47 results on '"Stephen D. Persell"'
Search Results
2. PS-BPC11-7: SEX DIFFERENCES IN BLOOD PRESSURE CONTROL FOLLOWING REMOTE PATIENT MONITORING IMPLEMENTATION WITH AND WITHOUT CARE COORDINATION: A PROSPECTIVE COHORT STUDY
- Author
-
Stephen D Persell, Lucia C Petito, Lauren Anthony, Yaw Peprah, Ji Young Lee, Jim Li, and Hironori Sato
- Subjects
Physiology ,Internal Medicine ,Cardiology and Cardiovascular Medicine - Published
- 2023
3. Effect of Peer Benchmarking on Specialist Electronic Consult Performance in a Los Angeles Safety-Net: a Cluster Randomized Trial
- Author
-
Mark W. Friedberg, Hal F. Yee, Noah J. Goldstein, Nancy Cayasso-McIntosh, Craig R. Fox, Dina Zein, Tara K. Knight, Stephen D. Persell, Jeffrey A. Linder, Stanley Dea, Paul Giboney, Jason N. Doctor, and Daniella Meeker
- Subjects
Behavioral Economics and eConsult Steering Committee ,Best practice ,Clinical Trials and Supportive Activities ,Clinical Sciences ,Psychological intervention ,Context (language use) ,behavioral economics ,law.invention ,Randomized controlled trial ,law ,quality of care ,Clinical Research ,General & Internal Medicine ,Internal Medicine ,Medicine ,Humans ,Cluster randomised controlled trial ,Referral and Consultation ,Original Research ,Medical education ,electronic consultation ,peer comparison ,business.industry ,Electronic consultation ,specialty care ,COVID-19 ,Benchmarking ,Health Services ,Los Angeles ,Test (assessment) ,Electronics ,business - Abstract
Background Since the advent of COVID-19, accelerated adoption of systems that reduce face-to-face encounters has outpaced training and best practices. Electronic consultations (eConsults), structured communications between PCPs and specialists regarding a case, have been effective in reducing face-to-face specialist encounters. As the health system rapidly adapts to multiple new practices and communication tools, new mechanisms to measure and improve performance in this context are needed. Objective To test whether feedback comparing physicians to top performing peers using co-specialists’ ratings improves performance. Design Cluster-randomized controlled trial Participants Eighty facility-specialty clusters and 214 clinicians Intervention Providers in the feedback arms were sent messages that announced their membership in an elite group of “Top Performers” or provided actionable recommendations with feedback for providers that were “Not Top Performers.” Main Measures The primary outcomes were changes in peer ratings in the following performance dimensions after feedback was received: (1) elicitation of information from primary care practitioners; (2) adherence to institutional clinical guidelines; (3) agreement with peer’s medical decision-making; (4) educational value; (5) relationship building. Key Results Specialists showed significant improvements on 3 of the 5 consultation performance dimensions: medical decision-making (odds ratio 1.52, 95% confidence interval 1.08–2.14, p
- Published
- 2022
4. Changes in COVID-19 Knowledge, Beliefs, Behaviors, and Preparedness Among High-Risk Adults from the Onset to the Acceleration Phase of the US Outbreak
- Author
-
Daniela P. Ladner, Pauline Zheng, Andrea M. Russell, Stephen D. Persell, Lauren Opsasnick, Laura M. Curtis, Mary J. Kwasny, Stacy Cooper Bailey, Marina Arvanitis, Marina Serper, Guisselle Wismer, Morgan Eifler, Theresa A. Rowe, Rachel O'Conor, Jeffrey A. Linder, Julia Yoshino Benavente, Stephanie Batio, and Michael S. Wolf
- Subjects
Male ,Chronic condition ,medicine.medical_specialty ,knowledge ,Health Knowledge, Attitudes, Practice ,behaviors ,Health literacy ,01 natural sciences ,03 medical and health sciences ,0302 clinical medicine ,Internal Medicine ,Medicine ,Humans ,030212 general & internal medicine ,Longitudinal Studies ,0101 mathematics ,Original Research ,Aged ,Chicago ,attitudes ,business.industry ,SARS-CoV-2 ,Public health ,010102 general mathematics ,Outbreak ,COVID-19 ,Middle Aged ,medicine.disease ,Comorbidity ,Confidence interval ,Health Literacy ,comorbidity ,Preparedness ,Relative risk ,Female ,Self Report ,business ,Demography - Abstract
Background The US outbreak of coronavirus disease 2019 (COVID-19) accelerated rapidly over a short time to become a public health crisis. Objective To assess how high-risk adults’ COVID-19 knowledge, beliefs, behaviors, and sense of preparedness changed from the onset of the US outbreak (March 13–20, 2020) to the acceleration phase (March 27–April 7, 2020). Design Longitudinal, two-wave telephone survey. Participants 588 predominately older adults with ≥ 1 chronic condition recruited from 4 active, federally funded studies in Chicago. Main Measures Self-reported knowledge of COVID-19 symptoms and prevention, related beliefs, behaviors, and sense of preparedness. Key Results From the onset to the acceleration phase, participants increasingly perceived COVID-19 to be a serious public health threat, reported more changes to their daily routine and plans, and reported greater preparedness. The proportion of respondents who believed they were “not at all likely” to get the virus decreased slightly (24.9 to 22.4%; p = 0.04), but there was no significant change in the proportion of those who were unable to accurately identify ways to prevent infection (29.2 to 25.7%; p 0.14). In multivariable analyses, black adults and those with lower health literacy were more likely to report less perceived susceptibility to COVID-19 (black adults: relative risk (RR) 1.62, 95% confidence interval (CI) 1.07–2.44, p = 0.02; marginal health literacy: RR 1.96, 95% CI 1.26–3.07, p < 0.01). Individuals with low health literacy remained more likely to feel unprepared for the outbreak (RR 1.80, 95% CI 1.11–2.92, p = 0.02) and to express confidence in the federal government response (RR 2.11, 95% CI 1.49–3.00, p < 0.001) Conclusions Adults at higher risk for COVID-19 continue to lack critical knowledge about prevention. While participants reported greater changes to daily routines and plans, disparities continued to exist in perceived susceptibility to COVID-19 and in preparedness. Public health messaging to date may not be effectively reaching vulnerable communities.
- Published
- 2020
5. Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement
- Author
-
Tiffany Brown, Daniella Meeker, Jody D. Ciolino, Jeffrey A. Linder, Mark W. Friedberg, Theresa A. Rowe, Stephen D. Persell, Ji Young Lee, and Jason N. Doctor
- Subjects
Male ,medicine.medical_specialty ,Urinalysis ,Intraclass correlation ,MEDLINE ,Urine ,01 natural sciences ,03 medical and health sciences ,0302 clinical medicine ,Diabetes mellitus ,Diabetes Mellitus ,Internal Medicine ,Humans ,Medicine ,030212 general & internal medicine ,0101 mathematics ,Aged ,Retrospective Studies ,Original Research ,Glycated Hemoglobin ,Geriatrics ,medicine.diagnostic_test ,business.industry ,010102 general mathematics ,Odds ratio ,Prostate-Specific Antigen ,medicine.disease ,United States ,Quartile ,Emergency medicine ,Female ,business - Abstract
IMPORTANCE: The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood. OBJECTIVE: To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. DESIGN: Retrospective analysis of overall means and clinician-level variation in performance on three new measures. SUBJECTS: Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017. MEASURES: Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication. RESULTS: Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8–54% for the PSA measure, 3–35% for the urinalysis/urine culture measure, and 13–49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively. CONCLUSIONS: Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05748-8) contains supplementary material, which is available to authorized users.
- Published
- 2020
6. Outreach to Promote Management of Cardiovascular Risk in Primary Care Among Patients With Rheumatoid Arthritis Seen in Rheumatology Practice
- Author
-
Dawid Lipiszko, Darcy S. Majka, Eric Ruderman, Yaw A. Peprah, Ji Young Lee, Stephen D. Persell, and Michael A. Schachter
- Subjects
medicine.medical_specialty ,lcsh:Diseases of the musculoskeletal system ,Statin ,medicine.drug_class ,business.industry ,MEDLINE ,Disease ,Original Articles ,medicine.disease ,Rheumatology ,Outreach ,Rheumatoid arthritis ,Intervention (counseling) ,Internal medicine ,Emergency medicine ,medicine ,Original Article ,lcsh:RC925-935 ,Risk factor ,business - Abstract
Objective Rheumatoid arthritis (RA) confers a 1.5‐ to 2.0‐fold increased risk of cardiovascular disease (CVD). A prior multifaceted quality improvement approach to improving CVD preventive care increased CVD risk factor assessments, but there was no significant effect on the management of risk factors. We tested the impact of adding a proactive outreach strategy promoting primary care treatment of CVD risk factors among patients with RA through their rheumatology practice. Methods Through electronic health record searches, we identified patients with RA who were potential candidates for hypertension treatment initiation or intensification, statin therapy, or a smoking‐cessation intervention. A nonclinician care manager contacted patients by phone and mail on behalf of the rheumatologists, provided information about the identified risk factor(s), recommend follow‐up with primary care physicians (PCPs), sent correspondence to PCPs, and followed up with patients to see what actions had been taken. We measured preventive cardiology quality indicators and compared preintervention and intervention time periods using interrupted time series methods. Results During the 6‐month intervention period, the proportion of patients prescribed at least moderate‐intensity statin treatment for primary prevention rose from 18.4% to 23.8%. The rate of increase was 1.06% greater per month than during the preceding period (P < 0.001). Rates of increase in hypertension diagnosis and control improved more rapidly during this phase (P < 0.001 for each) and reversed preceding negative trends. Conclusion Implementing proactive nonclinician outreach to encourage primary care–based treatment of CVD risk factors was associated with increases in statin prescribing and in hypertension diagnosis and control. Smoking was not affected.
