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Biomedical subjects

Eric S Holmboe

Publications and source records attributed to Eric S Holmboe.

At least 19 recordsLinked to original sources
PubMed2006

What factors account for referral delays for patients with suspected rheumatoid arthritis?

OBJECTIVE: Rheumatoid arthritis (RA) is a common, costly, and disabling disease. Early referral and treatment reduce long-term joint damage and improve functional outcomes. Despite efforts to improve referral, half of patients with RA are not referred in a timely manner. Our objective was to explore the factors influencing the decision of a primary care physician (PCP) to refer or not refer a patient with suspected RA, and to identify modifiable factors influencing timely referral. METHODS: Using qualitative methods and in-depth, face-to-face interviews, we asked Connecticut PCPs to describe the last patient encounter where they suspected RA and the factors influencing referral and nonreferral. Participants represented a range of clinical experience, access to rheumatologists, and practice settings. Sample size was determined by thematic saturation. Transcripts were coded and analyzed using the constant comparative method of qualitative data analysis. RESULTS: We interviewed 19 PCPs, 9 of whom were women. Our analysis identified clinical characteristics, patient preferences, access issues, clinical and administrative leadership, physician confidence and expectations, and interpersonal relationships as important domains influencing the referral decision. These domains interacted to impact timely referral and quality of care. Previously underappreciated factors, such as the magnitude of the effect of physician rapport, appeared to be critical in determining whether or not patients are promptly referred. CONCLUSION: Issues such as physician rapport, as well as clinical and system issues, influence referral for suspected RA. To improve referral for RA, clinical guidelines, medical education, and quality improvement efforts should address all domains influencing the referral decision.

Arthritis, Rheumatoid↗
PubMed2006

Improving the quality of preventive cardiovascular care provided by primary care physicians: insights from a US Quality Improvement Organization.

BACKGROUND: During 2000-03, Qualidigm, a US Quality Improvement Organization, conducted a project to improve the care received by elderly Medicare patients with coronary artery disease or cardiovascular risk factors. METHODS: We recruited primary care physicians in private practice in the state of Connecticut. Then, we identified approximately 30-50 patients per physician from the periods 1 January 2000 to 31 December 2000 and 1 November 2001 to 31 October 2002. We abstracted medical records to assess processes and outcomes of care, and we provided the physicians with performance data and a variety of practice-enhancing materials. The physicians utilized those materials that they perceived to be most helpful. RESULTS: We identified and recruited 974 primary care physicians to participate. Of these, 103 (10.6%) committed to participate, and 85 of the 103 completed the project. Among the intervention tools, physicians and their office personnel utilized personal digital assistants (PDAs) (36.5%) and patient education materials (34.1%) most commonly. Overall, quality of care improved for most physicians (mean quality score 62.0 to 67.8%, P < 0.001). However, not all improved, and most improvements were modest [mean absolute improvement in quality score 5.8%, standard deviation (SD) 6.8%]. CONCLUSIONS: Quality Improvement Organizations and others interested in improving outpatient quality of care face significant challenges in recruiting self-employed primary care physicians to quality improvement projects and in bringing about transformational change. Future primary care quality improvement projects should include careful assessments of practice-specific barriers, interventions that are linked to these barriers, and support of the practices on implementation.

Aged↗
PubMed2006

Promoting physicians' self-assessment and quality improvement: the ABIM diabetes practice improvement module.

