgical services following the intervention. The monthly incidence of catheterization decreased by 3.0 percentage points on medical units and 6.4 percentage points on surgical units immediately after the intervention, from an average of 14.5% and 15.0%, respectively, before the intervention. Similar degrees of improvement were observed for individuals of all ages, although older adults remained more likely to be catheterized. The effect persisted over nearly 3 years of observed follow-up. A relatively simple multimodal educational intervention targeting nurses and physicians resulted in a significant and sustained reduction in CDPP and the proportion of participants catheterized.

Antibiotic resistance rates and physician antibiotic prescription patterns of uncomplicated urinary tract infections in southern Chinese primary care.

Uncomplicated urinary tract infections (UTI) are common in primary care. Whilst primary care physicians are called to be antimicrobial stewards, there is limited primary care antibiotic resistance surveillance and physician antibiotic prescription data available in southern Chinese primary care. The study aimed to investigate the antibiotic resistance rate and antibiotic prescription patterns in female patients with uncomplicated UTI. Factors associated with antibiotic resistance and prescription was explored. A prospective cohort study was conducted in 12 primary care group clinics in Hong Kong of patients presenting with symptoms of uncomplicated UTI from January 2012 to December 2013. Patients’ characteristics such as age, comorbidity, presenting symptoms and prior antibiotic use were recorded by physicians, as well as any empirical antibiotic prescription given at presentation. Urine samples were collected to test for antibiotic resistance of uropathogens. Univariate analysis was conducted to identify factors associated with antibiotic resistance and prescription. A total of 298 patients were included in the study. E. coli was detected in 107 (76%) out of the 141 positive urine samples. Antibiotic resistance rates of E. coli isolates for ampicillin, co-trimoxazole, ciprofloxacin, amoxicillin and nitrofurantoin were 59.8%, 31.8%, 23.4%, 1.9% and 0.9% respectively. E. coli isolates were sensitive to nitrofurantoin (98.1%) followed by amoxicillin (78.5%). The overall physician antibiotic prescription rate was 82.2%. Amoxicillin (39.6%) and nitrofurantoin (28.6%) were the most common prescribed antibiotics. Meanwhile, whilst physicians in public primary care prescribed more amoxicillin (OR: 2.84, 95% CI: 1.67 to 4.85, P<0.001) and nitrofurantoin (OR: 2.01, 95% CI: 1.14 to 3.55, P = 0.015), physicians in private clinics prescribed more cefuroxime and ciprofloxacin (P<0.05). Matching of antibiotic prescription and antibiotic sensitivity of E. coli isolates occurred in public than private primary care prescriptions (OR: 6.72, 95% CI: 2.07 to 21.80 P = 0.001) and for other uropathogens (OR: 6.19, 95% CI: 1.04 to 36.78 P = 0.034). Mismatching differences of antibiotic prescription and resistance were not evident. In conclusion, nitrofurantoin and amoxicillin should be used as first line antibiotic treatment for uncomplicated UTI. There were significant differences in antibiotic prescription patterns between public and private primary care. Public primary care practitioners were more likely to prescribe first line antibiotic treatment which match antibiotic sensitivity of E. coli isolates and other uropathogens. Further exploration of physician prescribing behaviour and educational interventions, particularly in private primary care may helpful. Meanwhile, development and dissemination of guidelines for primary care management of uncomplicated UTI as well as continued surveillance of antibiotic resistance and physician antibiotic prescription is recommended.

Cancer screening, patient characteristics, and shared decision making (SDM): A complicated equation.

