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We surveyed 571 US hospitals about practices used to prevent Clostridium difficile infection (CDI). Most hospitals reported regularly using key CDI prevention practices, and perceived their strength of evidence as high. The largest discrepancy between regular use and perceived evidence strength occurred with antimicrobial stewardship programs.Infect. Control Hosp. Epidemiol. 2015;36(8):969–971

The increasing prevalence of diabetes and prediabetes makes the cost of diabetes care a pressing concern. Nurses in all settings play a critical role in helping to reduce the cost of diabetes not only for individual patients but ultimately for the health care system. This article focuses on four main issues related to the economic impact of diabetes for patients and health systems: (1) overall estimates of the direct and indirect costs of diabetes and its associated complications, (2) the impact of cost on diabetes care and health outcomes, (3) the ways in which federal- and state-mandated insurance for persons with diabetes is being used to promote more cost-effective and high-quality diabetes care, and (4) the use of cost-effectiveness analysis to evaluate interventions designed to prevent diabetes or diabetes-related complications.

OBJECTIVE—Many adults experience chronic pain, yet little is known about the consequences of such pain among individuals with diabetes. The purpose of this study was to examine whether and how chronic pain affects diabetes self-management. RESEARCH DESIGN AND METHODS—This is a cross-sectional study of 993 patients with diabetes receiving care through the Department of Veterans Affairs (VA). Data on chronic pain, defined as pain present most of the time for 6 months or more during the past year, and diabetes self-management were collected through a written survey. Multivariable regression techniques were used to examine the association between the presence and severity of chronic pain and difficulty with diabetes self-management, adjusting for sociodemographic and other health characteristics including depression. RESULTS—Approximately 60% of respondents reported chronic pain. Patients with chronic pain had poorer diabetes self-management overall (P = 0.002) and more difficulty following a recommended exercise plan (adjusted odds ratio [OR] 3.0 [95% CI 2.1–4.1]) and eating plan (1.6 [1.2–2.1]). Individuals with severe or very severe pain, compared with mild or moderate, reported significantly poorer diabetes self-management (P = 0.003), including greater difficulty with taking diabetes medications (2.0 [1.2–3.4]) and exercise (2.5 [1.3–5.0]). CONCLUSIONS—Chronic pain was prevalent in this cohort of patients with diabetes. Even after controlling for general health status and depressive symptoms, chronic pain was a major limiting factor in the performance of self-care behaviors that are important for minimizing diabetes-related complications. Competing demands, such as chronic pain, should be considered when working with patients to develop effective diabetes self-care regimens.

We assessed the impact of a quality improvement intervention to reduce urinary catheter use and associated urinary tract infections (UTIs) at a single hospital. After implementation, UTIs were reduced by 39% (P = .04). Additionally, we observed a slight decrease in catheter use and the number of catheters without an appropriate indication.

Purpose To evaluate the effects of a collaborative case management intervention for patients with poorly controlled type 2 diabetes on glycemic control, intermediate cardiovascular outcomes, satisfaction with care, and resource utilization. Methods We conducted a randomized controlled trial at two Department of Veterans Affairs Medical Centers involving 246 veterans with diabetes and baseline hemoglobin A 1C (HbA 1C ) levels ≥7.5%. Two nurse practitioner case managers worked with patients and their primary care providers, monitoring and coordinating care for the intervention group for 18 months through the use of telephone contacts, collaborative goal setting, and treatment algorithms. Control patients received educational materials and usual care from their primary care providers. Results At the conclusion of the study, both case management and control patients remained under poor glycemic control and there was little difference between groups in mean exit HbA 1C level (9.3% vs. 9.2%; difference=0.1%; 95% confidence interval: −0.4% to 0.7%; P = 0.65). There was also no evidence that the intervention resulted in improvements in low-density lipoprotein cholesterol level or blood pressure control or greater intensification in medication therapy. However, intervention patients were substantially more satisfied with their diabetes care, with 82% rating their providers as better than average compared with 64% of patients in the control group ( P = 0.04). Conclusion An intervention of collaborative case management did not improve key physiologic outcomes for high-risk patients with type 2 diabetes. The type of patients targeted for intervention, organizational factors, and program structure are likely critical determinants of the effectiveness of case management. Health systems must understand the potential limitations before expending substantial resources on case management, as the expected improvements in outcomes and downstream cost savings may not always be realized.

OBJECTIVE—To outline the principles that direct the Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) dedicated to diabetes quality improvement (QUERI-DM). RESEARCH DESIGN AND METHODS—We discuss the VA initiatives aimed at improving diabetes care for veterans as well as general issues that should be considered in quality improvement initiatives. We specifically describe some of the epidemiological, statistical, and organizational issues that have guided our quality improvement (QI) programs. RESULTS—The five principles that have guided the QUERI-DM process are: 1) treating clinical guidelines and goals distinct from quality standards and quality improvement priorities; 2) targeting high-risk patients and high-impact quality issues; 3) profiling processes over outcomes; 4) targeting processes that will improve patient outcomes; and 5) paying attention to the loci of practice variation. CONCLUSIONS—The authors recommend that all five principles be considered when moving from practice guidelines to performance measures and QI initiatives. Targeting high-priority problems and high-risk groups can greatly improve the effectiveness and efficiency of QI interventions.

OBJECTIVE—Although patient diabetes self-management is a key determinant of health outcomes, there is little evidence on whether patients’ own assessments of their self-management correlates with glycemic control and key aspects of high-quality diabetes care. We explored these associations in a nationwide sample of Veterans’ Affairs (VA) patients with diabetes. RESEARCH DESIGN AND METHODS—We abstracted information on achieved level of glycemic control (HbA1c) and diabetes processes of care (receipt of HbA1c test, eye examination, and nephropathy screen) from medical records of 1,032 diabetic patients who received care from 21 VA facilities and had answered the Diabetes Quality Improvement Program survey in 2000. The survey included sociodemographic measures and a five-item scale assessing the patients’ diabetes self-management (medication use, blood glucose monitoring, diet, exercise, and foot care [α = 0.68]). Using multivariable regression, we examined the associations of patients’ reported self-management with HbA1c level and receipt of each diabetes process of care. We adjusted for diabetes severity and comorbidities, insulin use, age, ethnicity, income, education, use of VA services, and clustering at the facility level. RESULTS—Higher patient evaluations of their diabetes self-management were significantly associated with lower HbA1c levels (P < 0.01) and receipt of diabetes services. Those in the 95th percentile for self-management had a mean HbA1c level of 7.3 (95% CI 6.4–8.3), whereas those in the 5th percentile had mean levels of 8.3 (7.4–9.2). For every 10-point increase in patients’ ratings of their diabetes self-management, even after adjusting for number of outpatient visits, the odds of receiving an HbA1c test in the past year increased by 15% (4–27%), of receiving an eye examination increased by 16% (7–27%), and of receiving a nephropathy screen increased by 13% (2–26%). CONCLUSIONS—In this sample, patients’ assessments of their diabetes self-care using a simple five-question instrument were significantly associated both with actual HbA1c control and with receiving recommended diabetes services. These findings reinforce the usefulness of patient evaluations of their own self-management for understanding and improving glycemic control. The mechanisms by which those patients who are more actively engaged in their diabetes self-care are also more likely to receive necessary services warrant further study.

