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At least 253 records · Page 14Linked to original sources
PubMed2005

Default from colposcopy and loop excision electrocautery procedure appointments in a military clinic.

OBJECTIVE: To determine the extent of nonadherence and impediments to care in a military colposcopy and loop excision electrocautery procedure (LEEP) clinic. MATERIALS AND METHODS: The nonadherence rate for colposcopy and LEEP appointments was determined for a 6-month period at Walter Reed Army Medical Center. Nonadherence was defined as failure to keep an appointment or cancellation within 24 hours of the scheduled time. A nurse coordinator telephoned all nonadherent women. Women who agreed to participate were administered a structured survey to elicit their reasons for default from their appointments. RESULT: Sixty-one (15%) of 405 women were nonadherent. Of the 61 nonadherent women, 55 (90%) agreed to participate, 4 (7%) were unable to be contacted, and 2 (3%) declined participation. The average age of participants was 30 years. Beneficiary status of the 55 women was as follows: dependent, 27 (49%); active duty, 25 (45%); retired, 2 (4%); and veteran, 1 (2%). The most common reasons for default overall for 55 women were onset of menses (15 [27%]), unplanned family or personal event (9 [16%]), forgetting (8 [15%]), and work conflict (7 [13%]). Leading reasons for 25 active duty women included work conflict (7 [28%]) and menses (6 [24%]). Leading reasons for 27 dependent women included menses (9 [33%]), unplanned family or personal event (6 [22%]), and forgetting (5 [19%]). CONCLUSIONS: Despite unrestricted access to care in the military clinic, the default rate was similar to rates reported for civilian clinics. Previsit interventions likely to improve compliance include sending informational packets to patients, better attention to scheduling around the time of expected menses, and initiating an appointment reminder system. To decrease the high percentage of nonadherence attributable to work conflicts for active duty women, supervisors need to be better informed about both medical and deployment implications of an unevaluated abnormal Pap smear.

Adult↗
PubMed2004

Multimodal and ubiquitous computing systems: supporting independent-living older users.

We document the rationale and design of a multimodal interface to a pervasive/ubiquitous computing system that supports independent living by older people in their own homes. The Millennium Home system involves fitting a resident's home with sensors--these sensors can be used to trigger sequences of interaction with the resident to warn them about dangerous events, or to check if they need external help. We draw lessons from the design process and conclude the paper with implications for the design of multimodal interfaces to ubiquitous systems developed for the elderly and in healthcare, as well as for more general ubiquitous computing applications.

Activities of Daily Living↗
PubMedDate not supplied

Continuous quality improvement techniques enhance HMO members' immunization rates.

To have a positive impact on the immunization rate of the 4,000 newborn infants it covers each year, Blue Care Network of Southeast Michigan (BCNSEM), a 240,000-member health maintenance organization that is based on an independent provider association model, convened a continuous quality improvement team. One of the results of this initiative was the development and implementation of an immunization registry, which is used as an internal tracking and reminder system for its members and providers. In recognition of its efforts, BCNSEM recently earned a Celebrating Innovation award from the American Association of Health Plans.

Blue Cross Blue Shield Insurance Plans↗
PubMedDate not supplied

Quality improvement interventions: what works?

Quality improvement efforts in healthcare focus on the use of interventions and tools to change identified processes. What interventions and tools are effective? A survey of the literature yields information on interventions and tools that have been used to successfully create quality improvement. Effective methods for changing clinical practice include face-to-face education outreach visits, involvement of local opinion leaders, reminder systems, repeated feedback from the senior medical staff, patient-mediated interventions, and a combination of interventions deployed simultaneously. Participation in an organized continuous quality improvement process is beneficial in conjunction with additional interventions.

Education, Continuing↗
PubMed1989

Adherence to recommendations for early repeat cervical smear tests.

