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Information on the impact of pay-for-performance programs is lacking in the nursing home setting. This literature review (1980-2007) identified 13 prior examples of pay-for-performance programs in the nursing home setting: 7 programs were active as of 2007, while 6 had been terminated. The programs were mostly short-lived, varied considerably in the choice of performance measures and pay incentives, and evaluations of the impact were rare.

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CONTEXT: Research suggests that pharmaceutical marketing influences prescribing and may cause cognitive dissonance for prescribers. This work has primarily been with physicians and physician-trainees. Questions remain regarding why prescribers continue to meet with pharmaceutical representatives (PRs). OBJECTIVE: To describe the reasons that prescribers from various health professions continue to interact with PRs despite growing evidence of the influence of these interactions. DESIGN, SETTING, AND PARTICIPANTS: Multi-disciplinary focus groups with 61 participants held in practice settings and at society meetings. RESULTS: Most prescribers participating in our focus groups believe that overall PR interactions are beneficial to patient care and practice health. They either trust the information from PRs or feel that they are equipped to evaluate it independently. Despite acknowledgement of study findings to the contrary, prescribers state that they are able to effectively manage PR interactions such that their own prescribing is not adversely impacted. Prescribers describe few specific strategies or policies for these interactions, and report that policies are not consistently implemented with all members of a clinic or institution. Some prescribers perceive an inherent contradiction between academic centers and national societies receiving money from pharmaceutical companies, and then recommending restriction at the level of the individual prescriber. Prescribers with different training backgrounds present a few novel reasons for these meetings. CONCLUSIONS: Despite evidence that PR detailing influences prescribing, providers from several health professions continue to believe that PR interactions improve patient care, and that they can adequately evaluate and filter information presented to them by PRs. Focus group comments suggest that cultural change is necessary to break the norms that exist in many settings. Applying policies consistently, considering non-physician members of the healthcare team, working with trainees, restructuring the current primary care model and offering convenient, individualized, non-biased educational options may aid success.

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UNLABELLED: OBJECTIVE To determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency. DESIGN Randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units. Measurement The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information. RESULTS The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units-relative risk 1.2 (1.0, 1.4). CONCLUSIONS Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions. TRIAL REGISTRATION: http://clinicaltrials.gov Identifier: NCT00599209.

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OBJECTIVES: To quantify the time required for nurses to complete the medication administration process in long-term care (LTC). DESIGN: Time-motion methods were used to time all steps in the medication administration process. SETTING: LTC units that differed according to case mix (physical support, behavioral care, dementia care, and continuing care) in a single facility in Ontario, Canada. PARTICIPANTS: Regular and temporary nurses who agreed to be observed. MEASUREMENTS: Seven predefined steps, interruptions, and total time required for the medication administration process were timed using a personal digital assistant. RESULTS: One hundred forty-one medication rounds were observed. Total time estimates were standardized to 20 beds to facilitate comparisons. For a single medication administration process, the average total time was 62.0+/-4.9 minutes per 20 residents on physical support units, 84.0+/-4.5 minutes per 20 residents on behavioral care units, and 70.0+/-4.9 minutes per 20 residents on dementia care units. Regular nurses took an average of 68.0+/-4.9 minutes per 20 residents to complete the medication administration process, and temporary nurses took an average of 90.0+/-5.4 minutes per 20 residents. On continuing care units, which are organized differently because of the greater severity of residents' needs, the medication administration process took 9.6+/-3.2 minutes per resident. Interruptions occurred in 79% of observations and accounted for 11.5% of the medication administration process. CONCLUSION: Time requirements for the medication administration process are substantial in LTC and are compounded when nurses are unfamiliar with residents. Interruptions are a major problem, potentially affecting the efficiency, quality, and safety of this process.

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OBJECTIVES: To evaluate the efficacy of computerized provider order entry with clinical decision support for preventing adverse drug events in long-term care. DESIGN: Cluster-randomized controlled trial. SETTING: Two large long-term care facilities. PATIENTS: One thousand one hundred eighteen long-term care residents of 29 resident care units. INTERVENTION: The 29 resident care units, each with computerized provider order entry, were randomized to having a clinical decision support system (intervention units) or not (control units). MEASUREMENTS: The number of adverse drug events, severity of events, and whether the events were preventable. RESULTS: Within intervention units, 411 adverse drug events occurred over 3,803 resident-months of observation time; 152 (37.0%) were deemed preventable. Within control units, there were 340 adverse drug events over 3,257 resident-months of observation time; 126 (37.1%) were characterized as preventable. There were 10.8 adverse drug events per 100 resident-months and 4.0 preventable events per 100 resident-months on intervention units. There were 10.4 adverse drug events per 100 resident-months and 3.9 preventable events per 100 resident-months on control units. Comparing intervention and control units, the adjusted rate ratios were 1.06 (95% confidence interval (CI)=0.92-1.23) for all adverse drug events and 1.02 (95% CI=0.81-1.30) for preventable adverse drug events. CONCLUSION: Computerized provider order entry with decision support did not reduce the adverse drug event rate or preventable adverse drug event rate in the long-term care setting. Alert burden, limited scope of the alerts, and a need to more fully integrate clinical and laboratory information may have affected efficacy.

