Provider Adherence Research Articles

Abstract 35: Age, Gender And Race Bias In Provider Adherence To The 2018 AHA/ACC Cholesterol Guidelines: A Single-Center Retrospective Cohort Analysis

Background: Cholesterol treatment is central to cardiovascular risk reduction, but disparities in management may exist. Our hypothesis is that demographic factors may predict guideline adherence. Methods: This retrospective cohort analysis included patients seen at an urban academic medical center between November 2018 to March 2021. Patient and provider demographics, cardiovascular comorbidities, and lab values were examined to determine if provider adherence to the 2018 AHA/ACC cholesterol guidelines demonstrated bias by age, gender, or race. Logistic models were estimated via generalized estimating equations to account for clustering by patient and provider and used to calculate odds ratios (OR), confidence intervals, and p-values. Results: 24,733 lipid panels were obtained from patients with mean age 57.8 ± 15.6, BMI 29.4 ± 6.8, 56.9% female, 44.2% White, 42.1% Black, 6.8% Asian, 6.8% Other, 26.5% tobacco use, 12.7% ASCVD, 51.1% hypertension, 21.1% diabetes. Significant adjusted OR for appropriate treatment was 0.91 (p<0.001) for each 1-year increase in age, 2.2 (p<0.001) for female, 0.88 (p=0.02) for Black relative to White, 1.36 (p=0.003) for Asian relative to White, 0.73 (p<0.001) for BMI>40 relative to BMI<25. Providers had mean age 51.1 ± 12.2, 60.5%female, 73.2% White, 6.9% Black, 18.6% Asian, 1.3% Other. On univariate analysis, OR for appropriate statin prescription were 0.82 (p=0.016) for provider-patient race discordance; 0.90 (p=0.251) for gender discordance, 0.34 (p<0.001) if provider age 10+ years younger than the patient, and 4.72 (p<0.001) if provider age 10+ years older. On multivariate analysis adjusted for clinical risk factors, none of these OR for patient-provider discordance were significantly different from 1: race 1.06 (p=0.42), gender 0.96 (p=0.34), provider 10+ years younger 1.05 (p=0.61), provider 10+ years older 0.91 (p=0.32). Conclusion: In this analysis, Black, male, morbidly obese and older patients were less likely to receive appropriate statin therapy. However, there was no evidence that inappropriate treatment was associated with patient-provider age, gender, or race discordance. Further investigation is needed to guide targeted interventions aimed at addressing these inequities.

Improving Stewardship of Clostridioides difficile Testing with EMR and Provider Phone Calls.

IntroductionModern laboratory techniques cannot differentiate between Clostridium difficile colonization and infection; therefore, testing must be indicated clinically. To reduce hospital-onset of C. difficile infections (HO-CDI), Ascension Via Christi Hospitals (AVCH) in Wichita intervened in three stages by introducing: 1) a C. diflcile testing algorithm; 2) an electronic medical record (EMR)-based decision support system to enforce said algorithm; and 3) phone calls from the infection prevention department to providers to discontinue tests not collected within 24 hours of the order. The goal of this study was to determine if these interventions improved the HO-CDI rate.MethodsAt AVCH, the three study periods were compared: baseline with algorithm training only, the EMR intervention, and the EMR intervention with additional phone calls (EMR with phone calls). Data were abstracted from the hospital EMR.ResultsA total of 311 charts were reviewed. Adherence to the algorithm increased from 34% at baseline to 52% after the EMR intervention (p = 0.010). During the EMR with phone calls period, more tests were discontinued (87%; n = 39) compared to baseline (54%; n = 15) and EMR (54%; n = 15; p = 0.003). The HO-CDI rate ranged from 8.5 cases per 10,000 patient-days at baseline, to 7.9 during EMR, to 4.0 during EMR with phone calls (p = 0.007).ConclusionsThe EMR and EMR with phone call interventions were associated with a significant decrease in the HO-CDI rate and an increase in provider adherence to the algorithm.