Most sectors of the health care industry are engaged in a massive campaign to profile individual health care providers (Green and Wintfeld 1995; Garnick et al. 1994; Welch, Miller, and Welch 1994; Jencks and Wilensky 1992). Profiling is viewed as a way to contain costs and control practice variation in hopes of improving the quality of care. Inevitably, the focus on practice variation moved from the geographic level to the hospital and health plan level and then to the individual provider in an attempt to understand the reasons for variation and to assign accountability (Wennberg 1998; Ashton et al. 1999; Gatsonis et al. 1995; Casparie 1996; Kassirer 1994; Corrigan and Nielsen 1993; Hanchak and Schlackman 1995; Evans, Hwang, and Nagarajan 1995; Eddy 1998). While appropriately placed accountability may be good for quality improvement, to date the effect of profiling on changing the practice patterns of individual providers has been mixed (Balas et al. 1996; Mainous et al. 2000; Weiss and Wagner 2000; Marshall et al. 2000; Evans, Hwang, and Nagarajan 1995). For example, while some studies demonstrated a positive effect of profiling on reducing hospital length of stay (Evans, Hwang, and Nagarajan 1995; Ross, Johnson, and Castronova 2000), others found that profiling had no apparent effect on physician prescribing behavior (Schectman et al. 1995; Mainous et al. 2000). Likewise, a meta-analysis of randomized clinical trials suggested that profiles had a statistically significant but minimal effect on the use of various clinical procedures, primarily medication prescribing and lab-test ordering (Balas et al. 1996). In addition to being of unclear value in achieving certain outcomes, profiling at the individual provider level is an expensive undertaking (Anonymous 1997; Eddy 1998; Hofer et al. 1999) and could adversely affect the professional careers of some providers (Blum 1996; Kassirer 1994). Moreover, if done in an uninformed way, profiling can produce meaningless rankings that will eventually undermine any possible positive effect on quality (Christiansen and Morris 1997; Goldstein and Spiegelhalter 1996; Normand, Glickman, and Gatsonis 1997), and provide an incentive for providers to act in ways that could actually worsen quality and access to care (Hofer et al. 1999; Hofer and Hayward 1996). The delivery of health care services depends not only on individual providers but also on the system in which the provider works (e.g., practitioners organized within a provider group or practice setting that cares for individuals with specific types of insurance coverage and/or social conditions), and all levels within this system could affect both care processes and outcomes (Westert and Groenewegen 1999; Herman 2000; Landon, Wilson, and Cleary 1998; McNeil, Pedersen, and Gatsonis 1992). Nonetheless, most studies of and applications that draw on practice variation, such as provider profiling, tend to focus on a single level (e.g., individual practitioners) without taking into account the amount of variation potentially attributable to other levels within the care system. The few studies that have assessed the amount of attributable variation at different levels of care have found strikingly little variation at the physician level (Orav et al. 1996; Sixma, Spreeuwenberg, and van der Pasch 1998; Hofer et al. 1999; Katon et al. 2000). However, these studies have not rigorously examined variation at levels above the physician and usually focus on outcomes and costs of care. It has been argued that process measures might show larger amounts of variation at the physician level than do outcome measures (Sandy 2000; Shojania and Wachter 2000), but little work has been done to systematically address this issue. Therefore, we examined the amount of practitioner level variation relative to other system effects for a broad selection of resource use, outcome, and process indicators for diabetes care. The Department of Veterans Affairs (VA) health care system, with its large number of facilities and single computerized information system, is one of the few places where it is possible to examine variation attributable to multiple levels within a health care system. The objectives of this study were: (1) to evaluate whether the greatest amount of variation in diabetes practice patterns occurs at the primary care provider (PCP), provider group, or facility level and whether provider level variation is more pronounced for measures based on processes of care; and, (2) to examine the reliability of performance profiles of high priority diabetes care quality and resource use indicators constructed using computerized hospital databases. This study is intended to help us better understand how to efficiently allocate resources for quality improvement and ensure that we focus on areas that are most likely to produce improvements in patient care.

Article-at-a-Glance Background Little is known about the relative reliability of medical record and clinical automated data, sources commonly used to assess diabetes quality of care. The agreement between diabetes quality measures constructed from clinical automated versus medical record data sources was compared, and the performance of hybrid measures derived from a combination of the two data sources was examined. Methods Medical records were abstracted for 1,032 patients with diabetes who received care from 21 facilities in 4 Veterans Integrated Service Networks. Automated data were obtained from a central Veterans Health Administration diabetes registry containing information on laboratory tests and medication use. Results Success rates were higher for process measures derived from medical record data than from automated data, but no substantial differences among data sources were found for the intermediate outcome measures. Agreement for measures derived from the medical record compared with automated data was moderate for process measures but high for intermediate outcome measures. Hybrid measures yielded success rates similar to those of medical record–based measures but would have required about 50% fewer chart reviews. Conclusions Agreement between medical record and automated data was generally high. Yet even in an integrated health care system with sophisticated information technology, automated data tended to underestimate the success rate in technical process measures for diabetes care and yielded different quartile performance rankings for facilities. Applying hybrid methodology yielded results consistent with the medical record but required less data to come from medical record reviews.

OBJECTIVE—Despite being a safe, effective therapy for lowering cardiovascular risk, only 20% of diabetic patients were using aspirin in the early 1990s. This study examines current physician practices and the use of aspirin therapy by individuals with diabetes. RESEARCH DESIGN AND METHODS—A random sample of diabetic patients receiving care in the Department of Veterans Affairs health care system were surveyed during January-March 2000. The association between aspirin counseling, aspirin use, and reported coronary vascular disease (CVD) and classical CVD risk factors were examined using logistic regression. The effect of increasing aspirin use on risk of myocardial infarction (MI) and cardiovascular mortality was demonstrated by simulation. RESULTS—Seventy-one percent of respondents reported being counseled about aspirin use, and 66% were taking daily aspirin. Individuals with known CVD were more likely to be counseled (odds ratio [OR] 4.9, 95% CI 2.9–8.1) and to use aspirin (2.1, 1.2–3.7). The factor most strongly associated with aspirin use was having been counseled about aspirin therapy by a doctor. We estimate that for this population, increasing daily aspirin use to 90% could prevent an additional 11,000 MIs and potentially save >8,000 lives. CONCLUSIONS—Compared with previous reports, a substantial proportion of these diabetic patients have been counseled about and use aspirin. Most clinicians recognize aspirin as an important treatment for patients with preexisting coronary disease. However, since diabetes is now considered a CVD equivalent, it is imperative that clinicians include counseling about aspirin therapy as a care priority for all their diabetic patients, as this simple intervention may prevent many cardiovascular events and deaths.

