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Biomedical subjects

Wilson D Pace

Publications and source records attributed to Wilson D Pace.

15 recordsLinked to original sources
PubMed2006

Evaluating sample medications in primary care: a practice-based research network study.

BACKGROUND: No reports have objectively evaluated safety of samples in primary care practices. A study was conducted to determine adherence to the Institute for Safe Medication Practices (ISMP) recommendations for safe distribution of medication samples to minimize medication errors. METHODS: In 2004, 17 urban and rural primary care practices participated in a two-phase observational study: (1) a site visit to collect inventory data and perform assessment of medication sample dispensing procedures and (2) a survey questionnaire for providers and patients upon sample medication provision. RESULTS: No practices were compliant with all seven ISMP recommendations. Twelve of 17 practices had policies for sample medication dispensing, and 7 had policies for labeling. Sample medication use was evaluated for 585 office visits and 27 patient surveys. Fifty-eight sample medications were dispensed during 55 of 585 patient visits. Common reasons for using sample medications included availability and need for a short-term trial for a chronic medication. Verbal communication only was provided most of the time for patient education regarding appropriate sample medication use and side effects. DISCUSSION: Primary care practices in this research network did not follow safe and appropriate sample medication dispensing procedures as outlined by ISMP. Both labeling and patient instructions were inadequate and may increase the risk for medication errors.

Colorado↗
PubMed2005

Patient preferences for notification of normal laboratory test results: a report from the ASIPS Collaborative.

BACKGROUND: Many medical errors occur during the laboratory testing process, including lost test results. Patient inquiry concerning results often represents the final safety net for locating lost results. This qualitative study sought to identify, from a patient perspective, specific preferences and factors that influence the process of communicating normal (negative) laboratory test results to patients. METHODS: We conducted 30-minute guided interviews with 20 adult patients. Patients were recruited from two practice-based research networks in Colorado that were participating in a medical errors study. A semi-structured interview elicited the participant's experience with and preference for laboratory test result notification. Quantitative descriptive statistics were generated for demographic and preference data. Qualitative results were analyzed by a team of experienced qualitative researchers using multiple styles of qualitative analyses, including a template approach and an editing approach. RESULTS: Ninety percent of participants wanted to be notified of all tests results. Important issues related to notification included privacy, responsive and interactive feedback, convenience, timeliness, and provision of details. Telephone notification was preferred, followed by regular mail. Electronic notification was perceived as uncomfortable because it was not secure. While 65% preferred being notified by a provider, participants acknowledge that this may be impractical; thus, they wanted to be notified by someone knowledgeable enough to answer questions. Participants do not normally discuss their preferences for test result notification with their providers. CONCLUSION: Privacy, responsive and interactive feedback, convenience, and timeliness with detailed information may be critical for patient satisfaction and for improving patient safety, and are features that may be incorporated into emerging communication channels.

Adult↗
PubMed2005

Missing clinical information during primary care visits.

CONTEXT: The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical information has not been explicitly investigated in the primary care setting. OBJECTIVE: To describe primary care clinicians' reports of missing clinical information. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded. MAIN OUTCOME MEASURES: Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering. RESULTS: Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10 minutes, 10.4%). After adjustment, reported missing clinical information was more likely when patients were recent immigrants (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-2.99), new patients (OR, 2.39; 95% CI, 1.70-3.35), or had multiple medical problems compared with no problems (1 problem: OR, 1.09; 95% CI, 0.69-1.73; 2-5 problems: OR, 1.87; 95% CI, 1.21-2.89; >5 problems: OR, 2.78; 95% CI, 1.61-4.80). Missing clinical information was less likely in rural practices (OR, 0.52; 95% CI, 0.29-0.92) and when individual clinicians reported having full electronic records (OR, 0.40; 95% CI, 0.17-0.94). CONCLUSIONS: Primary care clinicians report that missing clinical information is common, multifaceted, likely to consume time and other resources, and may adversely affect patients. Additional research on missing information is needed to focus on validating clinicians' perceptions and on conducting prospective studies of its causes and sequelae.

