American journal of medical quality : the official journal of the American College of Medical Quality最新文献

Providing feedback to clinicians on their prescribing is a promising approach to right-sizing opioid prescriptions. The present research investigated the perceived acceptability, appropriateness, helpfulness, and areas for improvement of a monthly report providing surgical clinicians feedback on their postoperative opioid prescribing relative to guidelines, peer prescribing, and patient-reported pills taken, as well as on patient-reported ability to manage pain. Between January and May 2023, surgeons, advanced practice providers, and residents who recently received these reports as part of a health system quality improvement intervention completed a survey (n = 38) or interview (n = 8). Mean (SD) acceptability of the prescribing report was 4.2 (0.8), and appropriateness was 4.2 (0.8); appropriateness varied by clinical role. All features of the report were rated as "very" or "extremely" helpful by a majority of respondents. Interviewees wished for fuller explanations, real-time updates, and improved accuracy. These findings can inform the design of clinician feedback in learning health systems.

This nationwide cross-sectional study explored the relationship between ambulatory care fragmentation and medication use in older US adults, examining variations by chronic conditions and race. Utilizing data from the 2003-2016 REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study linked with fee-for-service Medicare claims, the authors analyzed care fragmentation (measured by the reversed Bice-Boxerman Index) and medication counts through a 2-week in-person prescription inventory. They employed negative binomial regression, adjusting for potential confounders, and conducted subgroup analyses based on chronic conditions and race. Of the 4524 participants, 40.7% experienced high care fragmentation and 59.8% used 5 or more medications. High fragmentation was associated with a 4% overall increase in medication count ( P = 0.03), a 7% increase for those with 4+ chronic conditions ( P = 0.01), and a 9% increase for Black participants ( P = 0.01). In conclusion, fragmented care is independently associated with greater polypharmacy, particularly among Black older adults and those with multiple chronic conditions.

Risk adjustment plays a key role in payment, especially in value-based payment models, which use a practice's performance with cost and quality metrics to determine reimbursement. Inaccurate representation of a patient's medical complexity can cause a practice to fall below cost and/or quality performance targets, potentially leading to a substantial loss of shared savings dollars. This quality improvement study evaluated the effectiveness of a clinical documentation excellence program, focused on addressing hierarchical condition category diagnoses, involving the medical specialties. The program included tools in the electronic health record, metrics to monitor and provide feedback on clinician performance, and regular interactions with the nurse and physician leads for each specialty. For clinicians of medical specialties, the education program resulted in an increase in the percentage of hierarchical condition category diagnoses addressed at outpatient encounters from 25% to 62% over a 2-year period.

Timely closure of patient encounters and addressing tasks in the Electronic Health Record (EHR) inbox are essential for quality care and efficiency. Delinquent items in the EHR inbox impact patient care, cost of care, and overall patient and provider experience. This project aimed to improve the management of these items using a quality improvement initiative with a bundled intervention. This study was conducted using a quasi-experimental method with interrupted time series. Stakeholders were engaged to define policies and expectations based on root cause analysis. Interventions included creating policy and procedures with clear expectations, creating resources, addressing inbox management delinquency using Just Culture with consoling, coaching, and disciplining. Simple rubrics using the situation-behavior-impact framework and motivational interviewing questions were used for coaching. Data were analyzed using JMP Pro 16 with statistical process control charts for phase analysis. Poisson regression was used to explore statistically significant trends after the implementation of the intervention bundle. The average number of open encounters decreased from 71 per week preintervention to 33.8 per week in the rollout period, and 12.2 per week postintervention. The phase analysis on individual moving range control chart showed a significant shift in the process after the implementation of the intervention. Poisson regression showed a 78% decrease in the number of delinquent items ( P < 0.001) after the implementation of the bundled intervention. A multifaceted intervention significantly improved EHR inbox management with potentially positive impact on the quadruple aim.