In 2010, the US Department of Veterans Affairs (VA) launched national implementation of patient-centered medical homes (PCMH) through the Patient Aligned Care Teams (PACT) initiative, as described by Gordon Schectman and Richard Stark, the chief architects of PACT, in their commentary to this Supplement. Concurrently, the PACT initiative aimed to incorporate rigorous formative and summative evaluation of PACT implementation and to promote PACT-related innovation development and testing. To accomplish these goals, the initiative established a national evaluation team (based in Seattle) and competitively funded five PACT Demonstration Laboratories (in Ann Arbor, Los Angeles, Iowa City, Philadelphia, and Portland). In addition, embedded health services researchers and clinical leader partners from outside the Demonstration Laboratories undertook relevant studies. Together, the implementation and evaluation components of PACT as reported in this Supplement’s articles document opportunities and challenges in implementing a PCMH in integrated healthcare systems that are both specifically relevant to VA and informative to other managed care or Accountable Care Organizations (ACOs) engaged in implementing PCMH models. In addition, as highlighted in the Reid and Wagner commentary in this Supplement, the articles have implementation science implications as they delve into components of the Chronic Illness Care Model. Rather than a demonstration project, VA’s implementation of PACT represents a national rollout of PCMH to all VA primary care practices in more than 150 medical centers and over 800 community-based outpatient clinics. The articles in this Supplement therefore reflect realistic transformation on a national scale during its first 2 to 3 years. Funded by the VA Office of Patient Care Services’ Primary Care Program Office, this Journal of General Internal Medicine (JGIM) Supplement shares the lessons learned by researchers and their clinical and policy partners during early stages of PACT implementation. The 19 published articles underwent rigorous JGIM peer review along with nearly 50 additional manuscripts that were submitted in response to the supplement’s Call for Papers but not selected for the Supplement. The published articles touch upon virtually all facets of medical homes, including implementation strategies, performance measurement, care transitions, team development, mental health and pharmacy integration, quality improvement, and medical home neighborhood development. We organized the PACT Supplement to reflect different stages and levels of medical home implementation, starting with pre-implementation PACT challenges and insights about implementation strategies, closer examination of organizational structures, strengths and challenges of implementing team-based care, and ending with implications for specialty care relationships and addressing the needs of special populations.

Health care-associated infection (HAI) is costly to hospitals and potentially life-threatening to patients. Numerous infection prevention programs have been implemented in hospitals across the United States. Yet, little is known about infection prevention practices and implementation in rural hospitals. The purpose of this study was to understand the infection prevention practices used by rural Veterans' Affairs (VA) hospitals and the unique factors they face in implementing these practices.This study used a sequential, mixed methods approach. Survey data to identify the HAI prevention practices used by rural VA hospitals were collected, analyzed, and used to inform the development of a semistructured interview guide. Phone interviews were conducted followed by site visits to rural VA hospitals.We found that most rural VA hospitals were using key recommended infection prevention practices. Nonetheless, a number of challenges with practice implementation were identified. The 3 most prominent themes were: (1) lack of human capital including staff with HAI expertise; (2) having to cultivate needed resources; and (3) operating as a system within a system.Rural VA hospitals are providing key infection prevention services to ensure a safe environment for the veterans they serve. However, certain factors, such as staff expertise, limited resources, and local context impacted how and when these practices were used. The creative use of more accessible alternative resources as well as greater flexibility in implementing HAI-related initiatives may be important strategies to further improve delivery of these important services by rural VA hospitals.

Background Growing use of peripherally inserted central catheters (PICCs) has led to recognition of the risk of PICC-associated bloodstream infection. We sought to identify rates, patterns, and patient, provider, and device characteristics associated with this adverse outcome. Methods A retrospective cohort of consecutive adults who underwent PICC placement from June 2009 to July 2012 was assembled. Using multivariable logistic and Cox-proportional hazards regression models, covariates specified a priori were analyzed for their association with PICC-associated bloodstream infection. Odds ratios (OR) and hazard ratios (HR) with corresponding 95% confidence intervals (CI) were used to express the association between each predictor and the outcome of interest. Results During the study period, 966 PICCs were inserted in 747 unique patients for a total of 26,887 catheter days. Indications for PICC insertion included: long-term antibiotic administration (52%, n = 503), venous access (21%, n = 201), total parenteral nutrition (16%, n = 155), and chemotherapy (11%, n = 107). On bivariate analysis, intensive care unit (ICU) status (OR 3.23; 95% CI, 1.84-5.65), mechanical ventilation (OR 4.39; 95% CI, 2.46-7.82), length of stay (hospital, OR 1.04; 95% CI, 1.02-1.06 and ICU, OR 1.03; 95% CI, 1.02-1.04), PowerPICCs (C. R. Bard, Inc., Murray Hill, NJ; OR 2.58; 95% CI, 1.41-4.73), and devices placed by interventional radiology (OR 2.57; 95% CI, 1.41-4.68) were associated with PICC-bloodstream infection. Catheter lumens were strongly associated with this event (double lumen, OR 5.21; 95% CI, 2.46-11.04, and triple lumen, OR 10.84; 95% CI, 4.38-26.82). On multivariable analysis, only hospital length of stay, ICU status, and number of PICC lumens remained significantly associated with PICC bloodstream infection. Notably, the HR for PICC lumens increased substantially, suggesting earlier time to infection among patients with multi-lumen PICCs (HR 4.08; 95% CI, 1.51-11.02 and HR 8.52; 95% CI, 2.55-28.49 for double- and triple-lumen devices, respectively). Conclusions PICC-associated bloodstream infection is most associated with hospital length of stay, ICU status, and number of device lumens. Policy and procedural oversights targeting these factors may be necessary to reduce the risk of this adverse outcome.

He that is good for making excuses is seldom good for anything else.Benjamin FranklinEfforts to prevent catheter-associated urinary tract infection (CAUTI) are underway worldwide.1–4 Reducing indwelling urinary catheter (or ‘Foley’) use is a key component of most prevention initiatives, which makes sense given the evidence showing its effectiveness in reducing CAUTI rates.5 Such an approach, however, requires a specific focus on promoting the use of appropriate indications for a Foley at the time of insertion and throughout the duration of catheterisation. Unfortunately, data show substantial variability in both interpreting and applying such indications.6 The article by Murphy and colleagues7 uses robust qualitative methods to provide insights into decision-making about Foley insertion, including indications for use and the clinical context. This focus corresponds with what we and others have characterised as the socio-adaptive aspects of CAUTI prevention, including behaviour change and unit culture, as compared with the technical components, such as urinary catheter reminders or stop orders.8 Murphy et al 's work supports the use of certain strategies to promote more appropriate Foley use, such as better education about and availability of alternatives, including bladder scanning and external catheters (referred to as urinary sheaths in the paper). It also reinforces current wisdom about …