Evaluation of Posttraumatic Stress Disorder and Acute Stress Disorder VA/DoD Clinical Practice Guidelines Training.

This study evaluated the use of an online learning platform [Joint Knowledge Online (JKO)] for dissemination of the Veterans Affairs and Department of Defense Clinical Practice Guidelines for Management of Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD). User satisfaction with the training program was assessed, users were asked to estimate their knowledge base about PTSD and ASD, and users provided comments about how they might use the course material in their clinical practice. A total of 4,442 users took at least one of three courses offered via JKO related to the PTSD Clinical Practice Guidelines (CPG) between July 1, 2019 and June 25, 2020. A total of 1,663 users took the post-test after the JKO courses and 235 applied to a second website (J7) which granted Continuing Education (CE) credits. Data were gathered from the JKO post-course survey, as well as the J7 course survey, which also asked for respondents' written comments. User satisfaction was analyzed using the JKO survey Likert scale data for each course, and results found most users rated the courses as "good" or "great." Users were also asked to evaluate their knowledge about PTSD management before and after the course. Results from all three courses showed a statistically significant change in pre-post knowledge with a medium effect size. Thematic analysis was performed on the write-in comments from each course. Comments indicated participants found the assessment tools provided in the courses to be of particular value. The VA/DoD's online learning platform (JKO) was a user-friendly, effective tool for training users on PTSD and ASD clinical practice guidelines. Users were satisfied with their experience of the trainings on JKO and improved their knowledge base about the CPG. This study did not evaluate patient data for CPG compliance, but the future study may benefit from these outcomes to demonstrate provider adherence to the guidelines.

353 MFM Provider Adherence to USPSTF Low Dose Aspirin Guidelines for Preeclampsia Prevention in Nulliparous Patients

OBJECTIVES/GOALS: Recent studies suggest nulliparous patients benefit from low dose aspirin (LDA), yet there are limited studies examining MFM providers adherence to USPSTF guidelines and predictors of adherence. We identified demographic, obstetric, and clinical characteristics associated with guideline concordant counseling on LDA in nulliparous women. METHODS/STUDY POPULATION: Retrospective cohort study of pregnant nulliparous patients who received MFM prenatal care at a single tertiary center (1/1/2019-6/30/2020). Multiple gestations, > 2 spontaneous or therapeutic abortions, and contraindications to LDA were excluded. Maternal demographic and clinical characteristics were abstracted from the electronic medical record. The primary outcome was documented LDA counseling based on USPSTF guidelines. Data were analyzed using bivariate analysis and logistic regression using R 4.1.0 (R Core Team, 2021). RESULTS/ANTICIPATED RESULTS: Among 394 records in the analysis cohort, 316 met USPSTF guidelines for LDA. 164 (51.9%) meeting guidelines had documented LDA counseling. 67.4% of individuals with ?1 major USPSTF risk factors were counseled and 50.7% with ?2 moderate risk factors were counseled (Table 1). Age at the estimated due date (EDD), Black or Other race, chronic hypertension, and obesity are significantly associated with higher odds of aspirin counseling (Table 2). Patients with chronic hypertension had 4.15 higher odds of receiving low dose aspirin counseling compared to non-hypertensive patient (Table 2). DISCUSSION/SIGNIFICANCE: Our results suggest that only 51.9% of patients eligible for LDA received counseling despite MFM care. Increasing MFM provider awareness about the USPSTF guidelines and creating tools that facilitate guideline concordant counseling may increase the number of eligible patients who are counseled about LDA.