- Published
- 2020
7. Identifying and addressing social determinants of health in outpatient practice: results of a program-wide survey of internal and family medicine residents
- Author
-
Matthew J. O’Brien, Quentin R. Youmans, Andrew Cooper, Lauren A. Gard, Muriel Jean-Jacques, Paul Ravenna, Aashish K. Didwania, Mita Sanghavi Goel, and Stephen D. Persell
- Subjects
Adult ,Male ,medicine.medical_specialty ,Graduate medical education ,Black People ,lcsh:Medicine ,Primary care ,01 natural sciences ,White People ,Education ,03 medical and health sciences ,Social determinants of health ,0302 clinical medicine ,Asian People ,030225 pediatrics ,Ambulatory Care ,Internal Medicine ,medicine ,Humans ,0101 mathematics ,Referral and Consultation ,Competence (human resources) ,Veterans Affairs ,lcsh:LC8-6691 ,Career Choice ,Primary Health Care ,lcsh:Special aspects of education ,business.industry ,Professional Practice Location ,010102 general mathematics ,lcsh:R ,Age Factors ,Internship and Residency ,Hispanic or Latino ,General Medicine ,3. Good health ,Annual income ,Family medicine ,Veterans Health Services ,Income ,Female ,Clinical Competence ,Family Practice ,business ,Safety-net Providers ,Research Article - Abstract
Background Up to 60% of preventable mortality is attributable to social determinants of health (SDOH), yet training on SDOH competencies is not widely implemented in residency. The objective of this study was to assess internal and family medicine residents’ competence at identifying and addressing SDOH. Methods Residents’ perceived competence at identifying, discussing, and addressing SDOH in outpatient settings was assessed using a single questionnaire administered in March 2017. In this cross-sectional analysis, bivariate associations of resident characteristics with the following outcomes were examined: identifying, discussing, and addressing patients’ challenges related to SDOH through referrals. Results The survey was completed by 129 (84%) residents. Twenty residents (16%) reported an annual income of less than $50,000 during childhood. Overall, 108 residents (84%) reported previous SDOH training. Two-thirds had outpatient practices in Veterans Affairs or safety-net clinics. Thirty-nine (30%) intended to pursue a career in primary care. The following numbers of residents reported high levels of competence for performing these outcomes: identifying patients’ challenges related to SDOH: 37 (29%); discussing them with patients: 18 (14%); and addressing these challenges through referrals to internal and external resources: 13 (10%) and 11 (9%), respectively. Factors associated with higher competence included older age, lower childhood household income, prior education about SDOH, primary practice site and intention to practice primary care. Conclusions Most residents had previous SDOH training, yet only a small proportion of residents reported being highly competent at identifying or addressing SDOH. Providing opportunities for practical training may be a key component in preparing medical residents to identify and address SDOH effectively in outpatient practice.
- Published
- 2020
8. Six Recommendations for Accelerating Uptake of National Food Security Screening in Primary Care Settings
- Author
-
Namratha R. Kandula, Sabira Taher, and Stephen D. Persell
- Subjects
medicine.medical_specialty ,Food security ,Primary Health Care ,business.industry ,Primary care ,Food Supply ,Viewpoint ,Food Security ,Family medicine ,Internal Medicine ,medicine ,Humans ,Mass Screening ,business - Published
- 2021
9. Rethinking What Is Essential in the Office Visit Note
- Author
-
Heather L. Heiman and Stephen D. Persell
- Subjects
Medical education ,Viewpoint ,business.industry ,Office Visits ,Office visits ,Internal Medicine ,Medicine ,Humans ,business - Published
- 2021
10. Development of High-Risk Geriatric Polypharmacy Electronic Clinical Quality Measures and a Pilot Test of EHR Nudges Based on These Measures
- Author
-
Stephen D. Persell, Tiffany Brown, Jason N. Doctor, Craig R. Fox, Noah J. Goldstein, Steven M. Handler, Joseph T Hanlon, Ji Young Lee, Jeffrey A. Linder, Daniella Meeker, Theresa A Rowe, Mark D. Sullivan, and Mark W. Friedberg
- Subjects
Anti-Inflammatory Agents, Non-Steroidal ,Internal Medicine ,Polypharmacy ,Electronic Health Records ,Humans ,Inappropriate Prescribing ,Electronics ,Aged ,Quality Indicators, Health Care - Abstract
Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms.To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing.We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019.Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot.Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease.Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a "commitment nudge" that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a "justification nudge" that asked for a reason when high-risk polypharmacy was present. One practice received both.Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%).EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.
- Published
- 2021
11. Changes in Care After Implementing a Multifaceted Intervention to Improve Preventive Cardiology Practice in Rheumatoid Arthritis
- Author
-
Darcy S. Majka, Ji Young Lee, Elisha M. Friesema, Dawid Lipiszko, Yaw A. Peprah, Stephen D. Persell, and Eric Ruderman
- Subjects
Male ,medicine.medical_specialty ,Statin ,Quality management ,medicine.drug_class ,Disease ,Affect (psychology) ,Clinical decision support system ,Feedback ,Arthritis, Rheumatoid ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Intervention (counseling) ,medicine ,Humans ,030212 general & internal medicine ,Quality Indicators, Health Care ,Quality of Health Care ,business.industry ,030503 health policy & services ,Health Policy ,Middle Aged ,Decision Support Systems, Clinical ,medicine.disease ,Quality Improvement ,Rheumatology ,Cardiovascular Diseases ,Rheumatoid arthritis ,Emergency medicine ,Female ,Hydroxymethylglutaryl-CoA Reductase Inhibitors ,0305 other medical science ,business ,Risk Reduction Behavior - Abstract
Rheumatoid arthritis (RA) increases cardiovascular disease (CVD) risk. However, CVD risk factor identification and treatment is often inadequate. The authors implemented a multifaceted rheumatology practice intervention to improve CVD risk factor measurement, assessment, and management. The intervention included clinician education, point-of-care decision support, feedback, and care management. The authors measured quality indicators from electronic health records and assessed impact with interrupted time series. Following the intervention, more RA patients had all major CVD risk factors assessed (53% vs 72.2%), and the rate of increase was greater during the intervention period than baseline (difference of 0.74% per month, P = .0016). Moderate- or high-intensity statin prescribing increased (21.6% to 28.2%), but the rate of change was not different from baseline. Several other quality measures did not increase. Although CVD risk factor assessment improved, the intervention did not affect risk factor management and control. Other strategies are needed to optimize CVD prevention in RA.
- Published
- 2018
12. Effect of Electronic Health Record–Based Medication Support and Nurse-Led Medication Therapy Management on Hypertension and Medication Self-management: A Randomized Clinical Trial
- Author
-
Milton Eder, Kunal N. Karmali, Elisha M. Friesema, Alfred Rademaker, Ji Young Lee, Danielle Lazar, Michael S. Wolf, Darren Kaiser, Stephen D. Persell, Tiffany Brown, and Dustin D. French
- Subjects
medicine.medical_specialty ,Intention-to-treat analysis ,business.industry ,Psychological intervention ,Odds ratio ,030204 cardiovascular system & hematology ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Blood pressure ,Randomized controlled trial ,law ,Medication therapy management ,Emergency medicine ,Internal Medicine ,Medicine ,030212 general & internal medicine ,Dosing ,Medical prescription ,business ,Original Investigation - Abstract
Importance Complex medication regimens pose self-management challenges, particularly among populations with low levels of health literacy. Objective To test medication management tools delivered through a commercial electronic health record (EHR) with and without a nurse-led education intervention. Design, Setting, and Participants This 3-group cluster randomized clinical trial was performed in community health centers in Chicago, Illinois. Participants included 794 patients with hypertension who self-reported using 3 or more medications concurrently (for any purpose). Data were collected from April 30, 2012, through February 29, 2016, and analyzed by intention to treat. Interventions Clinics were randomly assigned to to groups: electronic health record–based medication management tools (medication review sheets at visit check-in, lay medication information sheets printed after visits; EHR-alone group), EHR-based tools plus nurse-led medication management support (EHR plus education group), or usual care. Main Outcomes and Measures Outcomes at 12 months included systolic blood pressure (primary outcome), medication reconciliation, knowledge of drug indications, understanding of medication instructions and dosing, and self-reported medication adherence. Medication outcomes were assessed for all hypertension prescriptions, all prescriptions to treat chronic disease, and all medications. Results Among the 794 participants (68.6% women; mean [SD] age, 52.7 [9.6] years), systolic blood pressure at 12 months was greater in the EHR-alone group compared with the usual care group by 3.6 mm Hg (95% CI, 0.3 to 6.9 mm Hg). Systolic blood pressure in the EHR plus education group was not significantly lower compared with the usual care group (difference, −2.0 mm Hg; 95% CI, −5.2 to 1.3 mm Hg) but was lower compared with the EHR-alone group (−5.6 mm Hg; 95% CI, −8.8 to −2.4 mm Hg). At 12 months, hypertension medication reconciliation was improved in the EHR-alone group (adjusted odds ratio [OR], 1.8; 95% CI, 1.1 to 2.9) and the EHR plus education group (adjusted odds ratio [OR], 2.0; 95% CI, 1.3 to 3.3) compared with usual care. Understanding of medication instructions and dosing was greater in the EHR plus education group than the usual care group for hypertension medications (OR, 2.3; 95% CI, 1.1 to 4.8) and all medications combined (OR, 1.7; 95% CI, 1.0 to 2.8). Compared with usual care, the EHR tools alone and EHR plus education interventions did not improve hypertension medication adherence (OR, 0.9; 95% CI, 0.6-1.4 for both) or knowledge of chronic drug indications (OR for EHR tools alone, 1.0 [95% CI, 0.6 to 1.5] and OR for EHR plus education, 1.1 [95% CI, 0.7-1.7]). Conclusions and Relevance The study found that EHR tools in isolation improved medication reconciliation but worsened blood pressure. Combining these tools with nurse-led support suggested improved understanding of medication instructions and dosing but did not lower blood pressure compared with usual care. Trial Registration ClinicalTrials.gov identifier:NCT01578577
- Published
- 2018
13. Frequency of Testing for Prostate Cancer Using Prostate-Specific Antigen Among Older Men in a Large Health System
- Author
-
Ji Young Lee, Joshua J. Meeks, Stephen D. Persell, and Theresa Rowe
- Subjects
Aged, 80 and over ,Chicago ,Male ,Oncology ,medicine.medical_specialty ,Diagnostic Tests, Routine ,Leadership and Management ,business.industry ,Prostatic Neoplasms ,Prostate-Specific Antigen ,medicine.disease ,Article ,Prostate cancer ,Prostate-specific antigen ,Internal medicine ,Ambulatory Care ,medicine ,Electronic Health Records ,Humans ,business ,Delivery of Health Care ,Aged - Published
- 2019
14. Nudging Physician Prescription Decisions by Partitioning the Order Set: Results of a Vignette-Based Study
- Author
-
Stephen D. Persell, Craig R. Fox, Jason N. Doctor, Mark W. Friedberg, Daniella Meeker, Elisha M. Friesema, David Tannenbaum, Noah J. Goldstein, and Jeffrey A. Linder
- Subjects
Male ,Gerontology ,medicine.medical_specialty ,MEDLINE ,Behavioural sciences ,Primary care ,Physicians, Primary Care ,Surveys and Questionnaires ,Internal Medicine ,medicine ,Electronic Health Records ,Humans ,Medical prescription ,health care economics and organizations ,Original Research ,Response rate (survey) ,business.industry ,Menu design ,Decision Support Systems, Clinical ,3. Good health ,Prescriptions ,Vignette ,Family medicine ,Female ,business ,Order set - Abstract
Healthcare professionals are rapidly adopting electronic health records (EHRs). Within EHRs, seemingly innocuous menu design configurations can influence provider decisions for better or worse. The purpose of this study was to examine whether the grouping of menu items systematically affects prescribing practices among primary care providers. We surveyed 166 primary care providers in a research network of practices in the greater Chicago area, of whom 84 responded (51 % response rate). Respondents and non-respondents were similar on all observable dimensions except that respondents were more likely to work in an academic setting. The questionnaire consisted of seven clinical vignettes. Each vignette described typical signs and symptoms for acute respiratory infections, and providers chose treatments from a menu of options. For each vignette, providers were randomly assigned to one of two menu partitions. For antibiotic-inappropriate vignettes, the treatment menu either listed over-the-counter (OTC) medications individually while grouping prescriptions together, or displayed the reverse partition. For antibiotic-appropriate vignettes, the treatment menu either listed narrow-spectrum antibiotics individually while grouping broad-spectrum antibiotics, or displayed the reverse partition. The main outcome was provider treatment choice. For antibiotic-inappropriate vignettes, we categorized responses as prescription drugs or OTC-only options. For antibiotic-appropriate vignettes, we categorized responses as broad- or narrow-spectrum antibiotics. Across vignettes, there was an 11.5 percentage point reduction in choosing aggressive treatment options (e.g., broad-spectrum antibiotics) when aggressive options were grouped compared to when those same options were listed individually (95 % CI: 2.9 to 20.1 %; p = .008). Provider treatment choice appears to be influenced by the grouping of menu options, suggesting that the layout of EHR order sets is not an arbitrary exercise. The careful crafting of EHR order sets can serve as an important opportunity to improve patient care without constraining physicians’ ability to prescribe what they believe is best for their patients.