Summary NorthMed HMO is viewed by its owners as an important vehicle for integrating rural providers in northern Michigan. Through the HMO, rural providers hope to be able to contract with government programs, while retaining private-sector patients through employer contracts. For most rural providers, NorthMed HMO does not yet represent a major source of revenues. However, the HMO is about to embark on an expansion that, if successful, will increase its importance to providers and its visibility within the service area. This planned expansion is likely to place severe demands on the financial and managerial resources of the organization. Physicians. NorthMed HMO offers a model of a rural-based HMO in which physicians play a dominant role. Rural physicians in northern Michigan own Northern Physician Organization, a physician organization which, in turn, is the major stockholder in NorthMed HMO. The geographic expansion of the HMO is tied, in large part, to the geographic expansion of the membership of Northern Physician Organization. NorthMed HMO enters new communities when a significant number of physicians in those communities joins Northern Physician Organization. When physicians purchase ownership shares in the physician organization, they indirectly become part owners of the HMO. Participation in NorthMed HMOs network has offered limited benefits to rural physicians at a minimal cost. By being a participating provider in NorthMed HMO, physicians can remain available to their patients who choose the HMO as a health insurance option. NorthMed HMO has not been aggressive in attempts to influence physician practices, and physicians bear no financial risk as a result of their participation. Participating physicians are paid under a fee-for-service arrangement with no risk sharing related to hospital use. Indirectly, through Northern Physician Organization's ownership role in the HMO, physicians have the potential to gain financially from NorthMed HMOs growth if the HMO were to be sold, but this diffuse incentive is unlikely to have an impact on physicians' day-to-day behavior. The relationship between NorthMed HMO and its physicians is likely to change soon. The number of HMO patients seen by physicians will increase if the HMO succeeds in securing Medicare and Medicaid contracts, and if its new point-of-service option attracts additional private-sector enrollees. NorthMed HMO plans to contract with Northern Physician Organization on a capitated basis to serve the HMOs enrollees, an arrangement that would place financial responsibility for managing care delivery more directly on participating physicians. This is likely to result in more aggressive utilization review and quality assurance measures. In effect, rural physicians will be faced with a difficult trade-off that they have, to this point, largely avoided: They will be asked to accept financial risk and oversight of their practices in return for the assurance that their HMO can successfully compete for local patients (and their insurance dollars) against health plans that are owned and managed by entities located outside of their rural area.

This paper synthesizes national data on rural HMO enrollment in commercial plans, Medicaid HMOs and prepaid plans, and Medicare risk-based plans. Although most rural counties now are incl...

The local supply of physicians has a strong influence on the availability and the quality of services provided by rural hospitals. Nevertheless, there are no published studies that describe the composition of rural hospital medical staffs and, in particular, the availability of specialists on these staffs. This study uses 1991 and 1994 survey data from rural hospitals located in eight states to describe the specialty composition and factors that influence the presence of specialists on rural hospital medical staffs. The results show a strong, positive association between the level of medical staff specialization in rural hospitals and the level of medical specialization of their closest rural neighbors, which suggests there is competition among rural hospitals based on the composition of the hospital medical staff. Analysis by specialty type, however, indicates that the degree of competition may differ for different types of specialists.

We introduce a mindful evidence-based practice model to operationalize mindfulness to improve bedside infection prevention practices. Using catheter-associated urinary tract infection prevention as an example, we illustrate how clinicians can be more mindful about appropriate catheter indications and timely catheter removal.

BACKGROUND A Michigan survey found variation in hospitalist-reported experience, practice, opinions, and knowledge related to peripherally inserted central catheters (PICCs). Whether these findings reflect a national trend is unknown. OBJECTIVE To investigate self-reported PICC practice among adult hospitalists in the United States. METHODS Society of Hospital Medicine-administered, anonymous, Web-based survey of practicing, adult, non-Michigan hospitalists. RESULTS Of the 2112 hospitalists who were sent an electronic invitation, 381 completed the online survey (18%). Eighty-six percent of hospitalists reported having placed a PICC solely for venous access (vs specific indications such as long-term antibiotics or parenteral nutrition). Eighty-two percent reported having cared for a patient who specifically requested a PICC. Only 25% of hospitalists reported examining PICCs for evidence of external problems, whereas 57% admitted to having, at least once, forgotten about the presence of a PICC. Only 9% of respondents knew that PICC tip verification was performed primarily to prevent venous thromboembolism. Finally, 42% of participants indicated that 10% to 25% of PICCs placed in their hospitals might be inappropriately placed and/or avoidable. CONCLUSIONS This national survey highlights several potential opportunities to improve hospitalist PICC practices. A research agenda dedicated to this issue is necessary to improve patient safety and hospital-based practice. Journal of Hospital Medicine 2013;8:635–638. © 2013 Society of Hospital Medicine

BackgroundChronic pain, especially back pain, is a prevalent condition that is associated with disability, poor health status, anxiety and depression, decreased quality of life, and increased health services use and costs. Current evidence suggests that exercise is an effective strategy for managing chronic pain. However, there are few clinical programs that use generally available tools and a relatively low-cost approach to help patients with chronic back pain initiate and maintain an exercise program. ObjectiveThe objective of the study was to determine whether a pedometer-based, Internet-mediated intervention can reduce chronic back pain-related disability. MethodsA parallel group randomized controlled trial was conducted with 1:1 allocation to the intervention or usual care group. 229 veterans with nonspecific chronic back pain were recruited from one Department of Veterans Affairs (VA) health care system. Participants randomized to the intervention received an uploading pedometer and had access to a website that provided automated walking goals, feedback, motivational messages, and social support through an e-community (n=111). Usual care participants (n=118) also received the uploading pedometer but did not receive the automated feedback or have access to the website. The primary outcome was measured using the Roland Morris Disability Questionnaire (RDQ) at 6 months (secondary) and 12 months (primary) with a difference in mean scores of at least 2 considered clinically meaningful. Both a complete case and all case analysis, using linear mixed effects models, were conducted to assess differences between study groups at both time points. ResultsBaseline mean RDQ scores were greater than 9 in both groups. Primary outcome data were provided by approximately 90% of intervention and usual care participants at both 6 and 12 months. At 6 months, average RDQ scores were 7.2 for intervention participants compared to 9.2 for usual care, an adjusted difference of 1.6 (95% CI 0.3-2.8, P=.02) for the complete case analysis and 1.2 (95% CI -0.09 to 2.5, P=.07) for the all case analysis. A post hoc analysis of patients with baseline RDQ scores ≥4 revealed even larger adjusted differences between groups at 6 months but at 12 months the differences were no longer statistically significant. ConclusionsIntervention participants, compared with those receiving usual care, reported a greater decrease in back pain-related disability in the 6 months following study enrollment. Between-group differences were especially prominent for patients reporting greater baseline levels of disability but did not persist over 12 months. Primarily, automated interventions may be an efficient way to assist patients with managing chronic back pain; additional support may be needed to ensure continuing improvements. Trial RegistrationClinicalTrials.gov NCT00694018; http://clinicaltrials.gov/ct2/show/NCT00694018 (Archived by WebCite at http://www.webcitation.org/6IsG4Y90E).

Antimicrobial devices are often used to prevent nosocomial infection, despite mixed evidence as to their efficacy. Using a national survey, we found that a hospital's use of an antimicrobial device to prevent one type of infection was associated with a higher likelihood that a similar device would be used to prevent a different infection.

