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Background Recommendations regarding signs and symptoms that should prompt referral of patients with inflammatory bowel disease (IBD) to an IBD specialist for a consultation could serve to improve the quality of care for these patients. Our aim was to develop a consult care pathway consisting of clinical features related to IBD that should prompt appropriate consultation. Methods A scoping literature review was performed to identify clinical features that should prompt consultation with an IBD specialist. A panel of 11 experts was convened over 4 meetings to develop a consult care pathway using the RAND/UCLA Appropriateness Method. Items identified via scoping review were ranked and were divided into major and minor criteria. Additionally, a literature and panel review was conducted assessing potential barriers and facilitators to implementing the consult care pathway. Results Of 43 features assessed, 13 were included in the care pathway as major criteria and 15 were included as minor criteria. Experts agreed that stratification into major criteria and minor criteria was appropriate and that 1 major or 2 or more minor criteria should be required to consider consultation. The greatest barrier to implementation was considered to be organizational resource allocation, while endorsements by national gastroenterology and general medicine societies were considered to be the strongest facilitator. Conclusions This novel referral care pathway identifies key criteria that could be used to triage patients with IBD who would benefit from IBD specialist consultation. Future research will be required to validate these findings and assess the impact of implementing this pathway in routine IBD-related care.

BACKGROUND Older adults who are discharged following emergency department evaluation are at increased risk for functional decline and health care utilization, and are likely to benefit from close follow-up and additional care services. Understanding factors associated with a return emergency department visit within 30 days among older fee-for-service Medicare beneficiaries discharged to the community may assist in identifying patients at greatest need for interventions.METHOD Predictors from Medicare data and public sources were evaluated in a retrospective data analysis of North and South Carolina residents (2011-2012) aged ≥ 65 years using Cox regression proportion hazards ratios (HR) and 95% confidence intervals (CI) for time-to-30-day return events.RESULTS 30-day return rates varied markedly among the 167 emergency department facilities studied (18%-39%). Predictors of 30-day return included: age (85+ versus 65-74; HR, 1.24; 95% CI, 1.22-1.27); male sex (HR, 1.11; 95% CI, 1.14-1.10); non-white race (HR, 1.07; 95% CI, 1.05-1.09); Medicaid eligibility (HR, 1.20; 95% CI, 1.18-1.22); Charlson Score (3+ vs. 0; HR, 1.33; 95% CI, 1.30-1.36); and prior emergency department encounter (3+ vs. 0; HR, 2.35; 95% CI 2.30-2.41).LIMITATIONS This study was limited to Medicare beneficiaries in North Carolina and South Carolina, 2011-2012. Administrative claims data are limited to information required for financial reimbursement. Because we limited our study to older fee-for-service patients, our findings may not be generalizable to managed care patients and other age groups. Patients transferred to another emergency department or facility were not included in the analysis.CONCLUSION Factors predicting 30-day return to the emergency department or hospitalization suggest the potential for care transition improvement efforts to better meet patient needs, thereby potentially improving post-emergency department outcomes.

The European Federation of Pharmaceutical Industries and Associations (EFPIA) representing the pharmaceutical industry operating in Europe, introduced three codes of conduct between 2007 and 2013, which had a common goal of self-regulating interactions with healthcare professionals and patient organisations. This former set of rules was appreciated as a first self-regulatory step, although self-regulation itself is still considered by many stakeholders as insufficient to provide thorough transparency. EFPIA agreed to replace the separate codes with a new, consolidated EFPIA Code of Practice. The consolidated Code was broadened to include a new section on medical education that outlines the scope of member companies' engagement in “medical education activities?. This new section is controversial as it explicitly confirms that EFPIA members can be involved in medical education. In our view “independent Medical Education“ per se prevents industry from “organising“ events, i.e. industry must not influence content, presentation, choice of lecturers or publication of results. What is more, only events respecting this key principle (amongst others) can be recognised for purposes of continuing medical education/continuing professional development (CME/CPD). A substantial portion of the medical education is currently funded by the pharmaceutical and medical device industries. This practice carries a significant risk to public and personal health, especially if it is not adequately safeguarded by a high standard of accreditation. We are most concerned by the fact that EFPIA, representing the pharmaceutical industry, is trying to broaden the approach to medical education, to include activities that are not independently evaluated as free from undue influence and conflicts of interest. We believe that in order to preserve scientific integrity and independence, pharmaceutical companies must not be granted the right to influence the content of medical education.