Providing feedback to clinicians on their prescribing is a promising approach to right-sizing opioid prescriptions. The present research investigated the perceived acceptability, appropriateness, helpfulness, and areas for improvement of a monthly report providing surgical clinicians feedback on their postoperative opioid prescribing relative to guidelines, peer prescribing, and patient-reported pills taken, as well as on patient-reported ability to manage pain. Between January and May 2023, surgeons, advanced practice providers, and residents who recently received these reports as part of a health system quality improvement intervention completed a survey (n = 38) or interview (n = 8). Mean (SD) acceptability of the prescribing report was 4.2 (0.8), and appropriateness was 4.2 (0.8); appropriateness varied by clinical role. All features of the report were rated as "very" or "extremely" helpful by a majority of respondents. Interviewees wished for fuller explanations, real-time updates, and improved accuracy. These findings can inform the design of clinician feedback in learning health systems.

A novel volunteer program was implemented in the adult emergency department waiting room to combat declining patient satisfaction, a crucial quality metric impacting everything from hospital reimbursement to clinical outcomes. Net Promotor Scores (NPS) were tracked in a retrospective cohort design, with patients interacting with volunteers serving as the intervention cohort and those who did not serving as control. Analysis using monthly NPS means was conducted from 2022 to 2023. The absolute difference in NPS between the 2 groups was 17.43. Using monthly means, an unpaired t -test was conducted. NPS in the intervention group was 51.86 with a standard deviation of 7.01. NPS in the control was 34.43 with a standard deviation of 5.32. Data is significant, with P = 0.0002. This emergency department waiting room volunteer program led to increases in patient satisfaction. Study authors think similar effects are achievable at other institutions, and future trials would be beneficial in confirming this suspected causal relationship.

Chest pain is one of the most common presenting complaints to emergency departments in the United States, and management centers on identifying myocardial infarction or other forms of rare but problematic cardiac diagnoses. The high-sensitivity troponin assay can detect abnormal troponin elevations at 10- to 100-fold lower levels compared with traditional troponin assays and thus can allow faster time to disposition and diagnosis, yet adoption has not been universal. Implementing a high-sensitivity troponin protocol with a risk prediction algorithm can decrease the numbers of patients admitted, reduce unnecessary testing, and shorten patient stays in the emergency department. This quality improvement project was undertaken in a community-academic health system lacking a system-wide protocol to workup patients presenting with chest pain to the emergency department. Key stakeholders evaluated multiple barriers and identified measures, planned implementation of the new assay and its associated algorithm, led postimplementation data monitoring and analysis, and delivered progress reports to organizational leaders. Chest pain admissions were managed by hospitalists in the absence of a cardiology inpatient service. The most important barriers were found to be individual provider strategy, electronic medical record design, and the lack of capacity for cardiology evaluations in both inpatient and outpatient settings. Stakeholder buy-in, monthly data reports, team meetings, and widespread education were used to support the changes in ordering patterns and evaluation. Postimplementation, 3293 patients were assessed over a 12-month period. Baseline mean length of stay for chest pain in the emergency department decreased from 297 minutes (SD, 53) to 274 minutes (SD, 33; P = 0.03). Hospital chest pain observation admissions decreased from 23% to 14% of patients presenting with chest pain ( P <0.001). Stress tests ordered for observation patients decreased from 12 per month to 3 ( P <0.001). Similarly, in observation patients, echocardiograms decreased from 61 to 46 per month ( P <0.001), cardiology consultation decreased from 125 per month to 81 ( P <0.001), and cardiac catheterization decreased from 41 per month to 32 following the intervention ( P = 0.003). Developing a standardized management protocol and selecting physician leaders to maintain and revise protocols were high-impact, low to moderate-effort interventions resulting in significant changes in practice. This study demonstrated that a high-sensitivity troponin assay, combined with a chest pain clinical management protocol based on the Heart, EKG, Age, Risk factor, Troponin score, was able to achieve a reduction in emergency department length of stay, a decrease in hospital observation admissions, and reduced cardiac testing in this patient population.