Spontaneous awakening trials (SATs) improve outcomes in mechanically ventilated patients, but implementation remains erratic. We examined variation in reported practice, prevalence of attitudes and fears regarding spontaneous awakening trials, and organizational practices associated with routine implementation of spontaneous awakening trials in an ICU quality improvement collaborative.Written survey.Michigan Health and Hospital Association's Keystone ICU, a quality improvement collaborative of 73 hospitals.Attendees of the yearly Keystone ICU meeting, January 2011, including nurses, physicians, hospital administrators, and other healthcare professionals.Respondents were asked about institutional characteristics, spontaneous awakening trial practice, attitudes and barriers regarding spontaneous awakening trials, and organizational cultural characteristics that might influence SAT practice. The association of organizational cultural characteristics and attitudes with reported spontaneous awakening trial use was evaluated using logistic regression.Three hundred nineteen participants attended the meeting. The survey response rate was 83.4%. Respondents reported wide variation in approach to spontaneous awakening trial performance and patient selection. 48.6% of respondents reported regular spontaneous awakening trial use, defined as greater than 75% of mechanically ventilated patients undergoing spontaneous awakening trials each day. In bivariable analysis, addressing sedation goals routinely in rounds and having spontaneous awakening trials as part of unit culture were positively associated with regular spontaneous awakening trial use, whereas the perception that spontaneous awakening trials increased short-term adverse effects, staff fears of spontaneous awakening trials, and the perception that spontaneous awakening trials are hard work were negatively associated with regular spontaneous awakening trial use. In multivariable analysis, only addressing sedation in rounds (odds ratio, 2.85 [95% CI, 1.55-5.23]), incorporation of spontaneous awakening trials into unit culture (odds ratio, 3.36 [95% CI, 1.75-6.43]), and the perception that spontaneous awakening trials are hard work (odds ratio, 0.53 [95% CI, 0.30-0.96]) remained statistically significantly associated with regular spontaneous awakening trial use. Respondents in managerial positions were less likely to perceive spontaneous awakening trials as hard work (odds ratio, 0.44 [95% CI, 0.22-0.85]).Even in a motivated statewide quality improvement collaborative, spontaneous awakening trial practice varies widely and concerns persist regarding spontaneous awakening trials. Cultural practices may counteract the effect of concerns regarding spontaneous awakening trials and are associated with increased performance of this beneficial intervention. Patient selection should be a focus for continuing medical education. Differences in perception of work between management and staff may also be a focus for improved communication.

Importance Preventing catheter-associated urinary tract infection (CAUTI), a common health care–associated infection, is important for improving the care of hospitalized patients and in meeting the goals for reduction of health care–associated infections set by the US Department of Health and Human Services. Objective To identify ways to enhance CAUTI prevention efforts based on the experiences of hospitals participating in the Michigan Health and Hospital Association Keystone Center for Patient Safety statewide program to reduce unnecessary use of urinary catheters (the Bladder Bundle). Design Qualitative assessment of data collected through semistructured telephone interviews with key informants at 12 hospitals and in-person interviews and site visits at 3 of the 12 hospitals. The analysis focused on perceptions and key issues identified by hospitals as influencing implementation of CAUTI prevention practices as recommended by the Bladder Bundle initiative. Setting Twelve purposefully sampled hospitals in Michigan. Participants Key informants including infection preventionists, clinical personnel, and senior executives. Results Common barriers to Bladder Bundle implementation and appropriate urinary catheter use included (1) difficulty with nurse and physician engagement, (2) patient and family request for indwelling catheters, and (3) catheter insertion practices and customs in the emergency department. Strategies to address these barriers were also identified by several of the participating hospitals, including (1) incorporating urinary management (eg, planned toileting) as part of other patient safety programs, such as a fall reduction program, (2) explicitly discussing the risks of indwelling urinary catheters with patients and families, and (3) engaging with emergency department nurses and physicians to implement a process that ensures that appropriate indications for catheter use are followed. Conclusions and Relevance The Bladder Bundle program provides a model for implementing strategies to reduce CAUTI. These findings provide actionable information to inform CAUTI prevention-related activities in hospitals throughout the country.

Background Catheter associated urinary tract infection (CAUTI) is one of the most commonly acquired health care associated infections within the United States. We examined the implementation of an initiative to prevent CAUTI, to better understand how health care providers’ perceptions of risk influenced their use of prevention practices and the potential impact these risk perceptions have on patient care decisions. Understanding such perceptions are critical for developing more effective approaches to ensure the successful uptake of key patient safety practices and thus safer care for hospitalized patients. Methods We conducted semi-structured phone and in-person interviews with staff from 12 hospitals. A total of 42 interviews were analyzed using open coding and a constant comparative approach. This analysis identified “risk” as a central theme and a “risk explanatory framework” was identified for its sensitizing constructs to organize and explain our findings. Results We found that multiple perceptions of risk, some non-evidence based, were used by healthcare providers to determine if use of the indwelling urethral catheter was necessary. These risks included normative work where staff deal with competing priorities and must decide which ones to attend too; loosely coupled errors where negative outcomes and the use of urinary catheters were not clearly linked; process weaknesses where risk seemed to be related to both the existing organizational processes and the new initiative being implemented and; workarounds that consisted of health care workers developing workarounds in order to bypass some of the organizational processes created to dissuade catheter use. Conclusions Hospitals that are implementing patient safety initiatives aimed at reducing indwelling urethral catheters should be aware that the risk to the patient is not the only risk of perceived importance; implementation plans should be formulated accordingly.

Background Limited data exist describing the perceived strength of evidence behind practices to prevent common health care-associated infections (HAIs). We conducted a national survey of infection prevention personnel to assess perception of the evidence for various preventive practices. We were also curious whether lead infection preventionist certification in infection prevention and control (CIC) correlated with perceptions of the evidence. Methods In 2009, we mailed surveys to 703 infection prevention personnel using a national random sample of US hospitals and all Veterans Affairs hospitals; the response rate was 68%. The survey asked the respondent to grade the strength of evidence behind prevention practices. We considered "strong" evidence as being 4 and 5 on a Likert scale. Multivariable logistic regression models assessed associations between CIC status and the perceived strength of the evidence. Results The following practices were perceived by 90% or more of respondents as having strong evidence: alcohol-based hand rub, aseptic urinary catheter insertion, chlorhexidine for antisepsis prior to central venous catheter insertion, maximum sterile barriers during central venous catheter insertion, avoiding the femoral site for central venous catheter insertion, and semirecumbent positioning of the ventilated patient. CIC status was significantly associated with the perception of the evidence for several practices. Conclusion Successful implementation of evidence-based practices should consider how key individuals in the translational process assess the strength of that evidence.