INTRODUCTION: The American Board of Internal Medicine (ABIM) recognized that certification and recertification must be based on an assessment of performance in practice as well as an examination of medical knowledge. Physician self-assessment of practice performance is proposed as one method that certification boards may use to evaluate competence in practice-based learning and improvement and systems-based practice. METHODS: Sixteen practicing general internists and endocrinologists with 10-year time-limited certification participated in a beta test of the ABIM's diabetes practice improvement module (PIM) as part of their recertification program. A PIM consists of a self-directed medical record audit, practice system survey, and patient survey. A quality improvement education specialist from the Connecticut Quality Improvement Organization provided on-site and distance consultation on quality improvement methods and tools. An independent audit assessed the reliability of physician self-audit. Qualitative interviews were conducted at 2 time points to assess for physician satisfaction and behavioral change in quality improvement. RESULTS: Fourteen physicians completed the diabetes PIM. All but 1 physician found the medical record audit to provide important information about the practice. Of the 11 physicians who completed a follow-up interview, 10 stated that the quality improvement education specialist helped improve their practice. DISCUSSION: Self-assessment using the ABIM diabetes PIM as part of recertification provides valuable practice information and can lead to meaningful behavioral change by physicians. Collaboration with an educator in quality improvement appears to facilitate the effects of the practice improvement module. Future work should investigate the effect on patient outcomes.

Adult↗
PubMed2006

The effects of patient volume on the quality of diabetic care for Medicare beneficiaries.

BACKGROUND: The quality of care for Medicare beneficiaries with diabetes remains suboptimal. The contributing factors at the physician level are not well characterized, especially the relationship of patient volume and physician performance. OBJECTIVE: We sought to determine associations between the number of Medicare diabetic patients cared for by a primary care physician and the receipt of important diabetic processes of care. DESIGN: Physicians were grouped into quintiles based on the number of Medicare patients with diabetes. Hierarchical generalized linear models were used to examine associations between number of patients, frequency of visits, physician experience, patient factors and the receipt of diabetes processes of care using Part A and B Medicare claims data for 2001. PARTICIPANTS AND PATIENTS: All Connecticut primary care physicians who cared for Medicare fee-for-service beneficiaries with diabetes in 2001. MAIN OUTCOME MEASURES: The main outcome measures were associations of the receipt of diabetes process of care measures with the number of diabetic Medicare patients in a physician practice panel, adjusted for frequency of visits, patient comorbidity, age, ethnicity, and physician experience. RESULTS: Patients in the highest volume physician quintile were significantly more likely to have received hemoglobin A1c measurements, lipid profiles, and retinal eye examinations than patients in the lowest physician quintile in 2001, even after adjustment for multiple factors. For each step up in quintile volume group among primary care physicians, the increased odds of receiving a hemoglobin A1c measurement was 1.16 (95% confidence interval [CI] 1.10-1.23), 1.12 (95% CI 1.07-1.18) for a lipid profile, 1.06 (95% CI 1.02-1.09) for a retinal eye examination, and 1.48 (95% CI 1.22-1.81) for receiving all 3 measures. CONCLUSIONS: This study suggests that Medicare fee-for-service patients with diabetes cared for by physicians with greater numbers of diabetic Medicare patients in their practice are more likely to receive important diabetes processes of care.

Aged↗
PubMed2006

Barriers to obesity training for pediatric residents: a qualitative exploration of residency director perspectives.

BACKGROUND: Obesity affects many children and has serious health consequences. Pediatricians are expected to help halt this epidemic, but little is known about either existing obesity curricula during residency or barriers to curriculum development. PURPOSES: The purpose of the study was to explore the following topics related to obesity training in pediatric residencies: current training offered, perceived barriers to training, recommendations for improving training, and educators' attitudes and beliefs regarding the role of the pediatrician in obesity prevention and management. METHODS: We conducted in-depth interviews with a purposeful sample of pediatric residency program directors (n = 16), and analyzed them using grounded theory. RESULTS: Limited training is currently offered in the area of obesity prevention and management in pediatric residencies. We developed a taxonomy of barriers to curriculum development and recommendations for improving training based on analysis of participant interviews. We also describe the varied findings regarding program directors' attitudes and beliefs about the pediatricians' role in obesity prevention and management. CONCLUSIONS: Pediatric residency program directors recognize obesity as a significant health issue, but little structured training is offered in this area. Numerous barriers limit curriculum development and implementation, but suggestions for curriculum development offered in these interviews may help in development of obesity curricula for pediatric residency programs.

Attitude of Health Personnel↗
PubMed2006

Qualitative analysis of mothers' decision-making about vaccines for infants: the importance of trust.