Objective To assess implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units. Design Mixed-methods implementation evaluation. Setting/Local Problem Labor and delivery units ( N = 18) in 10 states participating in the Safety Program for Perinatal Care (SPPC). Shoulder dystocia is unpredictable, requiring rapid and coordinated action. Participants Key informants were labor and delivery unit staff who implemented SPPC safety strategies. Intervention/Measurements The SPPC was implemented by using the TeamSTEPPS teamwork and communication framework and tools, applying safety science principles (standardization, independent checks, and learn from defects) to shoulder dystocia management, and establishing an in situ simulation program focused on shoulder dystocia to practice teamwork and communication skills. Unit staff received training, a toolkit, technical assistance, and unit-specific feedback reports. Quantitative data on unit-reported process improvement measures and qualitative data from staff interviews were used to understand changes in use of safety principles, teamwork/communication, and in situ simulation. Results Use of shoulder dystocia safety strategies improved on the units. Differences between baseline and follow-up (10 months) were as follows: in situ simulation (50% vs. 89%), teamwork and communication (67% vs. 94%), standardization (67% to 94%), learning from defects (67% vs. 89%), and independent checks (56% vs. 78%). Interview data showed reasons to address management of shoulder dystocia, various approaches to implement safety practices, and facilitators and barriers to implementation. Conclusion Successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The SPPC strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances.

Falls remain a major source of morbidity for nursing facility residents.1,2 Therefore, a substantial body of research has focused on fall reduction in this setting.3–10 Several randomized, controlled trials have demonstrated that multiple-risk-factor reduction can substantially reduce fall rates and prevent fractures. Risk factors addressed in these trials included environmental hazards, adaptive equipment maintenance, psychotropic drug use, physical therapy or exercise, staff education, postfall problem solving, and hip protectors. To implement the interventions, studies have provided on-site personnel and interdisciplinary consult teams.4,6,8–10 Translating these studies into effective clinical practice using existing nursing facility staff remains a challenge. The Resident Assessment Protocol for falls of the nursing home Resident Assessment Instrument was an early attempt to operationalize multiple-risk-factor reduction on a national scale, but an evaluation of falls rates before and after the introduction of the Resident Assessment Protocol in 1991 showed no change.11 Other attempts to promote multiple-risk-factor reduction in nursing facilities using pharmacy consultants and quality assurance training have had mixed results.12–14 In general, low levels of facility participation and nonsignificant changes in provider behavior have been reported. A widely used method for translating evidence from trials into clinical practice is the Quality Improvement Collaborative (QIC). Quality improvement teams from each facility participate in all-day learning sessions and teleconferences during which they meet with clinical experts, exchange ideas, and generate ‘‘enthusiasm and a shared sense of commitment.’’15–17 Between sessions, teams apply what they have learned by systematically testing small changes over time using ‘‘Plan-Do-Study-Act’’ cycles. The Institute for Healthcare Improvement has popularized the QIC method, and the U.S. Health Resources and Services Administration, the Veterans Health Administration, and the United Kingdom’s National Health Service have used it. However, recent studies have questioned the effectiveness of the QIC method and called for an improved evidence base for quality improvement initiatives.15,18 The current study reports the results of a statewide QIC focused on fall prevention in nursing facilities. The primary objective was to describe the changes in clinical practice resulting from QIC participation. As an exploratory analysis, it was desired to test whether facility fall rates were different in participating facilities than in nonparticipating facilities.

To evaluate an intervention to improve the quality of care of patients with heart failure in managed Medicare and Medicaid plans in North Carolina.Utilization of angiotensin-converting enzyme inhibitors (ACE-I) and beta-adrenergic receptor blockers (BB) in heart failure (HF) patients remains suboptimal despite evidence-based guidelines supporting their use.Managed care plans identified adult patients with HF during 2000 (preintervention) and from July 1, 2001, through June 30, 2002 (postintervention). Outpatient medical records were reviewed to obtain data regarding type of heart failure, demographics, comorbidities, and therapies. The intervention consisted of guideline summary dissemination, performance audit with feedback, patient-specific chart reminders, and patient activation mailings.We sampled 1613 patients from 5 plans during the preintervention period and 1528 patients during the postintervention period. Assessment of left ventricular function (LVF) increased from 88.2% to 92.5% of patients (P.0001). Among patients with moderate to severe left ventricular systolic dysfunction, there was no substantive change in treatment with ACE-I or vasodilators, whereas, appropriate treatment with BB increased from 48.3% (with another 11.9% with documented contraindications) to 67.9% (with another 7.5% with documented contraindications). The quality gap decreased from 39.8% to 24.6% (P.0001).LVF assessment improved despite high preintervention rates. Treatment rates with ACE-I and vasodilators remained high, but did not improve. Treatment rates with BB improved substantially translating into a significant public health benefit. Health-care payers should consider development of financial incentives to encourage collaborative quality improvement programs.