Provider adherence to training components from the Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) intervention

BackgroundThe Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) was a cluster randomized clinical trial evaluating a multicomponent program to improve infection management among residents with advanced dementia. This report examines facility and provider characteristics associated with greater adherence to training components of the TRAIN-AD intervention. MethodsLogistic regression was used to identify facility and provider characteristics associated with: 1. Training seminar attendance, 2. Online course completion, and 3. Overall adherence, defined as participation in neither seminar nor course, either seminar or course, or both seminar and course. ResultsAmong 380 participating providers (nurses, N = 298; prescribing providers, N = 82) almost all (93%) participated in at least one training activity. Being a nurse was associated with higher likelihood of any seminar attendance (adjusted odds ratio (AOR) 5.37; 95% confidence interval (CI), 2.80–10.90). Providers who were in facilities when implementation begun (AOR, 3.01; 95% CI, 1.34–6.78) and in facilities with better quality ratings (AOR, 2.70; 95% CI, 1.59–4.57) were more likely to complete the online course. Prevalent participation (AOR, 2.01; 95% CI, 1.02–3.96) and higher facility quality (AOR, 2.44; 95% CI, 1.27–4.66) were also significantly associated with greater adherence to either seminar or online course. ConclusionTRAIN-AD demonstrates feasibility in achieving high participation among nursing home providers in intervention training activities. Findings also suggest opportunities to maximize adherence, such as enhancing training efforts in lower quality facilities and targeting of providers who join the facility after implementation start-up.

Intraoperative opioid and analgesic adjuvant administration practice patterns following implementation of an enhanced recovery after surgery protocol for laparoscopic donor nephrectomy

Study objectiveThe primary aim of this study is to understand how intraoperative medication administration patterns change in response to ERAS® protocol implementation for patients who underwent laparoscopic donor nephrectomy. DesignSingle-center, retrospective analysis of laparoscopic donor nephrectomy patients. SettingLarge tertiary academic medical center. PatientsWe divided all cases of laparoscopic donor nephrectomies (n = 929) over seven years into three approximately equal time periods: Pre-ERAS 1 (n = 317), Pre-ERAS 2 (n = 297) and Post-ERAS (n = 315). MeasurementsWe examined patient demographics, intraoperative opioid and non-opioid pain adjuvant administration, Post Anesthesia Recovery Unit (PACU) pain scores and opioid use as well as PACU and hospital lengths of stay (LOS). Main resultsSegmented regression analysis of interrupted time series was utilized to evaluate the association of ERAS protocol implementation with the amount of intraoperative opioid and non-opioid pain adjuvant use. In adherence to our institutional ERAS protocol, there was a significant reduction in intraoperative fentanyl use after ERAS protocol of −70.2μg (95% CI -106.0, −34.2, p < 0.001) and a significant increase in intraoperative hydromorphone use of 0.47 mg (95% CI 0.284, 0.655, p < 0.001). However, in contrary to our ERAS protocol, we found no significant change in odds of receiving IV acetaminophen OR 1.31 (95% CI 0.450, 3.76, p = 0.613) or IV ketorolac OR 1.65 (95% CI 0.804, 3.41, p = 0.172) after ERAS protocol implementation. We found a significant reduction in PACU opioid use of −9.68 Morphine Milligram Equivalents (MME) (95% CI -17.1, −2.31, p = 0.010) but no significant change in PACU initial pain score, PACU LOS and hospital LOS. ConclusionsWe examined intraoperative practice pattern changes by anesthesiologists in response to ERAS protocol implementation for laparoscopic donor nephrectomies. Our results suggest that there was a variable uptake of recommendations from ERAS protocol. While ERAS protocols are often studied as a bundle of best practice recommendations, understanding the variability of provider adherence represents an important future research direction for the ERAS initiative.

Implementation of a Postpartum Note Reminder and Factors Associated with Postpartum Glucose Tolerance Screening.