BACKGROUND: The high visibility of controversies regarding vaccination makes it increasingly important to understand how parents decide whether to vaccinate their infants. OBJECTIVE: The purpose of this research was to investigate decision-making about vaccinations for infants. DESIGN: We conducted qualitative, open-ended interviews. PARTICIPANTS: Subjects included mothers 1 to 3 days postpartum and again at 3 to 6 months. RESULTS: We addressed 3 topics: attitudes to vaccination, knowledge about vaccination, and decision-making. Mothers who intended to have their infants vaccinated ("vaccinators," n = 25) either agreed with or did not question vaccination or they accepted vaccination but had significant concerns. Mothers who did not intend to vaccinate ("nonvaccinators," n = 8) either completely rejected vaccination or they purposely delayed vaccinating/chose only some vaccines. Knowledge about which vaccines are recommended for children was poor among both vaccinators and nonvaccinators. The theme of trust in the medical profession was the central concept that underpinned all of the themes about decision-making. Promoters of vaccination included trusting the pediatrician, feeling satisfied by the pediatrician's discussion about vaccines, not wanting to diverge from the cultural norm, and wanting to adhere to the social contact. Inhibitors included feeling alienated by or unable to trust the pediatrician, having a trusting relationship with an influential homeopath/naturopath or other person who did not believe in vaccinating, worry about permanent side effects, beliefs that vaccine-preventable diseases are not serious, and feeling that since other children are vaccinated their child is not at risk. CONCLUSION: Trust or lack of trust and a relationship with a pediatrician or another influential person were pivotal for decision-making of new mothers about vaccinating their children. Attempts to work with mothers who are concerned about vaccinating their infants should focus not only on providing facts about vaccines but also on developing trusting and positive relationships.

Adult↗
PubMed2006

Leveraging the benefits of Health Information Technology to support healthcare delivery model redesign.

Uninsured and low income underinsured patients create substantial challenges for local healthcare systems, yet their providers are not always included in community-wide implementations of health information technology. To address this deficit, prototypes of the recently proposed National Health Information Network must include providers who care for underserved populations. In 2003, a consortium of providers founded the Waterbury Health Access Program (WHAP) to implement an electronic medical record (EMR) system that would first address the needs of the region's vulnerable underserved patients. It was anticipated that lessons learned would be applicable to other patient populations as well. The WHAP consortium of competing hospitals and outpatient clinics developed a broad-based community-wide initiative to include implementing a common EMR system to share clinical information across all locations. The design includes 11 outpatient clinic locations linked to a common data-sharing tool that is accessible by each clinic, emergency department and community practitioner participating in a local, coordinated charity care program. The collaboration required to support community-wide implementations of health information technology also can be leveraged to facilitate additional quality improvement initiatives.

Ambulatory Care↗
PubMed2005

A randomized outpatient trial of a decision-support information technology tool.

BACKGROUND: Decision-support information technology is often adopted to improve clinical decision making, but it is rarely rigorously evaluated. Congress mandated the evaluation of Problem-Knowledge Couplers (PKC Corp, Burlington, Vt), a decision-support tool proposed for the Department of Defense's new health information network. METHODS: This was a patient-level randomized trial conducted at 2 military practices. A total of 936 patients were allocated to the intervention group and 966 to usual care. Couplers were applied before routine ambulatory clinic visits. The primary outcome was quality of care, which was assessed based on the total percentage of any of 24 health care quality process measures (opportunities to provide evidence-based care) that were fulfilled. Secondary outcomes included medical resources consumed within 60 days of enrollment and patient and provider satisfaction. RESULTS: There were 4639 health care opportunities (2374 in the Coupler group and 2265 in the usual-care group), with no difference in the proportion of opportunities fulfilled (33.9% vs 30.7%; P = .12). Although there was a modest improvement in performance on screening/preventive measures, it was offset by poorer performance on some measures of acute care. Coupler patients used more laboratory and pharmacy resources than usual-care patients (logarithmic mean difference, 71 dollars). No difference in patient satisfaction was observed between groups, and provider satisfaction was mixed. CONCLUSION: This study provides no strong evidence to support the utility of this decision-support tool, but it demonstrates the value of rigorous evaluation of decision-support information technology.