BACKGROUND Peripherally inserted central catheters (PICCs) are commonly inserted during hospitalization for a variety of clinical indications. OBJECTIVE To understand hospitalist experience, practice, knowledge, and opinions as they relate to PICCs. DESIGN AND SETTING Web-based survey of hospitalists in 5 healthcare systems (representing a total of 10 hospitals) across Michigan. RESULTS The overall response rate was 63% (227 hospitalists received invitations; 144 responded). Compared with central venous catheters, hospitalists felt that PICCs were safer to insert (81%) and preferred by patients (74%). Although 84% of respondents reported that placing a PICC solely to obtain venous access was appropriate, 47% also indicated that 10%–25% of PICCs inserted in their hospitals might represent inappropriate placement. Hospitalist knowledge regarding PICC-related venous thromboembolism was poor, with only 4% recognizing that PICC-tip verification was performed principally to prevent thrombosis. Furthermore, several potential practice-related concerns were identified: one-third of hospitalists indicated that they never examine PICCs for externally evident problems, such as exit-site infection; 48% responded that once inserted, they did not remove PICCs until a patient was ready for discharge; and 51% admitted that, at least once, they had “forgotten” that their patient had a PICC. CONCLUSIONS Hospitalist experiences, practice, opinions, and knowledge related to PICCs appear to be variable. Because PICC use is growing and is often associated with complications, examining the impact of such variation is necessary. Hospitals and health systems should consider developing and implementing mechanisms to monitor PICC use and adverse events. Journal of Hospital Medicine 2013;8:309–314. © 2013 Society of Hospital Medicine.

Importance Although survival of patients with in-hospital cardiac arrest varies markedly among hospitals, specific resuscitation practices that distinguish sites with higher cardiac arrest survival rates remain unknown. Objective To identify resuscitation practices associated with higher rates of in-hospital cardiac arrest survival. Design, Setting, and Participants Nationwide survey of resuscitation practices at hospitals participating in the Get With the Guidelines–Resuscitation registry and with 20 or more adult in-hospital cardiac arrest cases from January 1, 2012, through December 31, 2013. Data analysis was performed from June 10 to December 22, 2015. Main Outcomes and Measures Risk-standardized survival rates for cardiac arrest were calculated at each hospital and were then used to categorize hospitals into quintiles of performance. The association between resuscitation practices and quintiles of survival was evaluated using hierarchical proportional odds logistic regression models. Results Overall, 150 (78.1%) of 192 eligible hospitals completed the study survey, and 131 facilities with 20 or more adult in-hospital cardiac arrest cases comprised the final study cohort. Risk-standardized survival rates after in-hospital cardiac arrest varied substantially (median, 23.7%; range, 9.2%-37.5%). Several resuscitation practices were associated with survival on bivariate analysis, although only 3 were significant after multivariable adjustment: monitoring for interruptions in chest compressions (adjusted odds ratio [OR] for being in a higher survival quintile category, 2.71; 95% CI, 1.24-5.93; P = .01), reviewing cardiac arrest cases monthly (adjusted OR for being in a higher survival quintile category, 8.55; 95% CI, 1.79-40.00) or quarterly (OR, 6.85; 95% CI, 1.49-31.30; P = .03), and adequate resuscitation training (adjusted OR, 3.23; 95% CI, 1.21-8.33; P = .02). Conclusions and Relevance Using survey information from acute care hospitals participating in a national quality improvement registry, we identified 3 resuscitation strategies associated with higher hospital rates of survival for patients with in-hospital cardiac arrest. These strategies can form the foundation for best practices for resuscitation care at hospitals given the high incidence and variation in survival for in-hospital cardiac arrest.

Background In 2008, the Centers for Medicare and Medicaid Services (CMS) ceased additional payment for hospitalizations resulting in complications deemed preventable, including several health care-associated infections. We sought to understand the impact of the CMS payment policy on infection prevention efforts. Methods A national survey of infection preventionists from a random sample of US hospitals was conducted in December 2010. Results Eighty-one percent reported increased attention to HAIs targeted by the CMS policy, whereas one-third reported spending less time on nontargeted HAIs. Only 15% reported increased funding for infection control as a result of the CMS policy, whereas most reported stable (77%) funding. Respondents reported faster removal of urinary (71%) and central venous (50%) catheters as a result of the CMS policy, whereas routine urine and blood cultures on admission occurred infrequently (27% and 13%, respectively). Resource shifting (ie, less time spent on nontargeted HAIs) occurred more commonly in large hospitals (odds ratio, 2.3; 95% confidence interval: 1.0-5.1; P = .038) but less often in hospitals where front-line staff were receptive to changes in clinical processes (odds ratio, 0.5; 95% confidence interval: 0.3-0.8; P = .005). Conclusion Infection preventionists reported greater hospital attention to preventing targeted HAIs as a result of the CMS nonpayment policy. Whether the increased focus and greater engagement in HAI prevention practices has led to better patient outcomes is unclear.

A national survey of infection preventionists was conducted in Thailand to assess career satisfaction, perceived barriers to implementing infection control practices and current sources of continuing education. Despite positive career satisfaction, several barriers were identified, including a lack of physicians to champion infection control efforts and difficulty remaining current with new evidence-based recommendations.

We examined the association between mood symptoms and 10-year CVD risk estimated by Framingham risk score in a cohort of patients with bipolar disorder.Veterans with bipolar disorder and CVD risk factors (N=118) were recruited from outpatient VA clinics. CVD risk factor data were collected from electronic medical records and patient surveys, and used to calculate patient Framingham Scores. The relationship between mood symptoms (depressive, manic) and Framingham scores was examined, as was the relationship between mental health symptoms and individual CVD risk factors (lipids, blood pressure, weight, smoking, and fasting glucose).Mean sample age was 53 years (SD=9.9), 17% were female, and 5% were African-American. Almost 70% were obese (BMI≥30), 84% had hyperlipidemia, 70% were hypertensive, and 25% had diabetes. Nineteen percent had a Framingham score of20%, indicative of elevated 10-year risk of developing CVD. After adjusting for age, gender, diabetes diagnosis, smoking status, and mood symptoms, patients with clinically significant depressive symptoms had a 6-fold increased odds of having a Framingham score of20% (OR=6.1, p=0.03) while clinically significant manic symptoms were not associated with the Framingham score (OR=0.6, p=0.36). Depressive symptoms were also associated with elevated BMI, fasting glucose, and blood pressure.Single-site study reliant on cross-sectional and self-reported mood measures.After controlling for physiologic correlates, depressive symptoms were associated with greater relative 10-year risk for CVD mortality among patients with bipolar disorder. Interventions that address self-management of depressive symptoms may help persons with bipolar disorder decrease CVD risk.

Veteran activity levels may decrease between Active Duty and postdeployment. We examined attitudes and changes in self-reported activities between the two in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans using Department of Veterans Affairs (VA) services. We conducted an online cross-sectional survey (June-August 2008) of postdeployment OIF/OEF veterans registered with the VA Ann Arbor Healthcare System, Ann Arbor, Michigan. Descriptive statistics summarized demographic data and attitudes, while regression analyses compared physical activities during Active Duty with physical activities postdeployment. Participants (n = 319, 15.6% response rate) reported that they believe staying physically fit is important, they worry about gaining weight, and they believe exercise will keep them healthy (77%, 72%, and 90% agree or strongly agree, respectively). Running (30.0%), Exercise with Gym Equipment (21.5%), Occupational Activities (14.9%), and Walking (13.0%) were the most frequently reported Active Duty physical activities. The most frequently reported postdeployment physical activities included Walking (21.1%), Running (18.5%), and Exercise with Gym Equipment (17.9%). Health problems (39%) and chronic pain (52%) were common barriers to physical activity. Postdeployment OIF/OEF veterans using the VA believe physical activity is beneficial, yet many report health problems and/or chronic pain that makes exercise difficult. Physical activity promotes health, and strategies are needed to facilitate physical activity in this population.