164 Background: SDM may vary by patient and clinical decision. In a randomized trial of physician (MD) educational interventions to improve cancer screening guideline compliance, we studied patient (PT) and MD recall of discussions and factors that affected recall. Methods: In a cluster-randomized trial of educational supports for MDs, we are enrolling an age- (30-89 years) and sex-stratified sample of 216 PTs who underwent a physical examination at 2 urban hospitals, 18 for each of 12 primary care MDs. Screening guideline formatting (color-coding) and academic detailing were randomly assigned in a 2x2 design. Immediate post-encounter surveys recorded PT and MD recall of screening discussions. Results: The first 174 participants were diverse (63% white) and highly educated (77% college degree). PTs and MDs differed in recall of screening discussions, and the differences varied by screening test. When MDs reported a colorectal cancer (CRC) screening discussion, 21% of PTs did not; 20% of MDs disagreed when PTs reported the discussion. The discrepancies were greater for prostate specific antigen (PSA) screening, 29% and 29%, respectively, but much less for mammograms (MAM), 8% and 5%, respectively. Recall of the MD recommendation also differed: 15% of PTs disagreed when their MD reported it, and 33% of MDs when their PT reported it. For PSA, disagreement was 26% and 33%, respectively, and for MAM, disagreement was 17% and 10%, respectively. Overall, agreement between all PTs and MDs on whether screening was recommended was fair for CRC, PSA and MAM: kappa = 0.33, 0.34 and 0.29, respectively. Older PT age ( &gt; 70) sharply eroded agreement on recalled CRC and PSA recommendations (kappa = -0.02 and -0.03, respectively) but much higher for MAM (kappa = 0.39). Recall concordance improved when elements of SDM were recalled. For CRC, kappa rose from -0.12 to 0.52 if the MD recalled any MDM element. Conclusions: In a highly educated, diverse PT population, PTs and MDs surveyed immediately after their encounter often disagreed on what had occurred in screening discussions. Disagreement was greater for CRC and PSA vs. MAM, greater for older PTs but improved when SDM was recalled. Clinical trial information: NCT02430948.

Does shared decision making for PSA screening empower patients?

e549 Background: Participant characteristics affect shared decision making. In a randomized trial of physician (MD) educational interventions to improve cancer screening guideline compliance, we studied patient (PT) and MD recall of discussions and how PT characteristics affected recall. Methods: In a cluster-randomized trial of educational supports for MDs, we are enrolling an age- (30-89 years) and sex-stratified sample of 216 PTs who underwent a physical examination at two urban hospitals, 18 for each of 12 primary care MDs. Screening guideline formatting (color-coding) and academic detailing were randomly assigned in a 2x2 design. Immediate post-encounter surveys recorded PT and MD recall of screening discussions. Results: Of the first 174 participants, 92 were men. PTs were diverse (69% white) and well educated (73% college degree). When MDs reported a prostate specific antigen (PSA) screening discussion, 32% of PTs did not, and 26% of MDs disagreed when PTs reported the discussion occurred. Further, when the MD reported recommending screening, 26% of PTs disagreed, and 33% of MDs disagreed when their patients reported a recommendation. Overall, agreement between all PTs and MDs on whether screening was recommended was fair (kappa = 0.29) but there was no agreement for PTs over 70 years (kappa = -0.03). PTs reported more elements of shared decision making than MDs (data not shown). When both PT and MD or the MD alone reported that all elements of shared medical decision making had occurred, agreement on whether screening was recommended improved (kappa = 0.54 and 0.45, respectively). When PTs disagreed with their MD, they more often reported recommending for screening not against (11 vs. 4). Conclusions: In a highly educated, diverse PT population, PTs and MDs surveyed immediately after their encounter often disagreed on whether PSA screening was discussed and recommended. Disagreement was worse with older PT age but improved when both PT and MD or the MD alone reported all shared decision making elements. Clinical trial information: NCT02430948.

Do patients and doctors have the same conversation about colorectal cancer screening?