- Published
- 2014
15. Risk scoring for the primary prevention of cardiovascular disease
- Author
-
Stephen D. Persell, Mark D. Huffman, Pablo Perel, Mark A Berendsen, Donald M. Lloyd-Jones, and Kunal N. Karmali
- Subjects
Adult ,Medicine General & Introductory Medical Sciences ,Pediatrics ,medicine.medical_specialty ,Heart Diseases ,Risk management tools ,Blood Pressure ,030204 cardiovascular system & hematology ,Cochrane Library ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Medicine ,Humans ,Pharmacology (medical) ,030212 general & internal medicine ,Risk factor ,Antihypertensive Agents ,Randomized Controlled Trials as Topic ,business.industry ,Anticholesteremic Agents ,Absolute risk reduction ,Confidence interval ,3. Good health ,Clinical trial ,Primary Prevention ,Stroke ,Cholesterol ,Cardiovascular Diseases ,Relative risk ,business ,Risk assessment - Abstract
Background The current paradigm for cardiovascular disease (CVD) emphasises absolute risk assessment to guide treatment decisions in primary prevention. Although the derivation and validation of multivariable risk assessment tools, or CVD risk scores, have attracted considerable attention, their effect on clinical outcomes is uncertain. Objectives To assess the effects of evaluating and providing CVD risk scores in adults without prevalent CVD on cardiovascular outcomes, risk factor levels, preventive medication prescribing, and health behaviours. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2016, Issue 2), MEDLINE Ovid (1946 to March week 1 2016), Embase (embase.com) (1974 to 15 March 2016), and Conference Proceedings Citation Index-Science (CPCI-S) (1990 to 15 March 2016). We imposed no language restrictions. We searched clinical trial registers in March 2016 and handsearched reference lists of primary studies to identify additional reports. Selection criteria We included randomised and quasi-randomised trials comparing the systematic provision of CVD risk scores by a clinician, healthcare professional, or healthcare system compared with usual care (i.e. no systematic provision of CVD risk scores) in adults without CVD. Data collection and analysis Three review authors independently selected studies, extracted data, and evaluated study quality. We used the Cochrane 'Risk of bias' tool to assess study limitations. The primary outcomes were: CVD events, change in CVD risk factor levels (total cholesterol, systolic blood pressure, and multivariable CVD risk), and adverse events. Secondary outcomes included: lipid-lowering and antihypertensive medication prescribing in higher-risk people. We calculated risk ratios (RR) for dichotomous data and mean differences (MD) or standardised mean differences (SMD) for continuous data using 95% confidence intervals. We used a fixed-effects model when heterogeneity (I²) was at least 50% and a random-effects model for substantial heterogeneity (I² > 50%). We evaluated the quality of evidence using the GRADE framework. Main results We identified 41 randomised controlled trials (RCTs) involving 194,035 participants from 6422 reports. We assessed studies as having high or unclear risk of bias across multiple domains. Low-quality evidence evidence suggests that providing CVD risk scores may have little or no effect on CVD events compared with usual care (5.4% versus 5.3%; RR 1.01, 95% confidence interval (CI) 0.95 to 1.08; I² = 25%; 3 trials, N = 99,070). Providing CVD risk scores may reduce CVD risk factor levels by a small amount compared with usual care. Providing CVD risk scores reduced total cholesterol (MD −0.10 mmol/L, 95% CI −0.20 to 0.00; I² = 94%; 12 trials, N = 20,437, low-quality evidence), systolic blood pressure (MD −2.77 mmHg, 95% CI −4.16 to −1.38; I² = 93%; 16 trials, N = 32,954, low-quality evidence), and multivariable CVD risk (SMD −0.21, 95% CI −0.39 to −0.02; I² = 94%; 9 trials, N = 9549, low-quality evidence). Providing CVD risk scores may reduce adverse events compared with usual care, but results were imprecise (1.9% versus 2.7%; RR 0.72, 95% CI 0.49 to 1.04; I² = 0%; 4 trials, N = 4630, low-quality evidence). Compared with usual care, providing CVD risk scores may increase new or intensified lipid-lowering medications (15.7% versus 10.7%; RR 1.47, 95% CI 1.15 to 1.87; I² = 40%; 11 trials, N = 14,175, low-quality evidence) and increase new or increased antihypertensive medications (17.2% versus 11.4%; RR 1.51, 95% CI 1.08 to 2.11; I² = 53%; 8 trials, N = 13,255, low-quality evidence). Authors' conclusions There is uncertainty whether current strategies for providing CVD risk scores affect CVD events. Providing CVD risk scores may slightly reduce CVD risk factor levels and may increase preventive medication prescribing in higher-risk people without evidence of harm. There were multiple study limitations in the identified studies and substantial heterogeneity in the interventions, outcomes, and analyses, so readers should interpret results with caution. New models for implementing and evaluating CVD risk scores in adequately powered studies are needed to define the role of applying CVD risk scores in primary CVD prevention.
- Published
- 2017
16. ACC/AHA/SCAI/AMA–Convened PCPI/NCQA 2013 Performance Measures for Adults Undergoing Percutaneous Coronary Intervention
- Author
-
David J. Malenka, Lawrence A. Hamilton, John S. Rumsfeld, Richard Josephson, David P. Faxon, Jeffrey L. Anderson, Brahmajee K. Nallamothu, Stephen J. Stanko, James D. Mortimer, Sidney C. Smith, Joseph C. Cleveland, Kevin W. McCabe, Hitinder S. Gurm, Carl L. Tommaso, R. Adams Dudley, Kendrick A. Shunk, Manesh R. Patel, Stephen D. Persell, H. Vernon Anderson, Brook Watts, Calin V. Maniu, Neil C. Jensen, and Peter L. Duffy
- Subjects
medicine.medical_specialty ,Task force ,business.industry ,medicine.medical_treatment ,Psychological intervention ,Hospital quality ,Percutaneous coronary intervention ,Cardiovascular angiography ,Internal medicine ,medicine ,Cardiology ,Physical therapy ,Cardiology and Cardiovascular Medicine ,business - Published
- 2014
17. Meeting the Criteria of Medication Therapy Management—Reply
- Author
-
Stephen D. Persell and Michael S. Wolf
- Subjects
medicine.medical_specialty ,Medication Therapy Management ,business.industry ,Medicare Part D ,MEDLINE ,030204 cardiovascular system & hematology ,United States ,White People ,03 medical and health sciences ,0302 clinical medicine ,Hypertension ,Medication therapy management ,Internal Medicine ,medicine ,Electronic Health Records ,Humans ,030212 general & internal medicine ,Intensive care medicine ,business - Published
- 2018
18. Factors Influencing the Increasing Disparity in LDL Cholesterol Control Between White and Black Patients With Diabetes in a Context of Active Quality Improvement
- Author
-
Stephen D. Persell, Raymond Zhang, Ji Young Lee, and Muriel Jean-Jacques
- Subjects
Male ,Gerontology ,medicine.medical_specialty ,Quality management ,Psychological intervention ,Black People ,Context (language use) ,Article ,White People ,chemistry.chemical_compound ,Ambulatory care ,Diabetes mellitus ,Internal medicine ,parasitic diseases ,Diabetes Mellitus ,medicine ,Humans ,Healthcare Disparities ,Medical prescription ,Hypolipidemic Agents ,Retrospective Studies ,Cholesterol ,business.industry ,Health Policy ,Cholesterol, LDL ,Middle Aged ,medicine.disease ,Quality Improvement ,chemistry ,Female ,business ,Lipoprotein - Abstract
After implementing a multifaceted physician-directed quality improvement (QI) initiative, an increased disparity in low-density lipoprotein (LDL) cholesterol control between white and black diabetes patients was observed. To examine possible causes, a retrospective analysis of 962 black and white patients treated continuously between 2008 and 2010 was performed. At baseline, 55.0% of whites and 49.8% of blacks were controlled (5.2% disparity). The disparity increased, with 61.8% of whites and 44.6% of blacks having control in 2010 (17.2% disparity). Among patients uncontrolled at baseline, blacks were less likely to become controlled. Among patients controlled at baseline, blacks were less likely to remain controlled; accounting for patient characteristics and changes in lipid-lowering drug prescription regimens did not attenuate these relationships. Physician-facing, general QI interventions may be insufficient to produce equity in LDL cholesterol control. Helping patients maintain prior success controlling cholesterol appears as important in addressing this disparity as is helping uncontrolled patients achieve control.