Communication↗
PubMed2004

Applied strategies for improving patient safety: a comprehensive process to improve care in rural and frontier communities.

CONTEXT: Medical errors and patient safety have gained increasing attention throughout all areas of medical care. Understanding patient safety in rural settings is crucial for improving care in rural communities. PURPOSE: To describe a system to decrease medical errors and improve care in rural and frontier primary care offices. METHODS: Applied Strategies for Improving Patient Safety (ASIPS) was a demonstration project designed to collect and analyze medical error reports and use these reports to develop and implement interventions aimed at decreasing errors. ASIPS participants were clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). This paper describes ASIPS in HPRN. FINDINGS: Fourteen HPRN practices with a total of 150 clinicians and staff have participated in ASIPS. Participants have submitted 128 reports. Diagnostic tests were involved in 26% of events; medication errors appeared in 20% of events. Communication errors were reported in 72%. Two learning groups developed "Principles for Process Improvement" for medication errors and diagnostic testing errors. Several safety "alerts" were issued to improve care, and 2 interventions were implemented to decrease errors. CONCLUSIONS: A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in rural primary care settings. Information from reports can be used to identify processes that can be improved.

Colorado↗
PubMed2004

Clinical decisions regarding HbA1c results in primary care: a report from CaReNet and HPRN.

OBJECTIVE: To describe decisions made by primary care providers on elevated HbA(1c) results and their reasons for not intensifying therapy. RESEARCH DESIGN AND METHODS: In this cross-sectional study, a provider survey was administered in two practice-based research networks when HbA(1c) results were reviewed on all nonpregnant patients >18 years old with type 2 diabetes. Univariate and Mantel-Hantel analyses assessed associations between patient characteristics and clinical decisions. RESULTS: A total of 483 surveys were completed by at least 88 providers at 19 clinics. Most patients were female (62.5%), mean age was 60 years, and 28.6% were Hispanic. The overall action rate on HbA(1c) results >/=7% (n = 294) was 70.7%. Patients who were black or had Medicare without medication insurance had lower rates of action on HbA(1c) >/=7 and >/=8%, respectively (P < 0.05). The most common reasons providers reported for inaction were "patient improving/doing well," "competing demands," and "hypoglycemic risk." CONCLUSIONS: Primary care providers generally adhere to national glycemic control guidelines, although there may be disparities in black patients and patients without medication insurance coverage. A variety of reasons were given when control was not intensified.

Adult↗
PubMed2003

Database design to ensure anonymous study of medical errors: a report from the ASIPS Collaborative.

Medical error reporting systems are important information sources for designing strategies to improve the safety of health care. Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that collects and analyzes data on primary care medical errors and develops interventions to reduce error. The voluntary ASIPS Patient Safety Reporting System captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports; however, concerns exist about the confidentiality of those reports should the database be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error. The authors present the design and implementation of a database and administrative system that reduce this risk, facilitate research, and maintain near anonymity of the events, practices, and clinicians.

Computer Security↗
PubMed2002

Venlafaxine-associated vaginal bleeding.

A 41-year-old amenorrheic woman started taking venlafaxine 37.5 mg/day for treatment of depression; 7 days later, she experienced vaginal bleeding, which ceased 1 day after she stopped taking the drug. On rechallenge with venlafaxine, she again experienced vaginal bleeding that resolved after discontinuation. We found no published reports describing vaginal bleeding associated with venlafaxine. However, premarketing and postmarketing data report similar adverse effects in patients taking the agent. In addition, several cases of menstrual irregularities have occurred with two other antidepressants: fluoxetine and bupropion. This case report supports previous surveillance data indicating that venlafaxine may cause vaginal bleeding.

Adult↗
PubMedDate not supplied

Event reporting to a primary care patient safety reporting system: a report from the ASIPS collaborative.