OBJECTIVE: To assess adherence to recommendations for an early repeat cervical smear test in women with reports of cytological abnormalities, and to evaluate the impact of reminder letters to medical practitioners when such smear tests are overdue. DESIGN: Observational study. SETTING: Cytology (gynaecological) service for Victoria, Australia. SUBJECTS: Two groups of women who had abnormal cervical smears during 1985. Women in group A had some evidence of an important dysplasia and were advised to have a repeat smear in three months' time whereas women in group B had a less serious abnormality and were advised to have a repeat smear test in six months' time. In all, 971 of the 1036 women in group A and 1401 of the 1464 women in group B were eligible to have a repeat smear analysed by the service. INTERVENTION: If a repeat smear had not been received within three months of the recommended date a reminder letter generated by the service's computer was sent to the medical practitioner who had taken the smear. END POINT: Thirty six months after the report on the abnormal smear was issued. MEASUREMENTS AND MAIN RESULTS: In all, 870 (90%) of the women in group A and 1154 (82%) of the women in group B had a repeat smear test. The mean time to a repeat test was 3.0 months (95% confidence interval 0.5 to 16.4) in group A and 6.0 months (1.2 to 30.3) in group B. The reminder letter to the practitioner potentially increased the rate of return for a repeat smear test by 18% in group A and 24% in group B. Adherence to the recommendation for a repeat test increased with increasing age. CONCLUSIONS: Achieving high rates of follow up smear tests and appropriate management in women with cytological abnormalities is critical to the impact of a screening programme for cervical cancer. The reminder system used in this study was not labour intensive or expensive and provided a fail safe mechanism for ensuring that reports of abnormal smears were not overlooked.

Adult↗
PubMed2003

Sustaining better diabetes care in remote indigenous Australian communities.

PROBLEM: Inhabitants of Torres Strait Islands have the highest prevalence of diabetes in Australia and many preventable complications. In 1999, a one year randomised cluster trial showed improved diabetes care processes and reduced admissions to hospital when local indigenous health workers used registers, recall and reminder systems, and basic diabetes care plans, supported by a specialist outreach service. This study looked at whether those improvements were sustained two years after the end of the trial. DESIGN: Three year follow up clinical audit of 21 primary healthcare centres, and review of admissions to hospital in the previous 12 months. BACKGROUND AND SETTING: Remote indigenous communities in far north east Australia, population about 9600, including 921 people with diabetes. KEY MEASURES FOR IMPROVEMENT: Number of people on registers, care processes (regular measures of weight, blood pressure, haemoglobin A1c, urinary protein concentration, and concentrations of serum lipids and creatinine), appropriate clinical interventions (drug treatment and vaccinations), and intermediate patient outcome measures (weight, blood pressure, and glycaemic control). Admissions to hospital. STRATEGIES FOR CHANGE: Audit and feedback to clinicians and managers; provision of clinical guidelines and a clear management structure; workshops and training. EFFECTS OF CHANGE: The number of people on registers increased from 555 in 1999 to 921 in 2002. Most care processes and clinical interventions improved. The proportion of people with good glycaemic control (haemoglobin A1c < or = 7%) increased from 18% to 25% in line with increased use of insulin (from 7% to 16%). The proportion of those with well controlled hypertension (< 140/90) increased from 40% to 64%. The proportion admitted to hospital with a diabetes related condition fell from 25% to 20%. Mean weight increased from 87 kg to 91 kg. LESSONS LEARNT: In remote settings, appropriate management structures and clinical support for people with diabetes can lead to improvements in care processes, control of blood pressure, and preventable complications that result in admission to hospital. Control of weight and glycaemia are more difficult and requires more active community engagement. Priorities now include increasing the availability and affordability of good food, achieving weight loss, and increasing appropriate use of hypoglycaemic agents, including insulin.

Diabetes Mellitus, Type 2↗
PubMed2002

Early cervical cancer rescreening.