Use of angiotensin-converting enzyme (ACE) inhibitors and β-adrenergic receptor blockers in patients with heart failure (HF) remains low despite the results of clinical trials and evidence-based guidelines that support their use. The quality of HF care in managed Medicare and Medicaid programs in North Carolina participating in a HF quality improvement program was assessed. Managed care plans identified adult patients with 1 inpatient or 3 outpatient claims for HF during 2000. A stratified random sample of 971 Medicare and 642 Medicaid patients' outpatient medical records from 5 plans were reviewed by trained nurse abstractors to obtain data regarding type of HF, demographics, comorbidities, and therapies. Left ventricular function assessment was performed in 88% of patients. Among 494 patients with systolic dysfunction, 86% were appropriately treated with respect to ACE inhibitors (73% prescribed, 13% had a documented contraindication). In contrast, β-blocker therapy was appropriate in 61% (49% prescribed, 12% contraindication). There were no significant differences in drug use by insurance, gender, race, or age. Ventricular function assessment and ACE inhibitor prescription rates are higher than β-blocker prescription rates among Medicare and Medicaid managed care patients in North Carolina. Opportunities for improvement remain, particularly for β-blocker use.

Quality Improvement Organizations (QIOs) are an unbiased source of quality improvement support and expertise for health care professionals and institutions across the nation. The Carolinas Center for Medical Excellence, the QIO in North Carolina and South Carolina, is supporting the advancement of the National Quality Strategy.

To describe the changes in process of care before and after an evidence-based fall reduction quality improvement collaborative in nursing facilities.Natural experiment with nonparticipating facilities serving as controls.Community nursing homes.Thirty-six participating and 353 nonparticipating nursing facilities in North Carolina.Two in-person learning sessions, monthly teleconferences, and an e-mail discussion list over 9 months. The change package emphasized screening, labeling, and risk-factor reduction.Compliance was measured using facility self-report and chart abstraction (n = 832) before and after the intervention. Fall rates as measured using the Minimum Data Set (MDS) were compared with those of nonparticipating facilities as an exploratory outcome.Self-reported compliance with screening, labeling, and risk-factor reduction approached 100%. Chart abstraction revealed only modest improvements in screening (51% to 68%, P.05), risk-factor reduction (4% to 7%, P = .30), and medication assessment (2% to 6%, P = .34). There was a significant increase in vitamin D prescriptions (40% to 48%, P=.03) and decrease in sedative-hypnotics (19% to 12%, P = .04) but no change in benzodiazepine, neuroleptic, or calcium use. No significant changes in proportions of fallers or fall rates were observed according to chart abstraction (28.6% to 37.5%, P = .17), MDS (18.2% to 15.4%, P = .56), or self-report (6.1-5.6 falls/1,000 bed days, P = .31).Multiple-risk-factor reduction tasks are infrequently implemented, whereas screening tasks appear more easily modifiable in a real-world setting. Substantial differences between self-reported practice and medical record documentation require that additional data sources be used to assess the change-in-care processes resulting from quality improvement programs. Interventions to improve interdisciplinary collaboration need to be developed.

Background Heart failure (HF) is a common clinical syndrome resulting in high morbidity and mortality. We examined the spectrum of ventricular dysfunction, and investigated the predictors of angiotensin-converting enzyme (ACE) inhibitor, β-blocker, and spironolactone prescription in 1613 managed care patients with HF. Methods and Results The diagnosis of HF was made by a HF discharge diagnosis or at least 3 physician encounters with a HF diagnosis during 2000. Logistic regression was used to identify predictors of medication prescription. Preserved systolic function was documented in 37%, moderate-severe systolic dysfunction in 31%, mild systolic in 14%, and 18% had inadequate documentation. The mean age was 69 years, 58% were women, 24% African American, and 60% were Medicare patients. Patients without HF type documented were the least aggressively treated. Coronary artery disease, hypertension, and diabetes predicted increased utilization of ACE inhibitor and β-blocker therapies. History of nephropathy was associated with less ACE inhibitor prescription. Advancing age predicted less utilization of β-blockers and spironolactone. Neither ethnicity nor gender influenced medication prescription. Conclusion Preserved left ventricular function was common. Documentation of significant systolic dysfunction was associated with improved quality of care. Interventions to encourage documentation of HF type and further study of HF with preserved systolic function are warranted.

Use of angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic receptor blockers in patients with heart failure (HF) remains low despite the results of clinical trials and evidence-based guidelines that support their use. The quality of HF care in managed Medicare and Medicaid programs in North Carolina participating in a HF quality improvement program was assessed. Managed care plans identified adult patients with 1 inpatient or 3 outpatient claims for HF during 2000. A stratified random sample of 971 Medicare and 642 Medicaid patients' outpatient medical records from 5 plans were reviewed by trained nurse abstractors to obtain data regarding type of HF, demographics, comorbidities, and therapies. Left ventricular function assessment was performed in 88% of patients. Among 494 patients with systolic dysfunction, 86% were appropriately treated with respect to ACE inhibitors (73% prescribed, 13% had a documented contraindication). In contrast, beta-blocker therapy was appropriate in 61% (49% prescribed, 12% contraindication). There were no significant differences in drug use by insurance, gender, race, or age. Ventricular function assessment and ACE inhibitor prescription rates are higher than beta-blocker prescription rates among Medicare and Medicaid managed care patients in North Carolina. Opportunities for improvement remain, particularly for beta-blocker use.

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