Although reminder systems are used to increase provider adherence, we are not aware of any real-time reminder systems for provider adherence to postpartum glucose tolerance testing. We studied whether a reminder in the electronic medical records affects provider ordering of a postpartum glucose tolerance test. We also studied whether any demographic, medical history, prenatal, or delivery variables are associated with patient attendance to a postpartum visit and patient completion of the postpartum glucose tolerance test when ordered. This was a retrospective study of 246 women diagnosed as having gestational diabetes mellitus who completed prenatal care and delivered at a suburban public safety-net hospital. Implementation of the real-time postpartum note reminder system significantly improved provider adherence to postpartum glucose screening recommendations from 58.1% to 75.0% (P = 0.01). Delivery complications were significantly associated with increased odds for postpartum visit attendance (odds ratio [OR] 3.80, 95% confidence interval [CI] 1.63-8.86, P < 0.01). Increased gestational age at first prenatal visit was significantly associated with decreased odds for postpartum visit attendance (OR 0.93, 95% CI 0.87-0.99, P < 0.05). Speaking Spanish was associated with an increased odds for completion of the postpartum glucose tolerance test when ordered (OR 2.88, 95% CI 1.24-6.70, P = 0.01). We recommend that hospital managers include a reminder system in the electronic medical record. Providers should focus counseling on the potential future risks to the mother, in addition to encouraging continued adherence to postpartum care. Providers also should counsel those who present later to prenatal care about the importance of obtaining postpartum glucose tolerance tests.

Impact of a Vendor-Developed Opioid Clinical Decision Support Intervention on Adherence to Prescribing Guidelines, Opioid Prescribing, and Rates of Opioid-Related Encounters.

Provider prescribing practices contribute to an excess of opioid-related deaths in the United States. Clinical guidelines exist to assist providers with improving prescribing practices and promoting patient safety. Clinical decision support systems (CDSS) may promote adherence to these guidelines and improve prescribing practices. The aim of this project was to improve opioid guideline adherence, prescribing practices, and rates of opioid-related encounters through the implementation of an opioid CDSS. A vendor-developed, provider-targeted CDSS package was implemented in a multi-location academic health center. An interrupted time-series analysis was performed, evaluating 30 weeks pre- and post-implementation time periods. Outcomes were derived from vendor-supplied key performance indicators and directly from the electronic health record (EHR) database. Opioid-prescribing outcomes included count of opioid prescriptions, morphine milligram equivalents per prescription, counts of opioids with concurrent benzodiazepines, and counts of short-acting opioids in opioid-naïve patients. Encounter outcomes included rates of encounters for opioid abuse and dependence and rates of encounters for opioid poisoning and overdose. Guideline adherence outcomes included rates of provision of naloxone and documentation of opioid treatment agreements. The opioid CDSS generated an average of 1,637 alerts per week. Rates of provision of naloxone and opioid treatment agreements improved after CDSS implementation. Vendor-supplied prescribing outcomes were consistent with prescribing outcomes derived directly from the EHR, but all prescribing and encounter outcomes were unchanged. A vendor-developed, provider-targeted opioid CDSS did not improve opioid-prescribing practices or rates of opioid-related encounters. The CDSS improved some measures of provider adherence to opioid-prescribing guidelines. Further work is needed to determine the optimal configuration of opioid CDSS so that opioid-prescribing patterns are appropriately modified and encounter outcomes are improved.

Adherence to goal-directed therapy for patients with cirrhosis hospitalized with spontaneous bacterial peritonitis.

The American Association for the Study of Liver Diseases has developed a standard of care for the treatment of patients with spontaneous bacterial peritonitis (SBP). Evidence examining the adherence rate to these guideline recommendations is limited. This study aimed to determine the adherence rate to guideline-directed therapy for patients with cirrhosis hospitalized with SBP. This institutional review board-approved retrospective cohort study conducted at a large academic hospital evaluated the adherence rate to guideline-directed therapy in adult patients with cirrhosis hospitalized with SBP. Included hospitalized patients had a documented diagnosis of cirrhosis and acute SBP. The adherence rate to guideline-directed therapy was determined by receipt of paracentesis within 24 hours of admission, request of Gram stain and culture tests, avoidance of fresh frozen plasma, receipt of albumin on days 1 and 3, receipt of empiric antibiotics within 6 hours, receipt of SBP prophylaxis, receipt of deep vein thrombosis prophylaxis, and offer of pneumococcal vaccination. A total of 110 patients were included. Provider adherence to goal-directed therapy was poor, with criteria met for only 10 (9.1%) patients. The therapies with the lowest adherence rates included SBP prophylaxis on discharge (54.5%), receipt of albumin on day 3 (42.7%), and offer of pneumococcal vaccination during admission (43.6%). Patients with a gastrointestinal consult were more likely than those without a consult to obtain albumin on day 1 (69.4% vs 36.8%, P = 0.001) and albumin on day 3 (52.8% vs 23.7%, P = 0.004). This study demonstrated a lack of adherence to guideline-directed therapy for the management of SBP.