INTRODUCTION: The extent of early cervical rescreening, defined as rescreening earlier than the recommended interval for a given initial test result, is difficult to determine mainly because the testing history of women is incomplete, especially with newer population based screening registers. METHODS: Estimation of early rescreening is based on analysis of a 1 month cohort of women (February 1997) recorded on the New South Wales Pap Test Register (PTR) who initially tested negative and who had no recorded history of a positive test result. For the purposes of estimating early rescreening rates and sources of multiple screening occurring within the recommended 2 yearly screening interval for New South Wales, the cohort excluded the estimated proportion of women with an unrecorded history of a positive result. Approaches to exclusion were different for women with a history of a high grade result (CIN2 or higher) or a low grade result (CIN1 or lower). RESULTS: Characteristic rescreening peaks occurred at 6, 12, 18, 24 and 27 months according to negative result category. The rescreening peak at 27 months illustrates the effect of the PTR late reminder system. After adjusting the cohort for estimated proportions of women with a history of a lesion, the number of women estimated to have rescreened early was approximately 156 000 over 1997-8, and the early rescreening rate was estimated as 15.3% of women who have a Pap test. A feasible target for reducing rescreening through service provider interventions was estimated to be a reduction of 7.4%, based on reducing the overscreening proportion from 15.3% to 7.9% through truncating characteristic rescreening peaks to background levels of rescreening. This represents just under 200 000 screens that could be performed over 2 years on New South Wales women who are underscreened or unscreened without incurring additional costs due to screening. CONCLUSIONS: Reasonable estimates of early cervical rescreening can be derived but some assumptions in estimating the proportion of women with a positive test result history may be needed particularly if a screening programme is new and universal recording of screening data is only recent. Characteristic peaks, as departures from a background of random noise in time plots of rescreening indicate that a component of early rescreening is systemic and the chief source of such variation in screening behaviour would be service providers.

Adult↗
PubMed2004

Sustaining better diabetes care in remote indigenous Australian communities.

PROBLEM: Inhabitants of Torres Strait Islands have the highest prevalence of diabetes in Australia and many preventable complications. In 1999, a one year randomised cluster trial showed improved diabetes care processes and reduced admissions to hospital when local indigenous health workers used registers, recall and reminder systems, and basic diabetes care plans, supported by a specialist outreach service. This study looked at whether those improvements were sustained two years after the end of the trial. DESIGN: Three year follow up clinical audit of 21 primary health care centres, and review of admissions to hospital in the previous 12 months. BACKGROUND AND SETTING: Remote indigenous communities in far north east Australia, population about 9600, including 921 people with diabetes. KEY MEASURES FOR IMPROVEMENT: Number of people on registers, care processes (regular measures of weight, blood pressure, haemoglobin A1c, urinary protein concentration, and concentrations of serum lipids and creatinine), appropriate clinical interventions (drug treatment and vaccinations), and intermediate patient outcome measures (weight, blood pressure, and glycaemic control). Admissions to hospital. STRATEGIES FOR CHANGE: Audit and feedback to clinicians and managers; provision of clinical guidelines and a clear management structure; workshops and training. EFFECTS OF CHANGE: The number of people on registers increased from 555 in 1999 to 921 in 2002. Most care processes and clinical interventions improved. The proportion of people with good glycaemic control (haemoglobin A1c 7%) increased from 18% to 25% in line with increased use of insulin (from 7% to 16%). The proportion of those with well controlled hypertension (< 140/90) increased from 40% to 64%. The proportion admitted to hospital with a diabetes related condition fell from 25% to 20%. Mean weight increased from 87 kg to 91 kg. LESSONS LEARNT: In remote settings, appropriate management structures and clinical support for people with diabetes can lead to improvements in care processes, control of blood pressure, and preventable complications that result in admission to hospital. Control of weight and glycaemia are more difficult and requires more active community engagement. Priorities now include increasing the availability and affordability of good food, achieving weight loss, and increasing appropriate use of hypoglycaemic agents, including insulin.

Adult↗
PubMed1993

Change in prescribing patterns of intravenous histamine2-receptor antagonists results in significant cost savings without adversely affecting patient care.