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.

While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient–peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.

Ambulatory surgery centers (ASCs) potentially deliver care more efficiently than hospitals. However, ASC proliferation may increase discretionary surgery use because of financial incentives for the physicians who staff them. To explore this possibility, we measured the impact of the opening of an ASC in a health care market, as defined by the hospital service area (HSA), on rates of procedure use.With a 100% sample of outpatient surgery encounters, we measured annual rates of use for discretionary (cataract surgery, colonoscopy, and upper gastrointestinal [GI] tract endoscopy) and imperative (cancer-directed breast surgery) procedures among Medicare-eligible persons. Using a multiple time series research design, we compared the change in procedure use for HSAs where ASCs opened with that of HSAs where an ASC was never present.Florida HSAs.All patients 65 years or older undergoing outpatient surgery from January 1, 1998, through December 31, 2006. Main Outcome Measure Adjusted HSA-level rates of procedure use.In HSAs where an ASC opened, colonoscopy use increased by 1610 procedures per 100 000 per year (95% confidence interval, 736-2485; P.001) and upper GI tract endoscopy use increased by 775 procedures per 100 000 per year (159-1391; P = .01). However, rates of cancer-directed breast surgery remained flat. Among HSAs where an ASC opened, the relative increases in colonoscopy and upper GI tract endoscopy use were approximately 117% and 93% higher, respectively, 4 years after the opening compared with HSAs without ASCs.The opening of an ASC within an HSA is associated with significant increases in discretionary surgery use.

Implementing evidence-based infection prevention practices is challenging. Implementation science, which is the study of methods promoting the uptake of evidence into practice, addresses the gap between theory and practice. Just as healthcare epidemiology has emerged as a paradigm for patient safety, infection prevention may serve as a clinical model for implementation researchers.

OBJECTIVE: To test the efficacy of using hair stylists as lay health advisors to increase organ donation among African American clients. DESIGN: This study was a randomized, controlled intervention trial where we randomized 52 salons (2,789 clients) to receive a 4 session, stylist-delivered health education program (comparison) or a four session brief motivational intervention that encouraged organ donation (intervention). Intervention stylists received a four-hour training in organ donation education and counseling. Organ donation was measured by self-report questionnaire at 4-month posttest as well as by verified enrollment in the Michigan Organ Donor Registry. SETTING: Hair salons in Michigan urban areas. PARTICIPANTS: Blacks (n=2,449), non-Blacks (n=261) in Michigan. MAIN OUTCOME MEASURES: Self-reported donation status, registration in Michigan Organ Donor Registry. RESULTS: At posttest, rates of self-reported positive donation status were 19.8% in the intervention group and 16.0% in the comparison group. In multivariate analyses, intervention participants were 1.7 times (95% CI=0.98–2.8) more likely than comparison participants to report positive donation status at posttest. Based on verified organ registry data, enrollment rates were 4.8% and 2%, respectively for the intervention and comparison groups. In multivariate analyses, intervention group members were 4.4 (95% CI=1.3–15.3) more likely to submit an enrollment card than comparison participants. CONCLUSION: Clients of hair stylists trained to provide brief motivational intervention for organ donation were approximately twice as likely to enroll in the donor registry as comparison clients. Use of lay health advisors appears to be a promising approach to increase donation among African Americans.

Background Chronic back pain is a significant problem worldwide and may be especially prevalent among patients receiving care in the U.S. Department of Veterans Affairs healthcare system. Back pain affects adults at all ages and is associated with disability, lost workplace productivity, functional limitations and social isolation. Exercise is one of the most effective strategies for managing chronic back pain. Yet, there are few clinical programs that use low cost approaches to help patients with chronic back pain initiate and maintain an exercise program. Methods/Design We describe the design and rationale of a randomized controlled trial to assess the efficacy of a pedometer-based Internet mediated intervention for patients with chronic back pain. The intervention uses an enhanced pedometer, website and e-community to assist these patients with initiating and maintaining a regular walking program with the primary aim of reducing pain-related disability and functional interference. The study specific aims are: 1) To determine whether a pedometer-based Internet-mediated intervention reduces pain-related functional interference among patients with chronic back pain in the short term and over a 12-month timeframe. 2) To assess the effect of the intervention on walking (measured by step counts), quality of life, pain intensity, pain related fear and self-efficacy for exercise. 3) To identify factors associated with a sustained increase in walking over a 12-month timeframe among patients randomized to the intervention. Discussion Exercise is an integral part of managing chronic back pain but to be effective requires that patients actively participate in the management process. This intervention is designed to increase activity levels, improve functional status and make exercise programs more accessible for a broad range of patients with chronic back pain. Trial Registration Number NCT00694018

To assess the knowledge of recommended urinary catheter care practices among nursing home (NH) healthcare workers (HCWs) in southeast Michigan.Self-administered survey.Seven NHs in southeast Michigan.HCWs.The survey included questions about respondent characteristics and knowledge about indications, care, and personal hygiene pertaining to urinary catheters. The association between knowledge measures and occupation (nurses vs aides) was assessed using generalized estimating equations.Three hundred fifty-six of 440 HCWs (81%) responded. More than 90% of HCWs were aware of measures such as cleaning around the catheter daily, glove use, and hand hygiene with catheter manipulation. They were less aware of research-proven recommendations of not disconnecting the catheter from its bag (59% nurses, 30% aides, P.001), not routinely irrigating the catheter (48% nurses, 8% aides, P.001), and hand hygiene after casual contact (60% nurses, 69% aides, P=.07). HCWs were also unaware of recommendations regarding alcohol-based hand rub (27% nurses and 32% aides with correct responses, P=.38). HCWs reported informal (e.g., nurse supervisors) and formal (in-services) sources of knowledge about catheter care.Significant discrepancies remain between research-proven recommendations pertaining to urinary catheter care and HCWs' knowledge. Nurses and aides differ in their knowledge of recommendations against harmful practices, such as disconnecting the catheter from the bag and routinely irrigating catheters. Further research should focus on strategies to enhance dissemination of proven infection control practices in NHs.