Misbeliefs about non-specific low back pain and attitudes towards treatment by primary care providers in Spain: a qualitative study

AimTo identify misbeliefs about the origin and meaning of non-specific chronic low back pain and to examine attitudes towards treatment by primary health care providers.DesignGeneric qualitative study.MethodsTen semi-structured interviews were conducted between October and November 2016 with physicians and nurses from primary health care centres in Lleida. The interviews were transcribed and analysed using inductive thematic analysis via Atlas.ti-8 software.ResultsFive themes were identified: i. beliefs about the origin and meaning of chronic low back pain, ii. psychosocial aspects of pain modulators, iii. Therapeutic exercise as a treatment for chronic low back pain, iv. biomedical attitudes of primary health care providers, and v. difficulties in the clinical approach to chronic low back pain.ConclusionPrimary health care providers have a unifactorial view of chronic low back pain and base their approach on the biomedical model. Professionals attribute chronic low back pain to structural alterations in the lumbar spine while psychosocial factors are only recognized as pain modulators. For professionals, therapeutic exercise represents a possible solution to chronic low back pain; however, they still do not prescribe it and continue to educate on postural hygiene and recommend limiting physical and/or occupational activities, as opposed to clinical practice guidelines. These findings suggest that to improve the adherence of primary health care providers to the biopsychosocial model, it may be necessary first to modify their misbeliefs about non-specific chronic low back pain by increasing their knowledge on pain neurophysiology.Trial registrationClinicalTrials.gov Identifier: NCT02962817. Date of registration: 11/11/2016.

Creation and content validity of a scale for assessing adherence to good practices for COVID-19.

to create a scale for assessing the adherence of healthcare providers to good practices for COVID-19 in the hospital setting and determine its content and face validity. A methodological study was developed in three sequential phases: creation of items and domains based on a literature review and administration of the questionnaire to 16 nursing professionals; assessment of content and face validity by experts; and semantic analysis. The 51-item scale was submitted to the evaluation of seven experts. Items with a content validity index ≥ 0.83 were maintained. During the semantic analysis performed by the administration of the scale to 37 healthcare providers, no suggestions for changes were made and the comprehension rate was 87%. the 47-item instrument with three dimensions (personal, organizational, and psychosocial) achieved satisfactory content and face validity, meeting the parameters established in the literature.

The Quality of Primary Care in Cambodia: An Assessment of Knowledge and Effort of Public Sector Maternal and Child Care Providers

ABSTRACT Improving the quality of primary care is essential for achieving universal health coverage in low- and middle-income countries. This study examined the level and variation in primary care provider knowledge and effort in Cambodia, using cross-sectional data collected in 2014–2015 from public sector health centers in nine provinces. The data included clinical vignettes and direct observations of processes of antenatal care, postnatal care, and well-child visits and covered between 290–495 health centers and 370–847 individual providers for each service and type of data. The results indicate that provider knowledge and observed effort were generally low and varied across health centers and across individual providers. In addition, providers’ effort scores were generally lower than their knowledge scores, indicating the presence of a “know-do gap.” Although higher provider knowledge was correlated with higher levels of effort during patient encounters, knowledge only explained a limited fraction of the provider-level variation in effort. Due to low baseline performance and the know-do gap, improving provider adherence to clinical guidelines through training and practice standardization alone may have limited impact. Overall, the findings suggest that raising the low quality of care provided by Cambodia’s public sector will require multidimensional interventions that involve training, strategies that increase provider motivation, and improved health center management. The authors reported there is no funding associated with the work presented in this article.