532 Background: Participant characteristics affect shared decision making. In a randomized trial of physician (MD) educational interventions to improve cancer screening guideline compliance, we studied patient (PT) and MD recall of discussions and how PT characteristics affected recall. We report the first results for colorectal cancer screening. Methods: In a cluster-randomized trial of educational supports for MDs, we are enrolling an age- (30-89 years) and sex-stratified sample of 216 PTs who underwent a physical examination at two urban hospitals, 18 for each of 12 primary care MDs. Screening guideline formatting (color-coding) and academic detailing were randomly assigned to MDs in a 2x2 design. Immediate post-encounter surveys recorded PT and MD recall of screening discussions and recommendations. Results: We report on the first 174 participants. They were diverse (63% white) and well educated (77% college degree). When MDs reported a colorectal screening discussion, 20% of PTs did not, and MDs had similar disagreement when PTs reported the discussion. Greater disagreement occurred on the MD recommendation: 15% of PTs disagreed when the MD reported screening was recommended, and 33% of MDs disagreed when their patients reported they had recommended it. Agreement between PTs and MDs on whether screening was recommended was fair (kappa = 0.33), and there was no agreement for PTs over 70 years (kappa = -0.15). When PTs under 50 or 75 and older differed from their MDs on screening recommendations, it was for screening not against (8 vs. 2). PTs reported more elements of shared decision making than MDs (data not shown). Conclusions: In a highly educated population of PTs and MDs surveyed immediately after their encounter, reports of whether colorectal screening was discussed, the shared decision making elements and the MD recommendation had important discrepancies, especially for older PTs. Clinical trial information: NCT02430948.

Deprescription: The prescription metabolism.

Deprescribing is a structured approach to drug discontinuation. An alternative suggested term is “prescription metabolism.” The major aim of deprescription is to purge the drug(s) considered unwanted in a given patient, especially in the elderly patients with multiple comorbidities or in those suffering from chronic disease. Like drug metabolism, prescription metabolism is a way of eliminating unwanted, troublesome, or cost-ineffective medications. The removal of such drugs has been found to decrease the incidence of adverse drug reactions and improves the rate of medication adherence, thereby reducing the economic burden on the patient as well as on the health care providers. Certain categories of drugs are to be tapered rather than abruptly stopped. Despite the availability of many tools to minimize drug therapy-related problems, there is little guidance for the process of deprescribing in general clinical practice. Various methods to reduce the risks of polypharmacy include patient education, physician education, and regulatory intervention. The suggested S and S approach (seek and screen, save and severe, sensitize and supervise) may be tried for deprescribing in general practice. More research on deprescribing is the need of the hour in almost all branches of clinical medicine which may pave the way for the betterment of health care.

EMR documentation of physician-patient communication following genomic counseling for actionable complex disease and pharmacogenomic results.

Genomic risk information for potentially actionable complex diseases and pharmacogenomics communicated through genomic counseling (GC) may motivate physicians and patients to take preventive actions. The Ohio State University-Coriell Personalized Medicine Collaborative is a randomized trial to measure the effects of in-person GC on chronic disease patients provided with multiplex results. Nine personalized genomic risk reports were provided to patients through a web portal, and to physicians via electronic medical record (EMR). Active arm participants (98, 39% female) received GC within 1 month of report viewing; control arm subjects (101, 54% female) could access counseling 3-months post-report viewing. We examined whether GC affected documentation of physician-patient communication by reviewing the first clinical note following the patient's GC visit or report upload to the EMR. Multivariable logistic regression modeling estimated the independent effect of GC on physician-patient communication, as intention to treat (ITT) and per protocol (PP), adjusted for physician educational intervention. Counselees in the active arm had more physician-patient communications than control subjects [ITT, odds ratio (OR): 3.76 (95% confidence interval (CI): 1.38-10.22, p < 0.0094); PP, OR: 5.53 (95% CI: 2.20-13.90, p = 0.0017). In conclusion, GC appreciably affected physician-patient communication following receipt of potentially actionable genomic risk information.

Relationships between family physicians' referral for palliative radiotherapy, knowledge of indications for radiotherapy, and prior training: a survey of rural and urban family physicians.