- Published
- 2013
19. Association of arrhythmia-related genetic variants with phenotypes documented in electronic medical records
- Author
-
Rosetta M. Chiavacci, Teri A. Manolio, David R. Crosslin, Joshua C. Denny, Suzette J. Bielinski, Kimberly F. Doheny, James D. Ralston, Deborah A. Nickerson, David J. Carey, Janet E. Olson, Sara L. Van Driest, Terrie Kitchner, John Connolly, Quinn S. Wells, Murray H. Brilliant, David Carrell, Adam S. Gordon, Stuart A. Scott, Sarah C. Stallings, Vivian Pan, Noura S. Abul-Husn, Daniela Macaya, Marylyn D. Ritchie, Jamie D. Kapplinger, Thomas E. Callis, John R. Wallace, Max M. He, Eric B. Larson, Erwin P. Bottinger, Michael J. Ackerman, M. Benjamin Shoemaker, Gail P. Jarvik, William S. Bush, Laura J. Rasmussen-Torvik, Hakon Hakonarson, Marc S. Williams, Maureen E. Smith, Dan M. Roden, Jerry H. Kim, Stephen D. Persell, Zi Ye, Rex L. Chisholm, Iftikhar J. Kullo, Rongling Li, and Berta Almoguera
- Subjects
0301 basic medicine ,medicine.medical_specialty ,Pathology ,medicine.diagnostic_test ,business.industry ,Concordance ,Cardiac arrhythmia ,General Medicine ,030204 cardiovascular system & hematology ,medicine.disease ,QT interval ,Article ,Minor allele frequency ,03 medical and health sciences ,030104 developmental biology ,0302 clinical medicine ,Interquartile range ,Internal medicine ,medicine ,Allele ,business ,Genetic testing ,Brugada syndrome - Abstract
Importance Large-scale DNA sequencing identifies incidental rare variants in established Mendelian disease genes, but the frequency of related clinical phenotypes in unselected patient populations is not well established. Phenotype data from electronic medical records (EMRs) may provide a resource to assess the clinical relevance of rare variants. Objective To determine the clinical phenotypes from EMRs for individuals with variants designated as pathogenic by expert review in arrhythmia susceptibility genes. Design, Setting, and Participants This prospective cohort study included 2022 individuals recruited for nonantiarrhythmic drug exposure phenotypes from October 5, 2012, to September 30, 2013, for the Electronic Medical Records and Genomics Network Pharmacogenomics project from 7 US academic medical centers. Variants in SCN5A and KCNH2 , disease genes for long QT and Brugada syndromes, were assessed for potential pathogenicity by 3 laboratories with ion channel expertise and by comparison with the ClinVar database. Relevant phenotypes were determined from EMRs, with data available from 2002 (or earlier for some sites) through September 10, 2014. Exposures One or more variants designated as pathogenic in SCN5A or KCNH2 . Main Outcomes and Measures Arrhythmia or electrocardiographic (ECG) phenotypes defined by International Classification of Diseases, Ninth Revision ( ICD-9 ) codes, ECG data, and manual EMR review. Results Among 2022 study participants (median age, 61 years [interquartile range, 56-65 years]; 1118 [55%] female; 1491 [74%] white), a total of 122 rare (minor allele frequency ICD-9 code for arrhythmia was found in 11 of 63 (17%) variant carriers vs 264 of 1959 (13%) of those without variants (difference, +4%; 95% CI, −5% to +13%; P = .35). In the 1270 (63%) with ECGs, corrected QT intervals were not different in variant carriers vs those without (median, 429 vs 439 milliseconds; difference, −10 milliseconds; 95% CI, −16 to +3 milliseconds; P = .17). After manual review, 22 of 63 participants (35%) with designated variants had any ECG or arrhythmia phenotype, and only 2 had corrected QT interval longer than 500 milliseconds. Conclusions and Relevance Among laboratories experienced in genetic testing for cardiac arrhythmia disorders, there was low concordance in designating SCN5A and KCNH2 variants as pathogenic. In an unselected population, the putatively pathogenic genetic variants were not associated with an abnormal phenotype. These findings raise questions about the implications of notifying patients of incidental genetic findings.
- Published
- 2016
20. Predictors of cholesterol treatment discussions and statin prescribing for primary cardiovascular disease prevention in community health centers
- Author
-
Tiffany Brown, Ji Young Lee, Kunal N. Karmali, and Stephen D. Persell
- Subjects
Male ,medicine.medical_specialty ,Statin ,Epidemiology ,medicine.drug_class ,Population ,Disease ,030204 cardiovascular system & hematology ,Article ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Primary prevention ,medicine ,Humans ,cardiovascular diseases ,030212 general & internal medicine ,Intensive care medicine ,education ,Antihypertensive Agents ,Aged ,education.field_of_study ,Cholesterol ,business.industry ,Public Health, Environmental and Occupational Health ,Cholesterol, LDL ,Community Health Centers ,Middle Aged ,Primary Prevention ,chemistry ,Cardiovascular Diseases ,Community health ,Cardiology ,lipids (amino acids, peptides, and proteins) ,Disease prevention ,Female ,Hydroxymethylglutaryl-CoA Reductase Inhibitors ,Risk assessment ,business - Abstract
Although cholesterol guidelines emphasize cardiovascular disease (CVD) risk to guide primary prevention, predictors of statin use in practice are unknown. We aimed to identify factors associated with a cholesterol treatment discussion and statin prescribing in a high-risk population.We used data from a trial conducted among participants in community health centers without CVD or diabetes and a 10-year coronary heart disease (CHD) risk≥10%. Cholesterol treatment discussion was assessed at 6months and statin prescription at 1year. We used logistic regressions to identify factors associated with each outcome.We analyzed 646 participants (89% male, mean age 60±9.5years). Cholesterol treatment discussion occurred in 19% and statin prescription in 12% of participants. Ten-year CHD risk was not associated with treatment discussion (OR 1.11 per 1 SD increase, 95% CI 0.91-1.33) but was associated with statin prescription (OR 1.41 per 1 SD increase, 95% CI 1.13-1.75) in unadjusted models. After adjusting for traditional CVD risk factors that contribute to CHD risk, low-density lipoprotein cholesterol (LDL-C) was independently associated with statin prescription (OR 1.82 per 1 SD increase, 95% CI 1.66-1.99). Antihypertensive medication use was independently associated with both cholesterol treatment discussion (OR 3.68, 95% CI 2.35-5.75) and statin prescription (OR 3.98, 95% CI 3.30-4.81). Other drivers of CVD risk (age, smoking, and systolic blood pressure) were not associated with statin use.Single risk factor management strongly influences cholesterol treatment discussions and statin prescribing patterns. Interventions that promote risk-based statin utilization are needed.Clinicaltrials.gov.: NCT01610609.
- Published
- 2015
21. The marginal value of pre-visit paper reminders when added to a multifaceted electronic health record based quality improvement system
- Author
-
Stephen D. Persell, Jason A. Thompson, Abel N. Kho, Darren Kaiser, and David W. Baker
- Subjects
Quality management ,Medical Records Systems, Computerized ,Reminder Systems ,media_common.quotation_subject ,education ,Health Informatics ,Health literacy ,Marginal value ,Research and Applications ,Health informatics ,Nursing ,Electronic health record ,Internal Medicine ,Electronic Health Records ,Humans ,Medicine ,Performance measurement ,Quality (business) ,media_common ,business.industry ,medicine.disease ,Quality Improvement ,Workflow ,Chronic Disease ,Clinical Competence ,Preventive Medicine ,Medical emergency ,business - Abstract
Objective We have reported that implementation of an electronic health record (EHR) based quality improvement system that included point-of-care electronic reminders accelerated improvement in performance for multiple measures of chronic disease care and preventive care during a 1-year period. This study examined whether providing pre-visit paper quality reminders could further improve performance, especially for physicians whose performance had not improved much during the first year. Design Time-series analysis at a large internal medicine practice using a commercial EHR. All patients eligible for each measure were included (range approximately 100e7500). Measurements The proportion of eligible patients in the practice who satisfied each of 15 quality measures after removing those with exceptions from the denominator. To analyze changes in performance for individual physicians, two composite measures were used: prescribing seven essential medications and completion of five preventive services. Results During the year after implementing pre-encounter reminders, performance continued to improve for eight measures, remained stable for four, and declined for three. Physicians with the worst performance at the start of the pre-encounter reminders showed little absolute improvement over the next year, and most remained below the median performance for physicians in the practice. Conclusions Paper pre-encounter reminders did not appear to improve performance beyond electronic pointof-care reminders in the EHR alone. Lagging performance is likely not due to providers’ EHR workflow alone, and trying to step backwards and use paper reminders in addition to point-of-care reminders in the EHR may not be an effective strategy for engaging slow adopters. Electronic health records (EHR) have the potential to transform quality measurement and quality improvement methods, which are fundamental
- Published
- 2011
22. Electronic health record identification of prediabetes and an assessment of unmet counselling needs
- Author
-
Laura J. Zimmermann, Jason A. Thompson, and Stephen D. Persell
- Subjects
medicine.medical_specialty ,business.industry ,Health Policy ,Glucose Measurement ,Public Health, Environmental and Occupational Health ,Psychological intervention ,MEDLINE ,medicine.disease ,Impaired fasting glucose ,Clinical trial ,Endocrinology ,Diabetes mellitus ,Internal medicine ,Medicine ,Prediabetes ,business ,Body mass index - Abstract
Rationale, aims and objectives Large clinical trials demonstrate that lifestyle modification can prevent or delay the onset of diabetes in those with prediabetes. However, recent National Health and Nutrition Survey data suggest that prediabetes often goes unrecognized, and the majority of prediabetic individuals do not report having received lifestyle advice from physicians. We explored whether electronic health record (EHR) query of glucose measurements can identify prediabetic patients, and we estimated rates of prediabetic lifestyle counselling in a large, urban, primary care practice. Methods Electronic search identified patients with plasma glucose levels of 100 to 199 mg dL−1 between 1 June 2007 and 1 June 2009, excluding those with diabetes or diabetic medications/supplies. From these 5366 patients, 100 randomly selected patients underwent classification into provisional categories based on available EHR data: likely prediabetes, likely diabetes, glucose abnormality in the setting of acute illness, or normal glucose metabolism. In those likely to have prediabetes, we assessed lifestyle modification counselling. Results Fifty-eight per cent (95% CI 48% to 68%) of patients sampled were likely to have prediabetes. Fourteen per cent of those sampled were likely to have diabetes. Thirty-one per cent of prediabetics (95% CI 22% to 42%) had documented lifestyle counselling. Counselled patients had a significantly higher baseline mean body mass index compared to those not counselled (34.1 versus 29.9, P = 0.037). Conclusions EHR query using glucose measurements can identify prediabetic patients and those requiring further glucose metabolism evaluation, including those with undiagnosed diabetes. Future research should investigate EHR-based, population-level interventions to facilitate prediabetes recognition and counselling.