Provider Adherence to Malaria Test, Treat and Track Policy in the Binduri District of the Upper East Region of Ghana

Provider Adherence to Malaria Test, Treat and Track Policy in the Binduri District of the Upper East Region of Ghana

Provider Adherence to Aspirin Prophylaxis Prescription Guidelines for Preeclampsia Prevention - A Quality Improvement Project

Preeclampsia affects 2-8% of pregnancies leading to significant maternal and neonatal morbidity and mortality. The Society for Maternal-Fetal Medicine supports the use of low dose aspirin for the prevention of preeclampsia in women at risk. The aim of this study was to evaluate provider adherence to aspirin prophylaxis prescription guidelines for women at risk.

Academic detailing interventions for opioid-related outcomes: a scoping review.

BackgroundAcademic detailing (AD) is a tailored, interactive educational outreach intervention that may improve patient outcomes. Insight into the design of AD interventions and the extent to which they are effective can help inform future AD-based programmes. The objective of this scoping review was to characterize opioid-focused AD interventions and describe their findings.MethodsA scoping review focused on AD interventions for opioids was conducted in PubMed, EMBASE and CINAHL databases through July 1, 2021. Studies were eligible for inclusion if written in English, included interactive opioid-focused educational interventions, and were conducted either in person, virtually or via telephone. Four independent reviewers reviewed titles and abstracts. Data extraction from full-text publications was completed using a standardized form.ResultsOf 6086 articles initially identified, 22 articles met the inclusion criteria and 20 unique interventions were identified. The AD intervention was either delivered one-on-one (n=16) or in a small, interactive group setting (n=4). AD interventions varied in design. Effectiveness was evaluated in terms of opioid and naloxone prescribing rates, provider knowledge gaps, provider adherence to guidelines, and intervention feasibility. Sixteen (80%) interventions resulted in statistically significant improvement in one or more outcomes.ConclusionGenerally, opioid-related AD was effective and programmes were primarily conducted one-on-one between pharmacists and primary care providers for 16–30 minutes. A variety of metrics and outcomes were used to assess the success/effectiveness of AD interventions, which is an important consideration in future studies as no single metric captures the effectiveness of an educational outreach-based intervention for pain management.

Leveraging Clinical Informatics Tools to Extract Cumulative Anthracycline Exposure, Measure Cardiovascular Outcomes, and Assess Guideline Adherence for Children With Cancer.

Cardiovascular disease is a significant cause of late morbidity and mortality in survivors of childhood cancer. Clinical informatics tools could enhance provider adherence to echocardiogram guidelines for early detection of late-onset cardiomyopathy. Cancer registry data were linked to electronic health record data. Structured query language facilitated the construction of anthracycline-exposed cohorts at a single institution. Primary outcomes included the data quality from automatic anthracycline extraction, sensitivity of International Classification of Disease coding for heart failure, and adherence to echocardiogram guideline recommendations. The final analytic cohort included 385 pediatric oncology patients diagnosed between July 1, 2013, and December 31, 2018, among whom 194 were classified as no anthracycline exposure, 143 had low anthracycline exposure (< 250 mg/m2), and 48 had high anthracycline exposure (≥ 250 mg/m2). Manual review of anthracycline exposure was highly concordant (95%) with the automatic extraction. Among the unexposed group, 15% had an anthracycline administered at an outside institution not captured by standard query language coding. Manual review of echocardiogram parameters and clinic notes yielded a sensitivity of 75%, specificity of 98%, and positive predictive value of 68% for International Classification of Disease coding of heart failure. For patients with anthracycline exposure, 78.5% (n = 62) were adherent to guideline recommendations for echocardiogram surveillance. There were significant association with provider adherence and race and ethnicity (P = .047), and 50% of patients with Spanish as their primary language were adherent compared with 90% of patients with English as their primary language (P = .003). Extraction of treatment exposures from the electronic health record through clinical informatics and integration with cancer registry data represents a feasible approach to assess cardiovascular disease outcomes and adherence to guideline recommendations for survivors.

Primary care provider payment models and adherence to anticoagulation in patients with atrial fibrillation.