BackgroundThe primary objective of this research was to assess the relationship between FPs’ knowledge of palliative radiotherapy (RT) and referral for palliative RT.Methods1001 surveys were sent to FPs who work in urban, suburban, and rural practices. Respondents were tested on their knowledge of palliative radiotherapy effectiveness and asked to report their self-assessed knowledge.ResultsThe response rate was 33%. FPs mean score testing their knowledge of palliative radiotherapy effectiveness was 68% (SD = 26%). The majority of FPs correctly identified that painful bone metastases (91%), airway obstruction (77%), painful local disease (85%), brain metastases (76%) and spinal cord compression (79%) can be effectively treated with RT, though few were aware that hemoptysis (42%) and hematuria (31%) can be effectively treated. There was a linear relationship between increasing involvement in palliative care and both self-assessed (p < 0.001) and tested (p = 0.02) knowledge. FPs had higher mean knowledge scores if they received post-MD training in palliative care (12% higher; p < 0.001) or radiotherapy (15% higher; p = 0.002). There was a strong relationship between FPs referral for palliative radiotherapy and both self-assessed knowledge (p < 0.001) and tested knowledge (p = 0.01).ConclusionsSelf-assessed and tested knowledge of palliative RT is positively associated with referral for palliative RT. Since palliative RT is underutilized, further research is needed to assess whether family physician educational interventions improve palliative RT referrals. The current study suggests that studies could target family physicians already in practice, with educational interventions focusing on hemostatic and other less commonly known indications for palliative RT.

Abstract 2722: Anti-hypertensive Treatment Prolongs tPA Door-to-treatment Time: Secondary Analysis Of The Increasing Stroke Treatment Through Interventional Behavior Change Tactics (INSTINCT) Trial.

Background/Purpose: Increased time to tPA treatment is associated with worse outcomes. Thus, identifying modifiable treatment delays may improve stroke outcomes. We hypothesized that pre-thrombolytic anti-hypertensive treatment (AHT) may prolong door to treatment time (DTT). Methods: Secondary data analysis of consecutive tPA-treated patients at 24 randomly selected Michigan community hospitals in the INSTINCT trial. DTT among stroke patients who received pre-thrombolytic AHT were compared to those that did not receive pre-thrombolytic AHT. We then calculated a propensity score for the probability of receiving pre-thrombolytic AHT using a logistic regression model with covariates including demographics, stroke risk factors, antiplatelet or beta blocker as home medication, stroke severity (NIHSS), onset to door time, admission glucose, pretreatment systolic and diastolic blood pressure, EMS usage and location at time of stroke. A paired t-test was then performed to compare the DTT between the propensity matched groups. A separate generalized estimating equations (GEE) approach was also used to estimate the differences between patients receiving pre-thrombolytic AHT and those that did not while accounting for within hospital clustering. Results: A total of 557 patients were included in INSTINCT, however onset, arrival or treatment times were not able to be determined in 23, leaving 534 patients for this analysis. The unmatched cohort consisted of 95 stroke patients who received pre-thrombolytic AHT and 439 stroke patients who did not receive AHT from 2007-2010 ( table ). In the unmatched cohort, patients who received pre-thrombolytic AHT had a longer DTT (mean increase 9 minutes; 95% confidence interval (CI) 2-16 minutes) than patients who did not receive pre-thrombolytic AHT. After propensity matching (table), patients who received pre-thrombolytic AHT had a longer DTT (mean increase 10.4 minutes, 95% CI 1.9 - 18.8) than patients who did not receive pre-thrombolytic AHT. This effect persisted and its magnitude was not altered by accounting for clustering within hospitals. Conclusion: Pre-thrombolytic AHT is associated with modest delays in DTT. This represents a feasible target for physician educational interventions and quality improvement initiatives. Further research evaluating optimum hypertension management pre-thrombolytic treatment is warranted.