- Published
- 2011
23. Prevalence of Resistant Hypertension in the United States, 2003–2008
- Author
-
Stephen D. Persell
- Subjects
Adult ,medicine.medical_specialty ,National Health and Nutrition Examination Survey ,medicine.drug_class ,medicine.medical_treatment ,Population ,Drug Resistance ,Blood Pressure ,Risk Assessment ,Hydrochlorothiazide ,Drug Therapy ,Risk Factors ,Diabetes mellitus ,Internal medicine ,Prevalence ,Internal Medicine ,medicine ,Humans ,Antihypertensive drug ,education ,Antihypertensive Agents ,education.field_of_study ,business.industry ,Nutrition Surveys ,medicine.disease ,United States ,Surgery ,Blood pressure ,Cardiovascular Diseases ,Heart failure ,Hypertension ,Diuretic ,business ,medicine.drug - Abstract
The prevalence of resistant hypertension is unknown. Much previous knowledge comes from referral populations or clinical trial participants. Using data from the National Health and Nutrition Examination Survey from 2003 through 2008, nonpregnant adults with hypertension were classified as resistant if their blood pressure was ≥140/90 mm Hg and they reported using antihypertensive medications from 3 different drug classes or drugs from ≥4 antihypertensive drug classes regardless of blood pressure. Among US adults with hypertension, 8.9% (SE: 0.6%) met criteria for resistant hypertension. This represented 12.8% (SE: 0.9%) of the antihypertensive drug–treated population. Of all drug-treated adults whose hypertension was uncontrolled, 72.4% (SE: 1.6%) were taking drugs from P P
- Published
- 2011
24. Changes in Performance After Implementation of a Multifaceted Electronic-Health-Record-Based Quality Improvement System
- Author
-
Jason A. Thompson, Nancy C. Dolan, Janardan D. Khandekar, Stephen D. Persell, Thomas Gavagan, Sue Levi, David W. Baker, Darren Kaiser, Beth Andrews, and Elisha M. Friesema
- Subjects
Male ,Decision support system ,Process management ,Quality management ,Computer science ,Point-of-Care Systems ,Reminder Systems ,media_common.quotation_subject ,Coronary Disease ,Documentation ,Drug Prescriptions ,Outcome Assessment, Health Care ,Health care ,Diabetes Mellitus ,Internal Medicine ,Electronic Health Records ,Humans ,Performance measurement ,Quality (business) ,Longitudinal Studies ,Practice Patterns, Physicians' ,Aged ,Quality Indicators, Health Care ,media_common ,Chicago ,Heart Failure ,Total quality management ,business.industry ,Public Health, Environmental and Occupational Health ,Middle Aged ,Decision Support Systems, Clinical ,Quality audit ,Linear Models ,Female ,business ,Program Evaluation ,Total Quality Management - Abstract
Electronic health record (EHR) systems have the potential to revolutionize quality improvement (QI) methods by enhancing quality measurement and integrating multiple proven QI strategies.To implement and evaluate a multifaceted QI intervention using EHR tools to improve quality measurement (including capture of contraindications and patient refusals), make point-of-care reminders more accurate, and provide more valid and responsive clinician feedback (including lists of patients not receiving essential medications) for 16 chronic disease and preventive service measures.Time series analysis at a large internal medicine practice using a commercial EHR.All adult patients eligible for each measure (range approximately 100-7500).The proportion of eligible patients who satisfied each measure after removing those with exceptions from the denominator.During the year before the intervention, performance improved significantly for 8 measures. During the year after the intervention, performance improved significantly for 14 measures. For 9 measures, the primary outcome improved more rapidly during the intervention year than during the previous year (P0.001 for 8 measures, P = 0.02 for 1). Four other measures improved at rates that were not significantly different from the previous year. Improvements resulted from increases in patients receiving the service, documentation of exceptions, or a combination of both. For 5 drug-prescribing measures, more than half of physicians achieved 100% performance.Implementation of a multifaceted QI intervention using EHR tools to improve quality measurement and the accuracy and timeliness of clinician feedback improved performance and/or accelerated the rate of improvement for multiple measures simultaneously.
- Published
- 2011
25. Update in General Internal Medicine
- Author
-
David W. Baker, Toshiko Uchida, and Stephen D. Persell
- Subjects
medicine.medical_specialty ,Quality management ,business.industry ,Alternative medicine ,Update ,Internal medicine ,General practice ,Internal Medicine ,medicine ,Humans ,Family Practice ,Journal club ,business ,Randomized Controlled Trials as Topic - Abstract
The aim of this update is to briefly summarize the research articles published in 2008 that we think have the most important implications for General Internal Medicine practice. The wide breadth of General Internal Medicine practice always makes selecting articles a challenging and somewhat subjective process. In selecting articles, we relied heavily on the internal process we routinely use to do this in the Division of General Internal Medicine at Northwestern University. Each month, faculty members review an array of journals and journal aggregators (e.g., ACP Journal Club and Journal Watch General Medicine) to identify potential articles for discussion. A subgroup of the faculty then selects articles that deserve in-depth review and discussion by the entire faculty at our monthly Journal Club. If an article is judged to be particularly important and practice-changing, we then try to use this as a springboard for quality improvement efforts. For this review, we concentrate on eight articles with findings that we think should guide our practice in the future.
- Published
- 2009
26. Patient-Directed Intervention Versus Clinician Reminders Alone to Improve Aspirin Use in Diabetes: A Cluster Randomized Trial
- Author
-
Stephen D. Persell, Daniel P. Dunham, Therese A. Denecke-Dattalo, and David W. Baker
- Subjects
Male ,medicine.medical_specialty ,Leadership and Management ,Reminder Systems ,law.invention ,Interviews as Topic ,Randomized controlled trial ,law ,Internal medicine ,Intervention (counseling) ,Diabetes Mellitus ,medicine ,Humans ,Cluster randomised controlled trial ,Aged ,Physician-Patient Relations ,Aspirin ,Evidence-Based Medicine ,business.industry ,Telephone call ,Evidence-based medicine ,Middle Aged ,United States ,Confidence interval ,Physical therapy ,Patient Compliance ,Platelet aggregation inhibitor ,Female ,business ,Platelet Aggregation Inhibitors ,medicine.drug - Abstract
Article-at-a-Glance Background Physician-directed approaches have not eliminated the underuse of effective preventive therapies. Methods In a cluster-randomized design, 19 physicians caring for 334 eligible patients at least 40 years of age were randomized. All clinicians received computerized reminders at office visits. Intervention physicians received e-mails asking whether aspirin was indicated for each patient. If so, patients received a mailing and nurse telephone call addressing aspirin. The primary outcome was self-reported regular aspirin use. Results Outcome assessment telephone interviews were completed for 242 (72.5%) patients. At follow-up, aspirin use was reported by 60 (46%) of the 130 intervention patients and 44 (39%) of the 112 reminder-only patients, a nonsignificant 7.2% difference (95% confidence interval: –3.9 to 18 percentage points, p = .20). In the subgroup reporting no aspirin use at baseline and no contraindications, 33 (43%) of the 76 intervention and 22 (30%) of the 74 reminder-only patients used aspirin, a 10% difference accounting for clustering (95% CI: 2.2 to 18 percentage points, p = .013). Discussion A patient-directed intervention modestly increased aspirin use among diabetes patients beyond that achieved using computerized clinician reminders for ideal candidates. Obstacles included difficulty contacting patients, real or perceived contraindications, and failure to follow the nurse's advice.
- Published
- 2008
27. Limited Health Literacy is a Barrier to Medication Reconciliation in Ambulatory Care
- Author
-
Silvia Skripkauskas, Chandra Y. Osborn, Stephen D. Persell, Robert J. Richard, and Michael S. Wolf
- Subjects
Adult ,Male ,Health Knowledge, Attitudes, Practice ,Michigan ,medicine.medical_specialty ,Pediatrics ,media_common.quotation_subject ,MEDLINE ,Health literacy ,Literacy ,Patient Education as Topic ,Ambulatory care ,Ambulatory Care ,Internal Medicine ,medicine ,Humans ,Antihypertensive Agents ,Aged ,media_common ,business.industry ,Health services research ,Community Health Centers ,Middle Aged ,Medication Reconciliation ,Family medicine ,Hypertension ,Ambulatory ,Educational Status ,Original Article ,Female ,Health Services Research ,business ,Limited health literacy - Abstract
Limited health literacy may influence patients' ability to identify medications taken; a serious concern for ambulatory safety and quality.To assess the relationship between health literacy, patient recall of antihypertensive medications, and reconciliation between patient self-report and the medical record.In-person interviews, literacy assessment, medical records abstraction.Adults with hypertension at three community health centers.We measured health literacy using the short-form Test of Functional Health Literacy in Adults. Patients were asked about the medications they took for blood pressure. Their responses were compared with the medical record.Of 119 participants, 37 (31%) had inadequate health literacy. Patients with inadequate health literacy were less able to name any of their antihypertensive medications compared to those with adequate health literacy (40.5% vs 68.3%, p = 0.005). After adjusting for age and income, this difference remained (adjusted odds ratio [OR] = 2.9, 95% confidence interval [95%CI] = 1.3-6.7). Agreement between patient reported medications and the medical record was low: 64.9% of patients with inadequate and 37.8% with adequate literacy had no medications common to both lists.Limited health literacy was associated with a greater number of unreconciled medications. Future studies should investigate how this may impact safety and hypertension control.
- Published
- 2007
28. Prehypertension: Progression to hypertension and management considerations
- Author
-
Stephen D. Persell
- Subjects
Pharmacology ,medicine.medical_specialty ,business.industry ,Diastole ,medicine.disease ,Lower risk ,Prehypertension ,Clinical trial ,Blood pressure ,Weight loss ,Internal medicine ,medicine ,Cardiology ,Pharmacology (medical) ,medicine.symptom ,business ,Stroke ,Dyslipidemia - Abstract
Prehypertension is a designation used by the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure to describe untreated adults with blood pressure of 120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic. As the term implies, prehypertension frequently progresses to hypertension, though weight loss, exercise, and dietary changes can lower blood pressure and reduce the chance of progression to hypertension. Prehypertension often occurs along with other cardiovascular risk factors, such as dyslipidemia and impaired glucose metabolism. Prehypertension also carries independent cardiovascular risk. Recent clinical trials indicate that drug therapy should be considered for stable patients with prehypertension at high risk for cardiovascular disease or stroke. Whether using antihypertensive medication in lower risk persons with prehypertension is advantageous is not known.