BACKGROUND: We examined reports to a primary care, ambulatory, patient safety reporting system to describe types of errors reported and differences between anonymous and confidential reports. METHODS: Applied Strategies for Improving Patient Safety (ASIPS) is a demonstration project designed to collect and analyze medical error reports from clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). A major component of ASIPS is a voluntary patient safety reporting system that accepts reports of errors anonymously or confidentially. Reports are coded using a multiaxial taxonomy. RESULTS: Two years into this project, 33 practices with a total of 475 clinicians and staff have participated in ASIPS. Participants submitted 708 reports during this time (66% using the confidential reporting form). We successfully followed up on 84% of the confidential reports of interest within the allotted 10-day time frame. We ended up with 608 relevant, codable reports. Communication problems (70.8%), diagnostic tests (47%), medication problems (35.4%), and both diagnostic tests and medications (13.6%) were the most frequently reported errors. Confidential reports were significantly more likely than anonymous reports to contain codable data. CONCLUSION: A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in primary care settings. Information from confidential reports appears to be superior to that from anonymous reports and may be more useful in understanding errors and designing interventions to improve patient safety.

Confidentiality↗
PubMedDate not supplied

Electronic data collection options for practice-based research networks.

PURPOSE: We wanted to describe the potential benefits and problems associated with selected electronic methods of collecting data within practice-based research networks (PBRNs). METHODS: We considered a literature review, discussions with PBRN researchers, industry information, and personal experience. This article presents examples of selected PBRNs' use of electronic data collection. RESULTS: Collecting research data in the geographically dispersed PBRN environment requires considerable coordination to ensure completeness, accuracy, and timely transmission of the data, as well as a limited burden on the participants. Electronic data collection, particularly at the point of care, offers some potential solutions. Electronic systems allow use of transparent decision algorithms and improved data entry and data integrity. These systems may improve data transfer to the central office as well as tracking systems for monitoring study progress. PBRNs have available to them a wide variety of electronic data collection options, including notebook computers, tablet PCs, personal digital assistants (PDAs), and browser-based systems that operate independent of or over the Internet. Tablet PCs appear particularly advantageous for direct patient data collection in an office environment. PDAs work well for collecting defined data elements at the point of care. Internet-based systems work well for data collection that can be completed after the patient visit, as most primary care offices do not support Internet connectivity in examination rooms. CONCLUSIONS: When planning to collect data electronically, it is important to match the electronic data collection method to the study design. Focusing an inappropriate electronic data collection method onto users can interfere with accurate data gathering and may also anger PBRN members.

Biomedical Research↗
PubMedDate not supplied

Practice-based research network studies in the age of HIPAA.

PURPOSE: We wanted to explore potential effects of the Health Insurance Portability and Accountability Act (HIPAA) on research activities of practice-based research networks (PBRNs). METHODS: To understand the approaches PBRNs are using to advance their research while adhering to HIPAA standards, we combined a literature review, our experiences, and discussions with local HIPAA officers, PBRN researchers in the United States, and individuals involved in drafting HIPAA. RESULTS: HIPAA requires researchers to pay special attention to how they handle patients' protected health information (PHI). For researchers working within PBRNs, which collect information from patients and health care professionals in multiple institutions, the HIPAA Privacy Rule presents additional challenges. PBRN researchers can obtain patient authorization to use PHI, but this process is difficult and may taint the findings of some research studies. Some institutions may allow patients to provide a blanket authorization for study recruitment. PBRNs additionally can collect only "de-identified" data (data with identifying information removed) or, with a data use agreement, can work with a limited data set. PBRNs that blend quality improvement and research can work with PHI, but the researcher and practices must enter into a business agreement. PBRN researchers may need to play active, educational roles in institutional privacy boards to facilitate their research. CONCLUSIONS: There are a number of ways for PBRN researchers to comply with HIPAA short of obtaining patient consent and authorization for every study. Careful planning and consideration of HIPAA issues during study design can go a long way toward reducing frustration later.

Biomedical Research↗
PubMedDate not supplied

Seasonal variation in diagnoses and visits to family physicians.