BACKGROUND: Oral anticoagulation (OAC) is recommended for the prevention of stroke in atrial fibrillation (AF). However, only 50%-60% of AF patients in the United States are treated with OAC, and 60% of them adhere to OAC therapy over time. OBJECTIVES: To (1) compare adherent use of OAC between AF patients who received primary care from practices involved in shared-savings models and patients who received care from practices not involved in shared savings and (2) examine the trend of adherence to OAC over time. Because OAC can save downstream medical costs associated with averted stroke events, we hypothesized that OAC adherence would be higher among patients receiving care from practices involved in shared savings. METHODS: Using 2014-2019 claims data from a health insurer in western Pennsylvania, we identified 20,637 AF patients from 2015-2018. Patients were followed from the first AF diagnosis (index date) for 12 months or until disenrollment. We categorized patients according to the payment model of the practice from which they received primary care: shared savings (n = 8,844) and no shared savings (n = 11,793). The primary outcome was adherent use of OAC therapy, which was defined as having at least 80% of the followup period covered with OAC. Secondary outcomes included adherent use of direct oral anticoagulants (DOACs) and adherent use of warfarin. We constructed logistic regression models to assess the association between involvement in shared savings and adherent use of OAC, while controlling for demographics, clinical characteristics, and index year. RESULTS: 34% of patients in the shared-savings group adhered to OAC, compared with 32.7% in the no shared-savings group (P = 0.04). After adjustment, adherence was higher for the shared-savings group for OAC (adjusted odds ratio [aOR] = 1.07, 95% CI = 1.01-1.14) and warfarin (aOR = 1.11, 95% CI = 1.02-1.20) compared with the no shared-savings group. However, the odds of adherent use of DOACs did not statistically differ between shared savings and no shared savings (aOR = 0.99, 95% CI = 0.91-1.08). The odds of adherent OAC use increased over time: the aOR of adherent use of OAC was 1.21 (95% CI = 1.09-1.34) for index year 2016; 1.50 (95% CI = 1.36-1.67) for 2017; and 1.78 (95% CI 1.60-1.98) for 2018, all compared with 2015. CONCLUSIONS: Receipt of primary care from a practice involved in shared savings was associated with a higher adherent use of OAC and warfarin for patients with atrial fibrillation. Furthermore, adherent use of OAC improved over time for both treatment groups. Our research demonstrates that the alignment of financial incentives between providers and insurers may improve the use of therapies with downstream cost-saving potential. DISCLOSURES: This project was funded by the National Heart, Lung and Blood Institute (grant number K01HL142847). Hernandez has received consulting fees from Pfizer and BMS, outside of the submitted work. The other authors have nothing to disclose.

Sensor-Based Electronic Monitoring for Asthma: A Randomized Controlled Trial

To assess whether sensor-based monitoring of daily inhaled corticosteroids and short-acting b-agonist medications can improve asthma outcomes in diverse populationsA socioeconomically and racially diverse population of caregiver and children dyads were randomly assigned to control (n = 127) or sensor-based electronic monitoring (n = 125) for asthma.This was a randomized controlled multicenter trial of socioeconomically and racially diverse caregiver and children pairs from 5 Chicago medical clinics. The primary outcomes measured were the Asthma Control Test (ACT) (≥19 score equivalent to controlled asthma) and health care use (emergency department visits, hospitalizations, and oral corticosteroid prescriptions). Caregiver quality of life (QoL) and adherence to inhaled corticosteroids were also evaluated with multitiered models to ascertain changes.The intervention group had a significant increase in adjusted mean ACT scores (19.1 [n = 123; SE = 0.3] to 21.8 [n = 102; SE = 0.4]). The control group also had an increase in adjusted mean ACT scores (19.4 [n = 126; SE = 0.3] to 19.9 [n = 118; SE = 0.4]), the change was less than that of the intervention group at all time points (P < .01 for all comparisons). There was no difference in terms of the reported number of asthma attacks, missed school days, and steroid prescriptions in the ED and/or hospital. However, more children in the intervention group were prescribed steroids for asthma attacks during the 12 month study than controls were (72.5% intervention versus 34.6% control; P < .01). Improved QoL was reported by caregivers of the intervention group; this change was greater that of seen in the control group at 1 month follow-up, but there was no difference at 12 months.The outcomes of the study reveal that sensor-based inhaler monitoring with clinical participant–provider feedback may enhance asthma control and caregiver QoL in racially and socioeconomically diverse populations. However this improvement in outcomes for child and caregiver comes at the price of higher health care use, so further improvement in the sensor and participant–provider feedback system is needed.The authors should be recognized for demonstrating that use of sensor monitoring for asthma medications in children can improve asthma control and caregiver QoL in diverse populations. However, these improvements may come at a price of increasing health care use (steroid prescriptions). The limitations of the study include that data had to be manually entered because the blue chip device did not fit the inhaler and the absence of documentation or quantification of participant–provider phone feedback and adherence in both study groups as well as cost-effectiveness analysis.