- Published
- 2007
29. Criteria for waiver of informed consent for quality improvement research
- Author
-
David W. Baker and Stephen D. Persell
- Subjects
Male ,medicine.medical_specialty ,Quality management ,business.industry ,MEDLINE ,Tobacco Use Disorder ,Waiver ,Telemedicine ,Informed consent ,Family medicine ,Internal Medicine ,Medicine ,Humans ,Female ,Smoking Cessation ,business - Published
- 2015
30. Ambulatory hypercholesterolemia management in patients with atherosclerosis
- Author
-
John Z. Ayanian, Stephen D. Persell, Saverio M. Maviglia, and David W. Bates
- Subjects
Male ,medicine.medical_specialty ,Outpatient Clinics, Hospital ,Hypercholesterolemia ,Ethnic group ,Coronary Disease ,White People ,chemistry.chemical_compound ,Race (biology) ,Sex Factors ,Sex factors ,Internal medicine ,Internal Medicine ,Humans ,Medicine ,In patient ,Aged ,Cholesterol management ,Peripheral Vascular Diseases ,Academic Medical Centers ,Primary Health Care ,business.industry ,Cholesterol ,Vascular disease ,Original Articles ,Cholesterol, LDL ,Middle Aged ,medicine.disease ,Surgery ,Black or African American ,Cerebrovascular Disorders ,Logistic Models ,Outcome and Process Assessment, Health Care ,chemistry ,Ambulatory ,Female ,lipids (amino acids, peptides, and proteins) ,business - Abstract
To determine whether outpatient cholesterol management varies by gender or race among patients with atherosclerosis, and assess factors related to subsequent cholesterol control.Retrospective cohort study.Primary care clinics affiliated with an academic medical center.Two hundred forty-three patients with coronary heart disease, cerebrovascular disease, or peripheral vascular disease and low-density lipoprotein cholesterol (LDL-C)130 mg/dl.The primary process of care assessed for 1,082 office visits was cholesterol management (medication intensification or LDL-C monitoring). Cholesterol management occurred at 31.2% of women's and 38.5% of men's visits (P=.01), and 37.3% of black and 31.7% of white patients' visits (P=.09). Independent predictors of cholesterol management included female gender (adjusted risk ratio [ARR], 0.77; 95% confidence interval [CI], 0.60 to 0.97), seeing a primary care clinician other than the patient's primary care physician (ARR, 0.23; 95% CI, 0.11 to 0.45), and having a new clinical problem addressed (ARR, 0.60; 95% CI, 0.48 to 0.74). After 1 year, LDL-C130 mg/dl occurred less often for women than men (41% vs 61%; P=.003), black than white patients (39% vs 58%; P=.01), and patients with only Medicare insurance than with commercial insurance (37% vs 58%; P=.008). Adjustment for clinical characteristics and management attenuated the relationship between achieving an LDL-C130 mg/dl and gender.In this high-risk population with uncontrolled cholesterol, cholesterol management was less intensive for women than men but similar for black and white patients. Less intense cholesterol management accounted for some of the disparity in cholesterol control between women and men but not between black and white patients.
- Published
- 2005
31. Age-related differences in preventive care among adults with diabetes
- Author
-
Joel S. Weissman, Stephen D. Persell, John Z. Ayanian, and Alan M. Zaslavsky
- Subjects
Adult ,Male ,Gerontology ,medicine.medical_specialty ,Adolescent ,Office Visits ,Health Behavior ,Preventive care ,Diabetes Complications ,Internal medicine ,Diabetes mellitus ,Age related ,Preventive Health Services ,Ambulatory Care ,Diabetes Mellitus ,medicine ,Humans ,Aged ,business.industry ,Age Factors ,General Medicine ,Middle Aged ,medicine.disease ,United States ,Cross-Sectional Studies ,Endocrinology ,Socioeconomic Factors ,Female ,business - Published
- 2004
32. ACC/AHA/SCAI/AMA-Convened PCPI/NCQA 2013 performance measures for adults undergoing percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association-Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance
- Author
-
Brahmajee K. Nallamothu, David J. Malenka, Joseph C. Cleveland, Lawrence A. Hamilton, Carl L. Tommaso, James D. Mortimer, Calin V. Maniu, John S. Rumsfeld, Manesh R. Patel, H. Vernon Anderson, Jeffrey L. Anderson, Kevin W. McCabe, Brook Watts, Peter L. Duffy, Stephen D. Persell, Stephen J. Stanko, Hitinder S. Gurm, Kendrick A. Shunk, David P. Faxon, Sidney C. Smith, R. Adams Dudley, Neil C. Jensen, and Richard Josephson
- Subjects
Research Report ,Quality Assurance, Health Care ,medicine.medical_treatment ,Alternative medicine ,Psychological intervention ,Cardiorespiratory Medicine and Haematology ,Coronary Angiography ,Cardiovascular ,Cardiovascular angiography ,Scientific evidence ,Societies, Medical ,American Heart Association ,quality indicators ,AHA Scientific Statements ,ambulatory-level quality ,Heart Disease ,ACC/AHA/SCAI/AMA-PCPI/NCQA Performance Measures ,hospital quality ,Cardiology ,Public Health and Health Services ,Clinical Competence ,Cardiology and Cardiovascular Medicine ,Adult ,medicine.medical_specialty ,Clinical Sciences ,Advisory Committees ,MEDLINE ,Percutaneous Coronary Intervention ,Clinical Research ,Physiology (medical) ,Internal medicine ,Medical ,medicine ,Humans ,health policy and outcome research ,American Medical Association ,Heart Disease - Coronary Heart Disease ,business.industry ,Task force ,Prevention ,percutaneous coronary intervention ,Percutaneous coronary intervention ,Atherosclerosis ,United States ,Health Care ,Cardiovascular System & Hematology ,business ,Societies ,Quality Assurance ,Quality assurance - Abstract
Journal of the American College of Cardiology Ó 2014 by the American College of Cardiology Foundation, American Heart Association, Inc., American Medical Association, and National Committee for Quality Assurance Published by Elsevier Inc. Vol. 63, No. 7, 2014 ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2013.12.003 PERFORMANCE MEASURES ACC/AHA/SCAI/AMA–Convened PCPI/NCQA 2013 Performance Measures for Adults Undergoing Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association–Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance Developed in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation and Mended Hearts Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and Mended Hearts WRITING COMMITTEE MEMBERS Brahmajee K. Nallamothu, MD, MPH, FACC, FAHA, Co-Chair*; Carl L. Tommaso, MD, FACC, FAHA, FSCAI, Co-Chairy; H. Vernon Anderson, MD, FACC, FAHA, FSCAI*; Jeffrey L. Anderson, MD, FACC, FAHA, MACP*; Joseph C. Cleveland, J R , MDz; R. Adams Dudley, MD, MBA; Peter Louis Duffy, MD, MMM, FACC, FSCAIy; David P. Faxon, MD, FACC, FAHA*; Hitinder S. Gurm, MD, FACC; Lawrence A. Hamilton, Neil C. Jensen, MHA, MBA; Richard A. Josephson, MD, MS, FACC, FAHA, FAACVPRx; David J. Malenka, MD, FACC, FAHA*; Calin V. Maniu, MD, FACC, FAHA, FSCAIy; Kevin W. McCabe, MD; James D. Mortimer, Manesh R. Patel, MD, FACC*; Stephen D. Persell, MD, MPH; John S. Rumsfeld, MD, PhD, FACC, FAHAjj; Kendrick A. Shunk, MD, PhD, FACC, FAHA, FSCAI*; Sidney C. Smith, J R , MD, FACC, FAHA, FACP{; Stephen J. Stanko, MBA, BA, AA#; Brook Watts, MD, MS *ACC/AHA Representative. ySociety of Cardiovascular Angiography and Interventions Representative. zSociety of Thoracic Surgeons Representative. xAmerican Association of Cardiovascular and Pulmonary Rehabilitation Representative. kACC/AHA Task Force on Performance Measures Liaison. {National Heart Lung and Blood Institute Representative. #Mended Hearts Representative. The measure specifications were approved by the American College of Cardiology Board of Trustees, American Heart Association Science Advisory and Coordinating Committee, in January 2013 and the American Medical Association–Physician Consortium for Performance Improvement in February 2013. This document was approved by the American College of Cardiology Board of Trustees and the American Heart Association Science Advisory and Coordinating Committee in October 2013, and the Society of Cardiovascular Angiography and Interventions in December 2013. The American College of Cardiology requests that this document be cited as follows: Nallamothu BK, Tommaso CL, Anderson HV, Anderson JL, Cleveland JC, Dudley RA, Duffy PL, Faxon DP, Gurm HS, Hamilton LA, Jensen NC, Josephson RA, Malenka DJ, Maniu CV, McCabe KW, Mortimer JD, Patel MR, Persell SD, Rumsfeld JS, Shunk KA, Smith SC, Stanko SJ, Watts B. ACC/AHA/SCAI/AMA–Convened PCPI/NCQA 2013 perfor- mance measures for adults undergoing percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association–Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance. J Am Coll Cardiol 2014;63:722–45. This article has been copublished in Circulation. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Asso- ciation (http://my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints@elsevier.com. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/authors/obtaining- permission-to-re-use-elsevier-material). This Physician Performance Measurement Set (PPMS) and related data specifications were developed by the Physician Consortium for Performance Improvement (the Consortium), including the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Medical Association (AMA), to facilitate quality-improvement activities by physicians. The performance measures contained in this PPMS are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. Although copyrighted, they can be reproduced and distributed, without modification, for noncommercial purposesdfor example, use by health care prov