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A team of physicians, pharmacists, and informatics professionals developed a CDSS added to a commercial electronic medical record system to provide prescribers with patient-specific maximum dosing recommendations based on renal function. We tracked the time spent by team members and used US national averages of relevant hourly wages to estimate costs. The team required 924.5 hours and $48,668.57 in estimated costs to develop 94 alerts for 62 drugs. The most time intensive phase of the project was preparing the contents of the CDSS (482.25 hours, $27,455.61). Physicians were the team members with the highest time commitment (414.25 hours, $25,902.04). Estimates under alternative scenarios found lower total cost estimates with the existence of a valid renal dosing database ($34,200.71) or an existing decision support add-on for renal dosing ($23,694.51). Development of a CDSS for a commercial computerized prescriber order entry system requires extensive commitment of personnel, particularly among clinical staff.

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OBJECTIVE: To determine the relative impact of incorporating narrative evidence, statistical evidence or both into patient education about warfarin, a widely used oral anticoagulant medication. METHODS: 600 patients receiving anticoagulant therapy were randomly assigned to view one of three versions of a video depicting a physician-patient encounter where anticoagulation treatment was discussed, or usual care (no video). The videos differed in whether the physician used narrative evidence (patient anecdotes), statistical evidence, or both to highlight key information. 317 patients completed both the baseline and post-test questionnaires. Questions assessed knowledge, beliefs and adherence to medication and laboratory monitoring regimens. RESULTS: All three approaches positively effected patients' warfarin-related knowledge, and beliefs in the importance of lab testing; there was also some indication that viewing a video strengthened belief in the benefits of warfarin. There was some indication that narrative evidence had a greater impact than statistical evidence on beliefs about the importance of lab testing and on knowledge. No other evidence of the differential effectiveness of either approach was found. No statistically significant effect was found on intent to adhere, or documented adherence to lab monitoring. CONCLUSION: Videos depicting a physician-patient dialogue about warfarin were effective in educating patients about anticoagulant medication, and had a positive impact on their beliefs. The use of narrative evidence in the form of patient anecdotes may be more effective than statistical evidence for some patient outcomes. PRACTICE IMPLICATIONS: Patients on oral anticoagulant therapy may benefit from periodic educational efforts reinforcing key medication safety information, even after initial education and ongoing monitoring. Incorporating patient anecdotes into physician-patient dialogues or educational materials may increase the effectiveness of the message.

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BACKGROUND: Disclosure of medical errors is encouraged, but research on how patients respond to specific practices is limited. OBJECTIVE: This study sought to determine whether full disclosure, an existing positive physician-patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influenced patients' responses to medical errors. PARTICIPANTS: Four hundred and seven health plan members participated in a randomized experiment in which they viewed video depictions of medical error and disclosure. DESIGN: Subjects were randomly assigned to experimental condition. Conditions varied in type of medication error, level of disclosure, reference to a prior positive physician-patient relationship, an offer to waive costs, and clinical outcome. MEASURES: Self-reported likelihood of changing physicians and of seeking legal advice; satisfaction, trust, and emotional response. RESULTS: Nondisclosure increased the likelihood of changing physicians, and reduced satisfaction and trust in both error conditions. Nondisclosure increased the likelihood of seeking legal advice and was associated with a more negative emotional response in the missed allergy error condition, but did not have a statistically significant impact on seeking legal advice or emotional response in the monitoring error condition. Neither the existence of a positive relationship nor an offer to waive costs had a statistically significant impact. CONCLUSIONS: This study provides evidence that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. The clinical outcome also influences patients' responses. The impact of an existing positive physician-patient relationship, or of waiving costs associated with the error remains uncertain.

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CONTEXT: Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. OBJECTIVE: To identify major factors and areas of tension in trainees' learning from medical errors. DESIGN, SETTING, AND PARTICIPANTS: Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. RESULTS: Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. CONCLUSIONS: Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility.

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