RESUMEN
Computer-based clinical decision-support systems are effective interventions to improve compliance with guidelines and quality measures. However, understanding of their long-term impact, including unintended consequences, is limited. The authors assessed the clinical impact of the sequential implementation of 2 such systems to improve the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) in inpatients with heart failure. Compliance with the core measure improved from 91.0% at baseline to 93.6% with the Pharmacy Care (P-Care) Rule and to 96.4% with the Centricity-Blaze (CE-Blaze) Rule. At the same time, prescriptions for ACEIs/ARBs documented in the hospital discharge summary decreased from 83.2% at baseline to 75.8% with the P-Care rule and to 64.1% with the CE-Blaze Rule. The inpatient mortality rate and the 30-day readmission rate did not change significantly. Better documentation of contraindications in the electronic medical record seems to account for the core measure improvement, even as ACEI/ARB therapy has unexpectedly declined.
Asunto(s)
Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Sistemas de Apoyo a Decisiones Clínicas , Insuficiencia Cardíaca/tratamiento farmacológico , Anciano , Femenino , Adhesión a Directriz , Humanos , Masculino , Alta del Paciente/estadística & datos numéricos , Pautas de la Práctica en Medicina , Mejoramiento de la Calidad , Disfunción Ventricular Izquierda/tratamiento farmacológicoRESUMEN
BACKGROUND: National guidelines recommend angiotensin converting enzyme inhibitor (ACEi) or angiotensinogen receptor blocker (ARB) therapy for patients with left ventricular systolic dysfunction (LVSD), including those with symptomatic heart failure (HF). However, guideline adherence has not been optimal. The goal of this quality improvement project is to devise and implement a sustainable care-delivery model in a 920-bed academic hospital center that would improve ACEi/ARB adherence before hospital discharge. METHODS: The Model of intervention is: (1) a computer-based daily screening program; (2) inpatient pharmacist e-flag message; and (3) alerts for inpatient care teams. Its operating algorithm: If eligible adult HF/LVSD inpatients are not on ACEi or ARB nor documentation of contraindications, a flag alert is generated; deficiency is confirmed by a pharmacist and conveyed to the patient-care teams; if alert is acted on and care brought into adherence, the screening program would not re-flag the same patients the succeeding day; if not, the patients would be re-flagged daily until reaching adherence. We compared ACEi/ARB adherence before, during, and after the intervention. RESULTS: Baseline performance (percentage of eligible HF/LVSD patients receiving ACEi/ARB) was 87.5%. After implementation of the Model the ACEi/ARB adherence rate at the time of hospital discharge rose to 96.7% (P < 0.002) and was sustained for 21 months without needing additional personnel. CONCLUSIONS: A carefully designed, computer-based care-delivery model is highly efficient and sustainable for enhancing ACEi/ARB adherence.
Asunto(s)
Centros Médicos Académicos/normas , Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Adhesión a Directriz/normas , Insuficiencia Cardíaca Sistólica/tratamiento farmacológico , Calidad de la Atención de Salud/normas , Ensayos Clínicos Controlados Aleatorios como Asunto , Centros Médicos Académicos/métodos , Toma de Decisiones Asistida por Computador , Hospitalización , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto/normasRESUMEN
There continues to be a need for improved medical management of diabetes patients with hypertension in primary care. While several care models have shown effectiveness in achieving various outcomes among these patients, it remains unclear what care model is most effective in improving blood pressure control in primary care. In this prospective study, 54 patients with type 2 diabetes mellitus and blood pressure of >140/90 identified through the registry, were randomized into three groups. Group A attended a nurse educator-conducted class on diabetes and hypertension, group B attended the same class and was asked to monitor their home blood pressure using provided device, and group C served as control (usual care). Of the 24 subjects who completed the study, only 20% achieved the target blood pressure of <130/80 and there was no statistical difference in mean systolic and diastolic blood pressures among the three groups (p > 0.05). Efforts to intensify management of hypertension among type 2 diabetes patients did not result in better blood pressure control compared to usual care. Studies looking into factors which limit patients' participation in group classes and determining patients' preferences in disease management would be helpful in ensuring success of any chronic disease management program.
Asunto(s)
Antihipertensivos/uso terapéutico , Monitoreo Ambulatorio de la Presión Arterial , Presión Sanguínea/efectos de los fármacos , Diabetes Mellitus Tipo 2/complicaciones , Conocimientos, Actitudes y Práctica en Salud , Hipertensión/tratamiento farmacológico , Educación del Paciente como Asunto , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/enfermería , Diabetes Mellitus Tipo 2/fisiopatología , Femenino , Humanos , Hipertensión/complicaciones , Hipertensión/enfermería , Hipertensión/fisiopatología , Masculino , Persona de Mediana Edad , Cooperación del Paciente , Proyectos Piloto , Estudios Prospectivos , Sistema de Registros , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Screening mammography is recommended for early detection of breast cancer but screening rates remain suboptimal. METHODS: A primary care portal for a large academic primary practice was developed for all preventive services. Another Web-based system (PRECARES [PREventive CAre REminder System]) was developed for appointment secretaries to manage proactive breast cancer screening. Female patients aged 40 to 75 years were randomly assigned to a control group (usual care) and an intervention group. For the intervention group, 2 monthly letters inviting patients to undergo mammography were sent starting 3 months before they were due for annual screening, followed by a telephone call to nonresponding patients. A subgroup of women employees was further randomized to receive a reminder by either US mail or e-mail. RESULTS: Of the total eligible population of 6665 women identified as having consented to participate in research, 3339 were randomly assigned to the control group and 3326 to the intervention group. The screening rate for annual mammography was 64.3% for the intervention group and 55.3% for the control group (P <.001). There were no significant differences between the 2 groups for any of the other adult preventive services. For the employee subgroup, the screening rate was 57.5% for the control group, 68.1% for the US mail group, and 72.2% for the e-mail group (intervention vs control, P <.001; e-mail vs US mail; P = .24). CONCLUSION: The breast cancer screening rate improved significantly with the practice redesign of having appointment secretaries proactively manage breast cancer screening needs.