Objective.Healthcare-associated infection (HAI) is costly and causes substantial morbidity. We sought to understand why some hospitals were engaged in HAI prevention activities while others were not. Because preliminary data indicated that hospital leadership played an important role, we sought better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in US hospitals.Methods.We report phases 2 and 3 of a 3-phase study. In phase 2, 14 purposefully sampled US hospitals were selected from among the 72% of 700 invited hospitals whose lead infection preventionist had completed a quantitative survey on HAI prevention during phase 1. Qualitative data were collected during 38 semistructured phone interviews with key personnel at the 14 hospitals. During phase 3, we conducted 48 interviews during 6 in-person site visits to identify recurrent and unifying themes that characterize behaviors of successful leaders.Results.We found that successful leaders (1) cultivated a culture of clinical excellence and effectively communicated it to staff; (2) focused on overcoming barriers and dealt directly with resistant staff or process issues that impeded prevention of HAI; (3) inspired their employees; and (4) thought strategically while acting locally, which involved politicking before crucial committee votes, leveraging personal prestige to move initiatives forward, and forming partnerships across disciplines. Hospital epidemiologists and infection preventionists often played more important leadership roles in their hospital's patient safety activities than did senior executives.Conclusions.Leadership plays an important role in infection prevention activities. The behaviors of successful leaders could be adopted by others who seek to prevent HAI.

BACKGROUND: Given the uncertainty surrounding the optimal management for early stage bladder cancer, physicians vary in how they approach the disease. The authors of this report linked cancer registry data with medical claims to identify the sources of variation and opportunities for improving the value of cancer care. METHODS: By using data from the Surveillance, Epidemiology, and End Results-Medicare database (1992-2005), patients with early stage bladder cancer were abstracted (n ¼ 18,276). The primary outcome was the intensity of initial treatment that patients received, as measured by all Medicare payments for bladder cancer incurred in the 2 years after diagnosis. Multilevel models were fitted to partition the variation in treatment intensity attributable to patient versus provider factors, and the potential savings to Medicare from reducing the physician contribution were estimated. RESULTS: Provider factors accounted for 9.2% of the variation in treatment intensity. Increasing provider treatment intensity did not correlate with improved cancer-specific survival (P ¼ .07), but it was associated with the subsequent receipt of major interventions, including radical cystectomy (P < .001). If provider-level variation was reduced and clinical practice was aligned with that of physicians who performed in the 25th percentile of treatment intensity, then total payments made for the average patient could be lowered by 18.6%, saving Medicare $18.7 million annually. CONCLUSIONS: The current results indicated that a substantial amount of the variation in initial treatment intensity for early stage bladder cancer is driven by the physician. Furthermore, a more intensive practice style was not associated with improved cancer-specific survival or the avoidance of major interventions. Therefore, interventions aimed at reducing between-provider differences may improve the value of cancer care. Cancer 2010;116;3587–94. V C 2010 American Cancer Society.

Patient safety is a healthcare priority worldwide, with most hospitals engaging in activities to improve care quality, safety and outcomes. Despite these efforts, we have limited understanding of why quality improvement efforts are successful in some hospitals and not others. Using data collected as part of a multi-center study, we closely examined quality improvement efforts and the implementation of recommended practices to prevent central line-associated bloodstream infections (CLABSI) in U.S. hospitals. We compare and contrast the experiences among hospitals to better understand 'how' and 'why' certain hospitals were more successful with practice implementation when taking into consideration specific aspects of the organizational context. This study reveals that among a number of hospitals that focused on implementing practices to prevent CLABSI, the experience and outcomes varied considerably despite using similar implementation strategies. Moreover, our findings provide important insights about how and why different quality improvement strategies might perform across organizations with differing contextual characteristics.

Over the last two decades, escalating health care costs in the United States have led to sweeping reforms in reimbursement for physician services (The Omnibus Budget Reconciliation Act of 1989; Health Care Financing Administration 1991;). The overall effect of these reforms has been to increase compensation for outpatient evaluation and management, while decreasing reimbursement for many surgical procedures (Litwin, Sacher, and Cohen 1993; Goluboff and Olsson 1994;). These changes in reimbursement have compelled surgeons to seek alternative sources of revenue in order to maintain their income (Pham et al. 2004). Among urologists, lithotripsy for the treatment of urinary stones has served as one such economic resource (Lotan et al. 2004). Technological advances have improved the efficiency and decreased the morbidity of stone surgery, allowing more and more procedures to be done in the outpatient setting (Pearle, Calhoun, and Curhan 2005). The profitability of lithotripsy stems, in part, from the unique financial structure of the freestanding ambulatory surgery centers (ASCs) and lithotripsy centers in which many stone surgeries are currently performed. As the provision of lithotripsy services is exempted from the federal statute prohibiting physician self-referral (American Lithotripsy Society et al. vs. Tommy G. Thompson 2002), urologists can refer and treat patients at an ASC or lithotripsy center in which they are invested. Physicians with ownership interest in these centers collect not only a professional fee for the services provided, but they also share in their facilities' profits. Indeed, over the last decade urologists' financial interests in ASCs have increased from 12 to 21 percent, and the proportion of U.S. urologists invested in a lithotripsy center has risen from 36 percent to an estimated 54 percent (Gee et al. 1998; O'Leary et al. 2002;). While there are data to support medical therapy and observation for many patients with urinary stones (Hollingsworth et al. 2006), a variety of clinical factors may influence a urologist's decision to perform surgery, and the ultimate decision for intervention is left to the discretion of the surgeon. Thus, the potential exists for the perversion of those incentives associated with physician ownership. Specifically, urologists with investment in an ASC may be driven by financial pressures to relax their indications for treatment, which would manifest as higher stone surgery rates (McGuire and Pauly 1991; McGuire 2000;). With this in mind, we characterized use of stone surgery among urologists as they relate to their ownership status. The results of this analysis have relevance to the policy debate surrounding federal Anti-Kickback Statute safe harbors and Stark Law definitions that permit physician investment in ASCs.

A difficult to manage comorbid condition, like chronic pain, could adversely affect the delivery of recommended care for other serious health problems, such as hypertension.We examined whether addressing pain at a primary care visit acts as a competing demand in decisions to intensify blood pressure (BP) medications for diabetic patients with an elevated BP.Prospective cohort study.1,169 diabetic patients with a BPor = 140/90 prior to a primary care provider (PCP) visit were enrolled.After the visit, PCPs provided information about the top three issues discussed and whether hypertension medications were intensified or reasons for not intensifying. We used multi-level logistic regression to assess whether discussing pain during the visit decreased the likelihood of BP medication intensification. We calculated predicted probabilities of medication intensification by whether pain was discussed.PCPs discussed pain during 222 (20%) of the visits. Visit BP did not differ between patients with whom pain was and was not discussed. BP medications were intensified during 44% of the visits. The predicted probability of BP medication intensification when pain was discussed was significantly lower than when pain was not discussed (35% vs. 46%, p = 0.02).Discussing pain at a primary care visit competed with the intensification of BP medication. This finding is concerning given that controlling blood pressure may be the most important factor in decreasing long-term complications for patients with diabetes. Better care management models for complex patients are needed to ensure that both pain and other chronic conditions are adequately addressed.

The extent to which the use of alcohol-based handrub for hand hygiene has been adopted by US hospitals is unknown. A survey of infection control coordinators (response rate, 516 [72%] of 719) revealed that most hospitals (436 [84%] of 516) have adopted alcohol-based handrub. Leadership support and staff receptivity play a significant role in its adoption. Infect Control Hosp Epidemiol 2008; 29:1177-1180