Physician Champions Are Key to Improving Antibiotic Prescribing Quality

The previously reported IMPAACT study was a cluster randomized controlled trial of a patient and physician educational intervention designed to reduce antibiotic prescribing for acute respiratory tract infections (ARIs) in emergency departments (EDs) in the United States. On average, the intervention resulted in a modest improvement in antibiotic prescribing behavior at the end of Year 1 and further improvement after Year 2. Yet the intervention's impact was large at some sites but minimal or even negative at others. A study was undertaken to identify organizational factors that influenced the effectiveness (Organizational Effect Modifiers [OEMs]) of the intervention. Focus groups of nurses and ED staff and semistructured interviews of local project leaders, nurse managers, and quality improvement (QI) officers were performed at seven EDs across the United States. Effectiveness of the local project leader, institutional emphasis on patient satisfaction ratings, and institutional history with and approach to QI were initially identified as key potential OEMs. Two investigators independently read the transcripts for each site and, using prespecified rating scales, rated the presence of each OEM. The perceived effectiveness of the local project leader was most strongly linked to the effectiveness of the intervention. Perceived institutional emphasis on patient satisfaction and institutional history of and approach to QI (top down or bottom up) did not appear to be closely linked with intervention effectiveness. An effective local leader to serve as a physician champion was key to the success of this project. Organizational factors modify the effectiveness of QI interventions targeting individual physician performance and should be addressed during program implementation.

Antibiotic Prescriptions Are Associated with Increased Patient Satisfaction With Emergency Department Visits for Acute Respiratory Tract Infections

Health care providers cite patient satisfaction as a common reason for prescribing antibiotics for viral acute upper respiratory infections (URIs), even though quality performance measures emphasize nonantibiotic treatment for these conditions. In a secondary analysis of a cluster-randomized trial to test a combined patient and physician educational intervention to reduce antibiotic prescribing for URIs, the authors examined whether satisfaction is greater among patients diagnosed with URIs who are prescribed antibiotics in emergency department (ED) settings. This was a follow-up telephone survey of 959 patients who received care for acute respiratory infections at any of eight Veterans Administration (VA) hospital EDs or eight location-matched non-VA hospital EDs around the United States. Patients reported their satisfaction with the amount of time spent in the ED, the explanation of treatment, the provider treatment, and overall satisfaction on a five-point Likert scale. The primary measure of effect was the association between antibiotic prescription and visit satisfaction, adjusted for patient and visit characteristics. Antibiotic treatment was significantly associated with increased overall visit satisfaction in non-VA EDs (adjusted odds ratio [OR] = 1.97, 95% confidence interval [CI] = 1.23 to 3.17), but not VA EDs (adjusted OR = 1.13, 95% CI = 0.81 to 1.58). Patients managed in non-VA EDs who received antibiotics were also significantly more likely to be satisfied with the explanation of treatment and the manner in which they were treated by the provider. Antibiotic prescriptions are associated with increased overall patient satisfaction in non-VA, but not VA, ED visits for URIs. Continued efforts to reduce unnecessary prescriptions in these settings must address ways to maintain patient satisfaction and still reduce antibiotic prescriptions.

Improving on Our Goal to Reduce NSAID-Induced GI Complications: A Challenging Task?

A large number of at-risk patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs) do not receive prophylaxis for gastrointestinal (GI) complications. The combination of a 10-min physician educational intervention and a computer alert has been proved to increase the rate of prescribing gastroprotective therapy for high-risk patients who receive ulcerogenic drugs at hospital discharge from 45% to 67%. This improvement is remarkable; still, more than 30% of these high-risk patients did not receive appropriate therapy. Considering that most patients who receive NSAIDs are outpatients treated by generalists, and considering that adherence may be poor and self-medication with NSAIDs is common among patients with GI risk factors, closing the gap between patients treated with NSAIDs who do and do not receive adequate GI prophylaxis is a challenging endeavor. In order to more effectively pursue this goal, we will need to develop new and more complex approaches.

Detection of Intimate Partner Violence in a General Medicine Practice

In this study, an assessment phase is undertaken to determine intimate partner violence (IPV) prevalence. An anonymous survey is followed by a chart review documenting identification of IPV. Two methods are attempted to increase assessment/documentation of IPV: a physician educational intervention and a nursing routine inquiry intervention in one quadrant of the practice. The IPV physician educational intervention includes didactic sessions, an IPV counselor, and resource information. The routine inquiry intervention involves nurses screening female patients for IPV at check-in. IPV is found to be prevalent in a general medicine clinic. An enhanced educational intervention does not increase IPV documentation. A routine inquiry intervention significantly increases documentation of lifetime IPV but does not impact current IPV identification.