Adult↗
PubMed2005

Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it?

OBJECTIVES: We sought to recommend an approach for minimizing preventable delays in door-to-balloon time on the basis of experiences in top-performing hospitals nationally. BACKGROUND: Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity; however, door-to-balloon times often exceed the 90-min guideline set forth by the American College of Cardiology (ACC) and the American Heart Association (AHA). METHODS: We conducted a qualitative study using in-depth interviews (n = 122) of hospital staff at hospitals (n = 11) selected as top performers based on data from the National Registry of Myocardial Infarction from January 2001 to December 2002. We used the constant comparative method of qualitative data analysis to synthesize best practices across the hospitals. RESULTS: Top performers were those with median door-to-balloon times of < or =90 min for their most recent 50 PCI cases through December 2002 and the greatest improvement in median door-to-balloon times during the preceding four-year period 1999 to 2002. Several critical innovations are described, including use of pre-hospital electrocardiograms (ECGs) to activate the catheterization laboratory, allowing emergency physicians to activate the catheterization laboratory, and substantial interdisciplinary collaboration throughout the process. In the ideal approach, door-to-balloon time is 60 min for patients transported by paramedics with a pre-hospital ECG and 80 min for patients who arrive without paramedic transport and a pre-hospital ECG. CONCLUSIONS: Hospitals can achieve the recommended ACC/AHA guidelines for door-to-balloon time with specific process design efforts. However, the recommended best practices involve extensive interdisciplinary collaboration and will likely require explicit strategies for overcoming barriers to organizational change.

Angioplasty, Balloon, Coronary↗
PubMed2005

Teaching and improving quality of care in a primary care internal medicine residency clinic.

Purpose Learning and applying quality of care principles are essential to practice-based learning and improvement. The authors investigated the feasibility and effects of a self-directed curriculum in quality of care for residents. Method In 2001-02, 13 second-year residents at two community-based outpatient clinics in the Yale University primary care internal medicine residency program were asked to participate in a trial of a quality improvement curriculum (intervention group). Thirteen third-year residents in the same residency program served as the comparison group. The curriculum consisted of readings in quality of care, weekly self-reflection with a faculty member, completion of a commitment to change survey, and medical record audits. Study outcome measures were patient level quality of care measures for diabetes, satisfaction with the curriculum, and self-reported behavioral changes. Results In the follow-up, patients of the intervention group were significantly more likely to have received a monofilament foot examination and baseline electrocardiogram than were patients of the comparison group. When comparing the change between baseline and follow-up, patients for the second-year residents showed significantly more improvement in hemoglobin A1c and LDL cholesterol levels and Pneumovax administration than did patients of the comparison group. All residents in the intervention group were highly satisfied with the curriculum. Thirty-five of 54 residents' personal commitments to change were either partially or fully implemented six months after the curriculum. Conclusions A multifaceted curriculum in quality improvement led to modest improvements in the care of diabetic patients and meaningful changes in self-reported practice behaviors. Future research should include more focus on the microsystems of residency outpatient experiences.

Comorbidity↗
PubMed2005

The relationship between specialty choice and gender of U.S. medical students, 1990-2003.