OBJECTIVE: The cooperative efforts and educational activities associated with a major histamine2-receptor antagonist (H2RA) formulary change and the clinical and financial results are described. EVALUATION PROCESS: An extensive financial and clinical evaluation was conducted. Sources included primary literature, reference texts, institution-specific financial data, and reports of other hospitals' experiences. INTERVENTIONS: Through cooperative efforts with key members of the medical staff, several interventions were adopted: maintain only one parenteral H2RA on the formulary; develop guidelines for H2RA use and stress ulcer prophylaxis; investigate a target drug-reminder system to promote oral H2RA use. RESULTS: Within a month after implementing the formulary change and educational process, prescribing of parenteral H2RAs changed from 80 percent ranitidine to 99 percent cimetidine. Monitoring of nonformulary ranitidine use revealed only three cases of possible or probable association of adverse central nervous system effects with cimetidine in an eight-month period. Elevations of theophylline, lidocaine, or phenytoin serum concentrations; or prothrombin time above the therapeutic range during warfarin therapy occurred in only 5 of 142 monitored patients who received concomitant therapy with an H2RA. No change in serum theophylline concentrations above the therapeutic range was noted to the hospital before and after the conversion. Savings have been estimated at $250,000 in the first year and $775,000 over four years, mostly from the conversion from intravenous ranitidine to intravenous cimetidine therapy. CONCLUSIONS: Successful intervention can be accomplished by cooperation between the pharmacy and the medical staff to achieve cost savings without sacrificing the quality of care.

Cimetidine↗
PubMedDate not supplied

Follow-up of outpatient test results: a survey of house-staff practices and perceptions.

Failure to follow up outpatient test results is a potential patient safety concern; however, data about how house-staff physicians follow up on tests are sparse. The authors sought to assess internal medicine house-staff practices and perceptions regarding the follow-up of outpatient tests and identified barriers to timely follow-up. Seventy-five of 111 eligible house staff at a large urban teaching hospital (68%) completed the survey. Seventy-four percent reported they were sometimes unable to follow up on test results, 78% were at least somewhat worried about inadequate follow-up, and 46% stated that they have seen a patient's medical condition worsen due to a delay in test result follow-up at least a few times a year. Barriers to timely follow-up included lack of a reminder system (40%), difficulty accessing results (24%), too many competing demands on time (27%), and uncertainty about who should follow up on results (16%).

Attitude of Health Personnel↗
PubMed2006

Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions.

BACKGROUND: Despite awareness of inequities in health care quality, little is known about strategies that could improve the quality of healthcare for ethnic minority populations. We conducted a systematic literature review and analysis to synthesize the findings of controlled studies evaluating interventions targeted at health care providers to improve health care quality or reduce disparities in care for racial/ethnic minorities. METHODS: We performed electronic and hand searches from 1980 through June 2003 to identify randomized controlled trials or concurrent controlled trials. Reviewers abstracted data from studies to determine study characteristics, results, and quality. We graded the strength of the evidence as excellent, good, fair or poor using predetermined criteria. The main outcome measures were evidence of effectiveness and cost of strategies to improve health care quality or reduce disparities in care for racial/ethnic minorities. RESULTS: Twenty-seven studies met criteria for review. Almost all (n = 26) took place in the primary care setting, and most (n = 19) focused on improving provision of preventive services. Only two studies were designed specifically to meet the needs of racial/ethnic minority patients. All 10 studies that used a provider reminder system for provision of standardized services (mostly preventive) reported favorable outcomes. The following quality improvement strategies demonstrated favorable results but were used in a small number of studies: bypassing the physician to offer preventive services directly to patients (2 of 2 studies favorable), provider education alone (2 of 2 studies favorable), use of a structured questionnaire to assess adolescent health behaviors (1 of 1 study favorable), and use of remote simultaneous translation (1 of 1 study favorable). Interventions employing more than one main strategy were used in 9 studies with inconsistent results. There were limited data on the costs of these strategies, as only one study reported cost data. CONCLUSION: There are several promising strategies that may improve health care quality for racial/ethnic minorities, but a lack of studies specifically targeting disease areas and processes of care for which disparities have been previously documented. Further research and funding is needed to evaluate strategies designed to reduce disparities in health care quality for racial/ethnic minorities.