Pediatrician Adherence to Guidelines for Diagnosis and Management of High Blood Pressure

To assess pediatrician adherence to the 2017 American Academy of Pediatrics' clinical practice guideline for high blood pressure (BP). Pediatric primary care practices (n=59) participating in a quality improvement collaborative submitted data for patients with high BP measured between November 2018 and January 2019. Baseline data included patient demographics, BP, body mass index (BMI), and actions taken. Logistic regression was used to test associations between patient BP level and BMI with provider adherence to guidelines (BP measurement, counseling, follow-up, evaluation). A total of 2677 patient charts were entered for analysis. Only 2% of patients had all BP measurement steps completed correctly, with fewer undergoing 3-limb and ambulatory BP measurement. Overall, 46% of patients received appropriate weight, nutrition, and lifestyle counseling. Follow-up for high BP was recommended or scheduled in 10% of encounters, and scheduled at the appropriate interval in 5%. For patients presenting with their third high BP measurement, 10% had an appropriate diagnosis documented, 2% had appropriate screening laboratory tests conducted, and none had a renal ultrasound performed. BMI was independently associated with increased odds of counseling, but higher BP was associated with lower odds of counseling. Higher BP was independently associated with an increased likelihood of documentation of hypertension. In this multisite study, adherence to the 2017 American Academy of Pediatrics' guideline for high BP was low. Given the long-term health implications of high BP in childhood, it is important to improve primary care provider recognition and management. ClinicalTrials.gov: NCT03783650.

An initiative to improve pneumococcal immunization counseling in children with nephrotic syndrome.

BackgroundImmunization is essential in preventing life-threatening pneumococcal infections in children with nephrotic syndrome. An additional 23-valent pneumococcal polysaccharide vaccine (PPSV23) series is required for children with nephrotic syndrome. Despite current practice guidelines, many children with nephrotic syndrome do not receive PPSV23.MethodsOur nephrology clinic conducted a quality improvement project to improve the overall rate of PPSV23 counseling to more than 70% within a 12-month period by applying several targeted interventions to raise providers’ awareness, improve communication with primary care providers, and increase provider adherence. Data was collected from the electronic health record (EHR), and monthly performance was tracked via monthly control charts and overall immunization counseling rate charts.ResultsWe increased adherence to PPSV23 vaccination counseling from a baseline of 12 to 86%. The first intervention that effectively increased the vaccine counseling rate from 12 to 30% was improving a provider’s awareness of the PPSV23 literature and vaccine guidelines. Other interventions included regular performance reviews at division meetings, creating an immunization protocol, posting performance charts on the office bulletin board, and unifying vaccine recommendation templates. Lastly, specific and timely EHR reminders improved the total counseling rate from 52 to 86% and maintained adherence until the completion of the project.ConclusionBridging the knowledge gap in provider awareness and using specific EHR reminders can improve adherence to PPSV23 counseling in children with nephrotic syndrome. Such interventions could be applied to similar groups of immunocompromised patients in whom additional vaccines are indicated.Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information. Supplementary InformationThe online version contains supplementary material available at 10.1007/s00467-021-05305-3.