PURPOSE: Women have been postulated to be more responsible than men for the recent trend of lifestyle factors influencing the specialty choices of graduating U.S. medical students. The authors looked at the specialty choices of U.S. medical students between 1990 and 2003 to determine whether and to what degree women were responsible for the trends toward controllable lifestyle specialties. METHOD: Specialty preference was based on analysis of results from the American Association of Medical Colleges' Medical School Graduation Questionnaire. Specialty lifestyle (controllable vs. uncontrollable) was classified using a standard definition from prior research. A random effects regression model was used to assess differences between men and women in specialty choice over time and the proportion of variability in specialty preference from 1990 to 2003 explained by women. RESULTS: Overall, a greater proportion of women planned to pursue uncontrollable specialties compared with men in every year analyzed. Both women and men demonstrated a decreasing interest in uncontrollable lifestyle specialties by almost 20%. However, regression analysis found that women were more slightly more likely to choose an uncontrollable lifestyle specialty compared to men over time (p < .01). CONCLUSION: Among U.S. medical graduates, women were not more responsible than were men for the trend away from uncontrollable lifestyle specialties over the time period studied. Men and women expressed similar and significant rates of declining interest in specialties with uncontrollable lifestyles.

Adult↗
PubMed2005

Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction.

BACKGROUND: Hospitals are under increasing pressure to measure and improve quality of care, and substantial resources are being directed at a variety of quality improvement strategies; however, the evidence base supporting these strategies is limited. OBJECTIVE: We sought to identify quality improvement efforts that were associated with hospitals' beta-blocker prescription rates after acute myocardial infarction (AMI). RESEARCH DESIGN: This was a cross-sectional study using data from a telephone survey of quality management directors at participating hospitals linked with patient-level data from the National Registry of Myocardial Infarction (NRMI) during the study period, October 1997 to September 1999. SUBJECTS: A total of 60,363 patients discharged with a confirmed AMI from 234 US hospitals were included. MEASURES: Hospital performance based on beta-blocker rates characterized as the top 20%, lower 20%, and middle 40% of hospitals; reported quality improvement efforts, including system interventions, physician leadership, administrative support for quality improvement efforts, and data feedback; hospital teaching status, AMI volume, geographic location, and ownership type. RESULTS: The mean hospital-specific beta-blocker rate was 60.2%; however, the variation in beta-blocker use across hospitals was marked (range, 19.4-89.3%, standard deviation, 12.7% points), and quality improvement efforts used varied greatly. None of the quality improvement efforts distinguished higher from medium performers; the higher and the medium performers together were distinguished from the lower performers in organizational support for quality improvement efforts (fully adjusted odds ratio [OR] 1.89, 95% confidence interval [CI] 1.17-3.06) and physician leadership (fully adjusted OR 9.88, 95% CI 2.64-37.02). Among the specific quality improvement interventions, only standing orders were associated with having higher/medium versus lower performance, and their effect had borderline significance (fully adjusted OR 2.26, 95% CI 0.97-5.30, P = 0.07). CONCLUSIONS: Our findings highlight the organizational environment, specifically the absence of administrative support or physician leadership for quality improvement, as an important correlate of poor beta-blocker rates after AMI. Future studies are needed to isolate hospital quality improvement efforts that are associated with superior performance.

Adrenergic beta-Antagonists↗
PubMed2005

Internal medicine training in the inpatient setting. A review of published educational interventions.

PURPOSE: Although the inpatient setting has served as the predominant educational site of internal medicine training programs, many changes and factors are currently affecting education in this setting. As a result, many educational organizations are calling for reforms in inpatient training. This report reviews the available literature on specific internal medicine inpatient educational interventions and proposes recommendations for improving internal medicine training in this setting. METHOD: We searched Medline for articles published between 1966 and August 2004 which focused on internal medicine training interventions in the inpatient setting; bibliographies of Medline-identified articles, as well as articles suggested by experts in the field provided additional citations. We then reviewed, classified, and abstracted only articles where an assessment of learner outcomes was included. RESULTS: Thirteen studies of inpatient internal medicine educational interventions were found that included an outcome assessment. All were single institution studies. The majority of these studies was of poor methodological quality and focused on specific content areas of internal medicine. None assessed the effectiveness or impact of internal medicine core inpatient experiences or curriculum. CONCLUSION: This review identifies significant gaps in our understanding of what constitutes effective inpatient education. The paucity of high quality research in the internal medicine inpatient setting highlights the urgent need to formally define and study what constitutes an effective "core" inpatient curriculum.

Curriculum↗