- Published
- 2014
33. Studying Interventions to Prevent the Progression from Prehypertension to Hypertension: Does TROPHY Win the Prize?
- Author
-
David W. Baker and Stephen D. Persell
- Subjects
medicine.medical_specialty ,business.industry ,Biphenyl Compounds ,Treatment outcome ,Alternative medicine ,Psychological intervention ,Tetrazoles ,Trophy ,Prehypertension ,Treatment Outcome ,Bias ,Epidemiologic Research Design ,Hypertension ,Internal Medicine ,medicine ,Humans ,Benzimidazoles ,Intensive care medicine ,business ,Antihypertensive Agents ,Bias (Epidemiology) - Published
- 2006
34. Response to Evaluating the True Prevalence of Resistant Hypertension
- Author
-
Stephen D. Persell
- Subjects
medicine.medical_specialty ,education.field_of_study ,National Health and Nutrition Examination Survey ,business.industry ,Population ,Resistant hypertension ,Context (language use) ,Family medicine ,Internal Medicine ,medicine ,Medication Nonadherence ,Intensive care medicine ,education ,business - Abstract
The National Health and Nutrition Examination Survey is a set of studies that were not specifically designed to determine the prevalence of true resistant hypertension in the US population. Accordingly, the estimates of the prevalence of resistant hypertension determined using the National Health and Nutrition Examination Survey data should be interpreted in the context of known, and previously stated, limitations.1 The white-coat effect, partial medication nonadherence, and inadequate medication dosage cannot be excluded, and, therefore, some individuals would have been falsely classified as having resistant hypertension. Using the …
- Published
- 2011
35. Correction
- Author
-
Lawrence A. Hamilton, David P. Faxon, Carl L. Tommaso, Peter L. Duffy, Jeffrey L. Anderson, Stephen J. Stanko, H. V. Anderson, Calin V. Maniu, Brook Watts, Brahmajee K. Nallamothu, Stephen D. Persell, David J. Malenka, Hitinder S. Gurm, Kevin W. McCabe, Richard Josephson, Neil C. Jensen, Sidney C. Smith, James D. Mortimer, Kendrick A. Shunk, Manesh R. Patel, R. A. Dudley, John Rumsfeld, and Joseph C. Cleveland
- Subjects
medicine.medical_specialty ,business.industry ,Internal medicine ,medicine.medical_treatment ,medicine ,Cardiology ,Percutaneous coronary intervention ,Cardiology and Cardiovascular Medicine ,business - Published
- 2014
36. Patient outreach to promote colorectal cancer screening among patients with an expired order for colonoscopy: a randomized controlled trial
- Author
-
Tiffany Brown, David W. Baker, Jason Thompson, Kenzie A. Cameron, and Stephen D. Persell
- Subjects
Male ,medicine.medical_specialty ,Randomization ,Colorectal cancer ,Reminder Systems ,Colonoscopy ,Rate ratio ,law.invention ,Randomized controlled trial ,law ,Internal medicine ,Internal Medicine ,medicine ,Humans ,Mass Screening ,Aged ,medicine.diagnostic_test ,business.industry ,General surgery ,Fecal occult blood ,Primary care physician ,Sigmoidoscopy ,Middle Aged ,medicine.disease ,Female ,business ,Colorectal Neoplasms - Abstract
Background Targeted interventions to promote colorectal cancer screening among specific populations could increase screening rates. Patients with an expired order for screening colonoscopy might be persuaded to follow through with screening by such an intervention. Methods We conducted a randomized controlled trial of a combined reminder/outreach intervention among patients in a large general internal medicine practice. Participants included 628 patients aged 50 to 79 years with an expired order for screening colonoscopy. Patients were stratified based on receipt of any previous colorectal cancer screening and randomly assigned either to (1) an intervention group that received a mailing containing a reminder letter from their primary care physician, a brochure and digital video disc about colorectal cancer and colorectal cancer screening, and a follow-up telephone call or (2) a usual care control group. The primary outcome was receipt of fecal occult blood testing, sigmoidoscopy, or colonoscopy within 3 months of randomization. Screening outcomes were observed for an additional 3 months (6 months from randomization). Results Screening rates at 3 months were 9.9% (31 of 314 patients) in the intervention group and 3.2% (10 of 314 patients) in the control group (rate ratio, 3.1; 95% confidence interval, 1.5-6.2; P = .001). At 6 months, rates were 18.2% (57 of 314 patients) and 12.1% (38 of 314 patients), respectively (rate ratio, 1.5; 95% confidence interval, 1.03-2.2; P = .03). Conclusion Patient outreach to individuals with an expired order for colonoscopy may be an effective tool to modestly increase short-term completion of colorectal cancer screening. Trial registration clinicaltrials.gov Identifier: NCT00793455.
- Published
- 2010
37. Potential Use of 10-Year and Lifetime Coronary Risk Information for Preventive Cardiology Prescribing Decisions: a Primary Care Physician Survey
- Author
-
Kenzie A. Cameron, Donald M. Lloyd-Jones, Michael Zielinski, Charles Zei, and Stephen D. Persell
- Subjects
Adult ,Male ,Pediatrics ,medicine.medical_specialty ,Cardiology ,Coronary Disease ,Drug Prescriptions ,Article ,Decision Support Techniques ,Pharmacotherapy ,Fibrinolytic Agents ,Risk Factors ,Surveys and Questionnaires ,medicine ,Internal Medicine ,Humans ,Medical prescription ,Risk factor ,Practice Patterns, Physicians' ,Preventive healthcare ,Aspirin ,business.industry ,Anticholesteremic Agents ,Primary care physician ,Physicians, Family ,Guideline ,Middle Aged ,Lipids ,Primary Prevention ,Prescriptions ,Health Care Surveys ,Emergency medicine ,Practice Guidelines as Topic ,Female ,Guideline Adherence ,business ,Risk assessment ,Family Practice ,Fibrinolytic agent - Abstract
Background Data are sparse regarding how physicians use coronary risk information for prescribing decisions. Methods We presented 5 primary prevention scenarios to primary care physicians affiliated with an academic center and surveyed their responses after they were provided with (1) patient risk factor information, (2) 10-year estimated coronary disease risk information, and (3) 10-year and lifetime risk estimates. We asked about aspirin prescribing, lipid testing, and lipid-lowering drug prescribing. Results Of 202 physicians surveyed, 99 (49%) responded. The physicians made guideline-concordant aspirin decisions 51% to 91% of the time using risk factor information alone. Providing 10-year risk estimates increased concordant aspirin prescribing when the 10-year coronary risk was moderately high (15%) and decreased guideline-discordant prescribing when the 10-year risk was low (2 of 4 cases). Providing the lifetime risk information sometimes increased guideline-discordant aspirin prescribing. The physicians selected guideline-concordant thresholds for initiating treatment with lipid-lowering drugs 44% to 75% of the time using risk factor information alone. Selecting too low or too high low-density lipoprotein cholesterol thresholds was common. Ten-year risk information improved concordance when the 10-year risk was moderately high. Providing lifetime risk information increased willingness to initiate pharmacotherapy at low-density lipoprotein cholesterol levels that were lower than those recommended by guidelines when the 10-year risk was low but the lifetime risk was high. Conclusions Providing 10-year coronary risk information improved some hypothetical aspirin-prescribing decisions and improved lipid management when the short-term risk was moderately high. High lifetime risk sometimes led to more intensive prescription of aspirin or lipid-lowering medication. This outcome suggests that, to maximize the benefits of risk-calculating tools, specific guideline recommendations should be provided along with risk estimates.
- Published
- 2010
38. Frequency of inappropriate medical exceptions to quality measures
- Author
-
Jason A. Thompson, Nancy C. Dolan, Elisha M. Friesema, David W. Baker, Stephen D. Persell, and Darren Kaiser
- Subjects
medicine.medical_specialty ,Quality management ,media_common.quotation_subject ,Medical audit ,Observation ,Feedback ,Internal Medicine ,Medicine ,Electronic Health Records ,Humans ,Quality (business) ,Preventive healthcare ,media_common ,Medical Audit ,business.industry ,Guideline adherence ,Electronic medical record ,General Medicine ,medicine.disease ,Decision Support Systems, Clinical ,Coronary heart disease ,Practice Guidelines as Topic ,Medical emergency ,Guideline Adherence ,Illinois ,business ,Health care quality - Abstract
Quality improvement programs that allow physicians to document medical reasons for deviating from guidelines preserve clinicians' judgment while enabling them to strive for high performance. However, physician misconceptions or gaming potentially limit programs.To implement computerized decision support with mechanisms to document medical exceptions to quality measures and to perform peer review of exceptions and provide feedback when appropriate.Observational study.Large internal medicine practice.Patients eligible for 1 or more quality measures.A peer-review panel judged medical exceptions to 16 chronic disease and prevention quality measures as appropriate, inappropriate, or of uncertain appropriateness. Medical records were reviewed after feedback was given to determine whether care changed.Physicians recorded 650 standardized medical exceptions during 7 months. The reporting tool was used without any medical reason 36 times (5.5%). Of the remaining 614 exceptions, 93.6% were medically appropriate, 3.1% were inappropriate, and 3.3% were of uncertain appropriateness. Frequencies of inappropriate exceptions were 7 (6.9%) for coronary heart disease, 0 (0%) for heart failure, 10 (10.8%) for diabetes, and 2 (0.6%) for preventive services. After physicians received direct feedback about inappropriate exceptions, 8 of 19 (42%) changed management. The peer-review process took less than 5 minutes per case, but for each change in clinical care, 65 reviews were required.The findings could differ at other sites or if financial incentives were in place.Physician-recorded medical exceptions were correct most of the time. Peer review of medical exceptions can identify myths and misconceptions, but the process needs to be more efficient to be sustainable.Agency for Healthcare Research and Quality.
- Published
- 2010
39. National Cholesterol Education Program risk assessment and potential for risk misclassification
- Author
-
Stephen D. Persell, David W. Baker, and Donald M. Lloyd-Jones
- Subjects
Adult ,Male ,medicine.medical_specialty ,National Health and Nutrition Examination Survey ,Epidemiology ,Hypercholesterolemia ,Coronary Disease ,Disease ,Risk Assessment ,Age Distribution ,Internal medicine ,medicine ,Confidence Intervals ,Humans ,Myocardial infarction ,Risk factor ,Sex Distribution ,National Cholesterol Education Program ,Health Education ,Aged ,Framingham Risk Score ,business.industry ,Public Health, Environmental and Occupational Health ,Middle Aged ,medicine.disease ,Nutrition Surveys ,Confidence interval ,United States ,Physical therapy ,Female ,Risk assessment ,business - Abstract
Background. The National Cholesterol Education Program Adult Treatment Panel report from 2001 (ATP III) recommends clinicians calculate 10-year coronary risk using multivariable methods only for adults with 2 or more risk factors. We aimed to determine who would be falsely classified as low risk using this approach. Methods. We studied 4097 adults aged 20 to 79 years without diagnosed cardiovascular disease or diabetes from the National Health and Nutrition Examination Survey from 1999 to 2002. We determined the proportion with fewer than 2 risk factors who nonetheless had estimated 10-year risk of cardiac death or myocardial infarction ≥ 10% using multivariable methods. Results. Among persons with fewer than 2 risk factors, 5.3% (95% confidence interval 4.7 to 6.1%), had a 10-year risk ≥ 10% using the Framingham Risk Score and would be misclassified using the risk factor counting method (this corresponds to approximately 5,640,000 U.S. adults). Compared to individuals whose classification was unchanged, those misclassified as low risk were older (P Conclusions. Relying on the ATP III risk factor counting method rather than determining risk using multivariable methods in all patients resulted in misclassifiying as low risk over 5 million adults with at least moderately high risk of coronary heart disease, most of whom are middle-aged and older men.