BACKGROUND: Practice-based research networks (PBRNs) replicating the National Ambulatory Medical Care Survey (NAMCS) must sample more than 1 year to account for presumed seasonal variation in illnesses. This study evaluated the effects of seasonality on diagnoses within NAMCS family physician data. METHODS: Using combined data from the 1995-1998 NAMCS, diagnostic clusters that accounted for more than 1% of total visits were analyzed for seasonality. Seasons were coded categorically as dummy variables with summer as the reference category. A logistic regression was performed with each diagnosis as an outcome on the full data. To examine the ability of alternative sampling strategies to replicate the full year of data, a simulation study was carried out drawing 50 samples of 1,000 visits each for winter-summer and spring-fall sampling periods. RESULTS: We found 23 diagnostic clusters that had a frequency more than 1%, of which 10 had seasonal variations (P < or = .001), primarily between winter and summer. If sampling were restricted to spring, the diagnostic clusters of pregnancy and coronary artery disease would account for less than 1% of visits. All other diagnostic clusters, though changing rank order, would account for more than 1% if sampled in a single quarter. In the simulated sampling strategy, visit prevalence dropped below 1% for at least 1 diagnosis in 24 of 50 samples in spring-fall compared with 20 of 50 samples for winter-summer (P > .20). CONCLUSIONS: There is little seasonal variation in the 23 diagnoses that occur in more than 1% of visits to family physicians. There is, however, important seasonal variation in the rank order of these diagnoses. A sampling strategy that uses any quarter of the year but spring (March, April, May) could be used to understand what diagnoses are frequently seen within a PBRN.

Adult↗
PubMedDate not supplied

Exploring patient reactions to pen-tablet computers: a report from CaReNet.

PURPOSE: We wanted to study patient receptivity to using pen-tablet computers for collecting data in a practice-based research network. METHODS: We analyzed exit interviews and field notes collected by trained research assistants as part of a larger Colorado Research Network (CaReNet) study comparing pen-tablet and paper-pencil methods to collect data for the Primary Care Network Survey (PRINS). RESULTS: A total of 168 patients completed a patient exit interview after completion of the pen-tablet-based survey instrument. Analyses of these brief interviews and field notes indicated that patients had favorable reactions to using pen-tablet computers. The most common barriers were related to glitches in the technology; the voice recognition software was the most problematic, with patients (as well as clinicians) finding this feature to be frustrating. CONCLUSIONS: Patients were able and willing to use pen-tablet computers for completing forms within busy primary care offices. Increasing patient involvement in practice-based research may be even more practicable through the use of this novel technology, which can allow patient-directed data collection at a single point in time as well as longitudinally.

Attitude to Computers↗
PubMedDate not supplied

Harm resulting from inappropriate telephone triage in primary care.

PURPOSE: Our objective was to assess and categorize harm occurring to patients who called their physicians' office after-hours but did not have their call forwarded to the physician because they stated that their call was not an emergency. METHODS: We collected data on 4949 calls handled by our answering service for 1 year in a family medicine residency office in Denver, CO. Of the 2835 after-hours clinical calls, we reviewed all 288 clinical calls that were not forwarded to the "on-call" physician. Complete data on 119 clinical calls included reason for call, frequency of next day appointments, Emergency Department visits, hospital admissions and outcomes. Outcomes were reviewed and coded for harm to the patient by experienced medical errors coders. RESULTS: When patient calls were not forwarded, 51% had an appointment, 4% an Emergency Department visit, and 2% were admitted to the hospital within 2 weeks. Analysis revealed that 3% suffered harm, and 26% experienced discomfort due to the delay. Although 66% required no intervention, 1% required emergency transport and 4% a medication change. CONCLUSIONS: Harm may occur when patients' calls are not forwarded to the on-call physician. Although the level of harm is generally temporary and minimal, the potential exists for serious harm to occur. Physicians need to re-evaluate the way they handle after-hours calls.

Adult↗