Ethnicity↗
PubMedDate not supplied

Real-time notification of laboratory data requested by users through alphanumeric pagers.

The authors developed a novel feature in their clinical information systems, which allows clinicians to request notification about laboratory results. Clinicians who are expecting a particular laboratory result for a particular patient can request a report of the result via an alphanumeric pager as soon as the result is filed into the patient database. This feature has gained popularity and is heavily used in both inpatient and outpatient settings, at a rate of about 2,300 times per month. This event-monitor-based feature illustrates one way that information technology can be applied to improve communication in health care.

Clinical Laboratory Information Systems↗
PubMed2000

Long-term patient adherence to antiretroviral therapy.

OBJECTIVE: To measure patient adherence to antiretroviral therapy over a two-year period and to identify factors impacting adherence. METHODS: In a regional HIV treatment center, 100 consecutive patients starting any new antiretroviral agent were enrolled in this study, which consisted of a one-year retrospective data review and a one-year prospective component. The tools used for evaluating adherence were the monthly prescription refill data and a patient questionnaire. Data analyzed included overall adherence, adherence to individual antiretrovirals, and change in adherence over time, as well as factors reported as influencing adherence. RESULTS: Greater than 80% adherence in taking prescribed doses was seen in 75% of patients during the retrospective phase of the study; adherence increased to 84% in the prospective phase. Throughout the prospective phase of the study, monthly median adherence rates were 98-100%. Suboptimal adherence secondary to pill fatigue or number of daily pills did not occur. Reported nonadherence to dietary restrictions varied among drugs. The primary cause given for poor adherence was difficulty remembering followed by inconvenient dosing schedule and difficulty scheduling administration times around meals. At least one adherence tool was used by 61% of patients. A diagnosis of AIDS was associated with lower adherence in our patient population (p = 0.039); substance abuse and psychiatric history had no influence. CONCLUSIONS: Adherence to antiretroviral treatment regimens did not diminish over the two years studied. Several patients with poor adherence were identified, emphasizing the importance of addressing this issue both prior to and throughout treatment. A personalized approach by healthcare providers can optimize patient adherence to antiretroviral therapy by providing careful drug selection in addition to routine follow-up and the provision of information, feedback, and reminder systems.

Acquired Immunodeficiency Syndrome↗
PubMed2006

Community-based participatory research increases cervical cancer screening among Vietnamese-Americans.

Using community-based participatory research methods, a community-research coalition in Santa Clara County, California (SCC) conducted a quasi-experimental, controlled trial to increase Pap test receipt and to build community capacity among Vietnamese-American women. From 1999 to 2004, the Coalition planned and implemented an Action Plan with six components: multimedia campaign, lay health worker outreach, Vietnamese Pap clinic with patient navigation, registry and reminder system, continuing medical education for Vietnamese physicians, and restoring a Breast and Cervical Cancer Control Program site. Components were evaluated individually. Community-wide, cross-sectional telephone surveys of Vietnamese women in SCC (intervention community) and Harris County, Texas (comparison community) measured overall project impact. Receipt and currency of Pap tests increased significantly in the intervention compared with the comparison community. Community involvement, system changes, community and research capacity building, dissemination of results, and program sustainability were also demonstrated. Community-based participatory research is feasible and effective in Vietnamese-American communities.

Adolescent↗
PubMedDate not supplied

A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors.