- Published
- 2005
40. Aspirin use among adults with diabetes: recent trends and emerging sex disparities
- Author
-
Stephen D. Persell and David W. Baker
- Subjects
Adult ,Male ,medicine.medical_specialty ,Disease ,Rate ratio ,Sex Factors ,Risk Factors ,Internal medicine ,Diabetes mellitus ,Internal Medicine ,Diabetes Mellitus ,Medicine ,Humans ,Antipyretic ,Cardiac risk ,Socioeconomic status ,Aged ,Aspirin ,business.industry ,Middle Aged ,medicine.disease ,Confidence interval ,United States ,Surgery ,Cardiovascular Diseases ,Female ,business ,medicine.drug - Abstract
Background Despite high cardiovascular risk among adults with diabetes mellitus, aspirin use has been low. Methods To assess recent self-reported regular aspirin use among adults 35 years or older with diabetes, we used statewide telephone surveys conducted in 7 states in 1997 and 20 states in 1999 and 2001 including 875, 3205, and 4272 subjects in 1997, 1999, and 2001, respectively. Results Aspirin use increased from 37.5% in 1997 to 48.7% in 2001. In 2001, 74.2% (95% confidence interval [CI], 70.9%-77.5%) of diabetic adults with cardiovascular disease, but only 37.9% (95% CI, 35.1%-40.7%) of those without cardiovascular disease, used aspirin regularly, including less than 40% with diagnosed hypertension or hypercholesterolemia or who smoked. After adjusting for cardiac risk factors and socioeconomic characteristics, among those without cardiovascular disease, aspirin use was less common in women aged 35 to 49 years (adjusted rate ratio [RR], 0.35; 95% CI, 0.24-0.51) and 50 to 64 years (RR, 0.69; 95% CI, 0.53-0.88) and in men aged 35 to 49 years (RR, 0.62; 95% CI, 0.43-0.85) compared with men 65 years and older. For those with diagnosed cardiovascular disease, aspirin use was lower among women (RR, 0.81 compared with men; 95% CI, 0.70-0.90) and adults younger than 50 years (RR compared with those ≥65 years, 0.81; 95% CI, 0.61-0.98). The disparity in aspirin use between men and women appeared between 1997 and 2001. Conclusions Aspirin use among adults with diabetes has increased. However, many high-risk individuals, especially women and those younger than 50 years, do not use this effective and inexpensive therapy.
- Published
- 2004
41. Reply to: From TROPHY With Pride
- Author
-
David W. Baker and Stephen D. Persell
- Subjects
Pride ,business.industry ,media_common.quotation_subject ,Internal Medicine ,Medicine ,Religious studies ,business ,Trophy ,media_common - Published
- 2007
42. Contextual Errors and Failures in Individualizing Patient Care
- Author
-
Stephen D. Persell, Saul J. Weiner, Frances M. Weaver, Marilyn M. Schapira, Ben Preyss, Alan Schwartz, Richard Abrams, Rachel Yudkowsky, Julie H. Goldberg, Amy Binns-Calvey, Elizabeth A. Jacobs, and Gunjan Sharma
- Subjects
Adult ,Male ,Pediatrics ,medicine.medical_specialty ,Decision Making ,MEDLINE ,Context (language use) ,law.invention ,Randomized controlled trial ,law ,Patient-Centered Care ,Health care ,Internal Medicine ,Humans ,Medicine ,Medical History Taking ,Veterans Affairs ,Aged ,Service (business) ,Medical Errors ,business.industry ,FLAGS register ,Health services research ,General Medicine ,Middle Aged ,medicine.disease ,Patient Simulation ,Logistic Models ,Outcome and Process Assessment, Health Care ,Female ,Medical emergency ,business - Abstract
Background A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care. Objective To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes. Design An incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked. Setting 14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U.S. Department of Veterans Affairs facilities. Measurements Primary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans. Results Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters. Limitations Only 4 case scenarios were used. The study assessed physicians' propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context. Conclusion Inattention to contextual information, such as a patient's transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance. Primary funding source U.S. Department of Veterans Affairs Health Services Research and Development Service
- Published
- 2010
43. Elevated Creatinine Levels and Quality of Care in Heart Failure
- Author
-
David W. Baker, Karen S. Kmetik, and Stephen D. Persell
- Subjects
Creatinine ,medicine.medical_specialty ,business.industry ,General Medicine ,medicine.disease ,Elevated creatinine ,chemistry.chemical_compound ,chemistry ,Heart failure ,Emergency medicine ,Internal Medicine ,Medicine ,Quality of care ,business ,Health care quality ,Asthma - Published
- 2007
44. Beware the Burden of Measurement—Reply
- Author
-
Karen S. Kmetik, Stephen D. Persell, David W. Baker, and Jason A. Thompson
- Subjects
Medication review ,medicine.medical_specialty ,Decision making encouragement ,business.industry ,Quality measurement ,Cervical cancer screening ,Coronary heart disease ,Chronic disease ,Reference values ,Internal Medicine ,medicine ,Physical therapy ,Quality of care ,Intensive care medicine ,business - Published
- 2007
45. Automated Review of Electronic Health Records to Assess Quality of Care for Outpatients with Heart Failure
- Author
-
David W. Baker, David T. Liss, Karen S. Kmetik, Neilesh S. Soman, Karen M. Burgner, Jason A. Thompson, and Stephen D. Persell
- Subjects
Medical Records Systems, Computerized ,health care facilities, manpower, and services ,Adrenergic beta-Antagonists ,Angiotensin-Converting Enzyme Inhibitors ,Observation ,Signs and symptoms ,Health records ,Drug Prescriptions ,Ventricular Function, Left ,Angiotensin Receptor Antagonists ,Electronic health record ,health services administration ,Outcome Assessment, Health Care ,Ambulatory Care ,Internal Medicine ,Humans ,Medicine ,Quality of care ,health care economics and organizations ,Aged ,Aged, 80 and over ,Heart Failure ,business.industry ,Arrhythmias, Cardiac ,social sciences ,General Medicine ,Middle Aged ,medicine.disease ,Medical emergency ,business ,Health care quality - Abstract
Electronic health records (EHRs) may be used to assess quality of care.To evaluate the accuracy of automated review of EHR data to measure quality of care for outpatients with heart failure.Observational study of quality of care for heart failure comparing automated review of EHR data with automated review followed by manual review of electronic notes for patients with apparent quality deficits (hybrid review).An academic general internal medicine clinic with several years' experience using a commercial EHR.517 adults with a qualifying International Classification of Diseases, Ninth Revision, diagnosis of heart failure in their EHR data and 2 or more clinic visits over the past 18 months.Left ventricular ejection fraction (LVEF), prescription of a beta-blocker and an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) for patients with left ventricular systolic dysfunction (LVEF0.40) and prescription of warfarin for patients with comorbid atrial fibrillation.Performance based on automated review of EHR data was similar to that based on hybrid review for assessing LVEF measurement (94.6% vs. 97.3%), prescription of beta-blockers (90.9% vs. 92.8%), and prescription of ACE inhibitors or ARBs (93.9% vs. 98.7%). However, performance based on automated review was lower than that based on hybrid review for prescription of warfarin for atrial fibrillation (70.4% vs. 93.6%), primarily because automated review did not detect documentation of accepted reasons for not prescribing warfarin.The findings may not be applicable to other practices and other EHRs. The authors used EHR data to identify eligible patients, so the study may have excluded some patients with heart failure. Patient charts were manually reviewed only if a provider appeared to fail a quality measure on automated review and did not determine the sensitivity and specificity of automated review according to standard definitions.Automated review of EHR data to measure the quality of care of outpatients with heart failure missed many exclusion criteria for medications documented only in providers' notes. As a result, it sometimes underestimated performance on medication-based quality measures.
- Published
- 2007
46. Assessing the Validity of National Quality Measures for Coronary Artery Disease Using an Electronic Health Record
- Author
-
Jennifer M. Wright, David W. Baker, Stephen D. Persell, Karen S. Kmetik, and Jason A. Thompson
- Subjects
medicine.medical_specialty ,Medical Records Systems, Computerized ,media_common.quotation_subject ,Coronary Artery Disease ,Coronary artery disease ,Diabetes mellitus ,Ambulatory Care ,Internal Medicine ,medicine ,Humans ,Quality (business) ,Myocardial infarction ,Quality Indicators, Health Care ,Retrospective Studies ,media_common ,business.industry ,Medical record ,Lipid Measurement ,medicine.disease ,United States ,Surgery ,Outcome and Process Assessment, Health Care ,Blood pressure ,Emergency medicine ,Ambulatory ,business - Abstract
Background Nationally endorsed, clinical performance measures are available that allow for quality reporting using electronic health records (EHRs). To our knowledge, how well they reflect actual quality of care has not been studied. We sought to evaluate the validity of performance measures for coronary artery disease (CAD) using an ambulatory EHR. Methods We performed a retrospective electronic medical chart review comparing automated measurement with a 2-step process of automated measurement supplemented by review of free-text notes for apparent quality failures for all patients with CAD from a large internal medicine practice using a commercial EHR. The 7 performance measures included the following: antiplatelet drug, lipid-lowering drug, β-blocker following myocardial infarction, blood pressure measurement, lipid measurement, low-density lipoprotein cholesterol control, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for patients with diabetes mellitus or left ventricular systolic dysfunction. Results Performance varied from 81.6% for lipid measurement to 97.6% for blood pressure measurement based on automated measurement. A review of free-text notes for cases failing an automated measure revealed that misclassification was common and that 15% to 81% of apparent quality failures either satisfied the performance measure or met valid exclusion criteria. After including free-text data, the adherence rate ranged from 87.5% for lipid measurement and low-density lipoprotein cholesterol control to 99.2% for blood pressure measurement. Conclusions Profiling the quality of outpatient CAD care using data from an EHR has significant limitations. Changes in how data are routinely recorded in an EHR are needed to improve the accuracy of this type of quality measurement. Validity testing in different settings is required.
- Published
- 2006
47. Implications of Changing National Cholesterol Education Program Goals for the Treatment and Control of Hypercholesterolemia
- Author
-
Stephen D. Persell, Donald M. Lloyd-Jones, and David W. Baker
- Subjects
Internal Medicine - Published
- 2006
Catalog
Discovery Service for Jio Institute Digital Library
For full access to our library's resources, please sign in.