BACKGROUND: Notions about the most common errors in medicine currently rest on conjecture and weak epidemiologic evidence. We sought to determine whether cascade analysis is of value in clarifying the epidemiology and causes of errors and whether physician reports are sensitive to the impact of errors on patients. METHODS: Eighteen US family physicians participating in a 6-country international study filed 75 anonymous error reports. The narratives were examined to identify the chain of events and the predominant proximal errors. We tabulated the consequences to patients, both reported by physicians and inferred by investigators. RESULTS: A chain of errors was documented in 77% of incidents. Although 83% of the errors that ultimately occurred were mistakes in treatment or diagnosis, 2 of 3 were set in motion by errors in communication. Fully 80% of the errors that initiated cascades involved informational or personal miscommunication. Examples of informational miscommunication included communication breakdowns among colleagues and with patients (44%), misinformation in the medical record (21%), mishandling of patients' requests and messages (18%), inaccessible medical records (12%), and inadequate reminder systems (5%). When asked whether the patient was harmed, physicians answered affirmatively in 43% of cases in which their narratives described harms. Psychological and emotional effects accounted for 17% of physician-reported consequences but 69% of investigator-inferred consequences. CONCLUSIONS: Cascade analysis of physicians' error reports is helpful in understanding the precipitant chain of events, but physicians provide incomplete information about how patients are affected. Miscommunication appears to play an important role in propagating diagnostic and treatment mistakes.

Adolescent↗
PubMed2000

Assessing the value of pharmacists' health-systemwide services: clinical pathways and treatment guidelines.

Practice guidelines and clinical pathways are increasingly being used as tools to enhance the quality of health care services and to manage costs better. This article reviews the role of guidelines and clinical pathways in health care as defined within the broader concept of practice policies. The factors that increase the effectiveness of practice policies are examined. These include the origin of development, dissemination technique, and implementation strategy. Policies that are internally developed and implemented with concurrent reminder systems are the most effective. Clinical pathways fit these criteria and are therefore highly effective policy types. The roles that pharmacists within health systems can undertake in policy development are described. These include writing the policy document, providing expert review, providing education, and most important, facilitating the desired outcomes by implementing pharmacy services that promote compliance with the guidelines. Examples of pharmacy-based guideline and pathway implementation from the Henry Ford Health System are described for inpatient anticoagulation, outpatient preferred drug formulary policy, and outpatient lipid therapy management.

Anticoagulants↗
PubMed2002

Individualized drug use assessment in the elderly.

STUDY OBJECTIVE: To quantify how seniors' ability to take oral prescription drugs safely may correlate with age, sex, socioeconomic status, education, cognitive impairment, depression, and drug self-management. DESIGN: Cross-sectional study SETTING: Three retirement communities and an adult day care center. PATIENTS: Fifty-seven elderly individuals (mean age 79.49 +/- 7.26 yrs; mean education 11.33 +/- 3.8 yrs; 72% women). INTERVENTION: After completing a comprehensive medical history, and with drug vials and pillboxes available for consultation, each subject described how he or she was taking prescribed oral drugs. MEASUREMENTS AND MAIN RESULTS: The MedTake test evaluated dosage, indication, food or water coingestion, and regimen. For each agent, the test was scored as percentage of correct actions, equally weighted, and compared with label directions or self-expressed physician changes. A composite MedTake test score (0-100%) summarized a subject's overall ability to take their drug(s) safely A follow-up qualitative assessment by a single pharmacist assigned each agent to one of four potential risk categories: correct use, partial correct use without potential clinical significance, partial correct use with potential clinical significance, or incorrect use with high potential of clinical significance. Most subjects (80%) managed their own drug therapy; 70% used reminder systems (calendar, pillbox). The number of medical conditions and prescription drugs was 6.11 +/- 4.2 and 5.88 +/- 3.44, respectively. Of 325 agents, correct dosage was reported for 94% (306), correct indication for 95% (309), correct coingestion with food or water for 97% (314), and correct regimen for 89% (288). The composite MedTake test score was 88.5 +/- 21.3%. The multivariate model, with that score as the dependent variable, adjusted for age and sex, used Mini-Mental State Examination (p = 0.002) and Medicaid assistance within 10 years (p = 0.021) as significant factors. The most frequent problem was underdosing of cardiovascular drugs. CONCLUSION: Seniors' ability to take oral prescription drugs safely was affected by cognitive function and socioeconomic status. Although the MedTake test helped identify some problems with therapy adherence, a pharmacist's follow-up evaluation of comprehensive medical and drug histories identified additional potentially clinically significant problems in 20% of subjects.

Administration, Oral↗