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BACKGROUND: Healthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread. OBJECTIVE: To describe EBQI as an approach for promoting VAs PACT and to assess initial implementation of planned EBQI elements. DESIGN: Descriptive. PARTICIPANTS: Regional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region. INTERVENTION: EBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites. APPROACH: We developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents. RESULTS: Nearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread. DISCUSSION: EBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.

ObjectiveContinuous quality improvement (CQI) methods are foundational approaches to improving healthcare delivery. Publications using the term CQI, however, are methodologically heterogeneous, and labels other than CQI are used to signify relevant approaches. Standards for identifying the use of CQI based on its key methodological features could enable more effective learning across quality improvement (QI) efforts. The objective was to identify essential methodological features for recognizing CQI.DesignPrevious work with a 12-member international expert panel identified reliably abstracted CQI methodological features. We tested which features met rigorous a priori standards as essential features of CQI using a three-phase online modified-Delphi process.SettingPrimarily United States and Canada.Participants119 QI experts randomly assigned into four on-line panels.InterventionParticipants rated CQI features and discussed their answers using online, anonymous and asynchronous discussion boards. We analyzed ratings quantitatively and discussion threads qualitatively. Main outcome measure(s) Panel consensus on definitional CQI features.Results/st> Seventy-nine (66%) panelists completed the process. Thirty-three completers self-identified as QI researchers, 18 as QI practitioners and 28 as both equally. The features 'systematic data guided activities,' 'designing with local conditions in mind' and 'iterative development and testing' met a priori standards as essential CQI features. Qualitative analyses showed cross-cutting themes focused on differences between QI and CQI.ConclusionsWe found consensus among a broad group of CQI researchers and practitioners on three features as essential for identifying QI work more specifically as 'CQI.' All three features are needed as a minimum standard for recognizing CQI methods.

Surveys of directors of special education, Medicaid, and public health departments in all 50 states examined the financing arrangements covering health-related services for students with special health care needs in the schools. Results indicated that schools tapped traditional health resources to supplement educational dollars in paying for related services in schools. Medicaid was the most common source. (SM)

Uncontrolled macrophage activation is now considered to be a critical event in the pathogenesis of chronic inflammatory diseases such as atherosclerosis, multiple sclerosis, and chronic venous leg ulcers. However, it is still unclear which environmental cues induce persistent activation of macrophages in vivo and how macrophage-derived effector molecules maintain chronic inflammation and affect resident fibroblasts essential for tissue homeostasis and repair. We used a complementary approach studying human subjects with chronic venous leg ulcers, a model disease for macrophage-driven chronic inflammation, while establishing a mouse model closely reflecting its pathogenesis. Here, we have shown that iron overloading of macrophages--as was found to occur in human chronic venous leg ulcers and the mouse model--induced a macrophage population in situ with an unrestrained proinflammatory M1 activation state. Via enhanced TNF-α and hydroxyl radical release, this macrophage population perpetuated inflammation and induced a [p16.sup.INK4a]-dependent senescence program in resident fibroblasts, eventually leading to impaired wound healing. This study provides insight into the role of what we believe to be a previously un-described iron-induced macrophage population in vivo. Targeting this population may hold promise for the development of novel therapies for chronic inflammatory diseases such as chronic venous leg ulcers., Introduction Chronic venous leg ulcers (CVUs) represent the final outcome of lower-extremity chronic venous insufficiency in most cases (1, 2). It is a debilitating, recurrent complication with a steady increase [...]

A recent Institute of Medicine (IOM) report describes a chasm in health care quality that we must cross for patients to receive better care in the 21st century. The report [...]

Doctors must do a better job of providing palliative care for children with cancer. Researchers surveyed 103 parents whose child had died of cancer. According to the survey, 89% of the children suffered a lot in their last month of life. Most of the suffering was caused by pain, fatigue, or shortness of breath. Only 27% of the children who received treatment for pain were completely free of pain. Suffering from pain was more common in children whose doctors were not actively involved in providing end-of-life care.

Failure to adjust for a physician's case mix when evaluating referral rates may lead to calculation of falsely high or falsely low rates. A general practitioner's referral of patients for specialist care is sometimes used to evaluate the practitioner. Case mix refers to the numbers of patients seen by a doctor and the severity of their illnesses. The referrals made by 52 general practitioners caring for 37,830 patients were analyzed. The statistically unadjusted average number of referrals was 0.79 per patient. When the data was unadjusted to account for case mix 15 doctors had significantly lower, and 13 doctors had significantly higher, referral rates than average when only the age and sex of the doctors' patients was considered. When case mix was accounted for, only three of the 15 doctors identified as having lower referral rates remained below average. Only two of the 13 identified as having higher referral rates remained above average when case mix was accounted for., Objective.--To assess the influence of patient characteristics on practice profiling. Using the example of specialty referrals by primary care physicians, we evaluated the impact of adjusting for patient characteristics (age/sex vs case mix) on the estimation of practice variation, the identification of outlier practices, and the evaluation of potential predictors of variation. Design and Setting.--We applied several measurement strategies to a retrospective cohort of patients (N=37 830) within 52 physician practices in a large staff-model health maintenance organization during a 1-year period. Outcome Measures.--We calculated unadjusted referral rates and adjusted standardized referral ratios for each physician. Using these, we determined coefficients of variation and statistical "outlier status." Results.--Adjustment for patient characteristics decreased the observed variation in referral profiles, with a decrease of more than 50% in the coefficient of variation. Three quarters of the physicians identified as statistical outliers with use of an age/sex-adjusted measure were no longer identified as such with use of a case-mix-adjusted measure. Several key predictors of unadjusted referral rate (including physician age, practice tenure, site of practice, and extent of laboratory test ordering) dropped out of regression models when the outcome variable was adjusted for patient characteristics. Conclusion.--Failure to adjust for case mix in physician practice profiles may lead to overestimates of variation and misidentification of outliers. To the extent that unadjusted practice profiles are used for decisions about education, sanctions, or employment, physicians may be subject to inequitable decisions and actions. Misinformation about the causes and extent of practice variation may also lead to misdirection of scarce resources for quality improvement efforts. (JAMA. 1994;272:871-874)

An educational outreach visit by a transfusion specialist may improve the blood transfusion practices of surgeons and physicians. These visits include a lecture on appropriate transfusion practices and a 30-minute meeting with each transfusing physician. Among 101 transfusing surgeons and attending physicians from a community or teaching hospital, 55 participated in an educational outreach visit and 46 did not. Researchers audited 1,449 red blood cell transfusions that took place six months before and after an outreach visit for compliance with blood transfusion guidelines. After the outreach visit, a 40% decrease in the proportion of non-compliant transfusions occurred among physicians who participated. A 9% increase occurred over the same time period among the physicians who did not participate in an outreach visit., Objective.--To determine whether brief, face-to-face educational outreach visits can improve the appropriateness of blood product utilization. Design.--Randomized, controlled multicenter trial with 6-month-follow-up. Setting.--Surgical and medical services of two pairs of matched community and teaching hospitals in Massachusetts. Participants.--One hundred one transfusing staff surgeons and attending medical physicians. Intervention.--A professionally based transfusion specialist presented one surgical- or medical-service-wide lecture emphasizing appropriate indications, risks, and benefits of red blood cell transfusions; brief, graphic, printed educational guidelines; and one 30-minute visit with each transfusing physician. No data feedback was provided. Educational messages emphasized the lack of utility of the traditional threshold for red blood cell transfusions (hematocrit, 30%) and transfusion risks (eg, viral hepatitis). Measures.--Proportion of red blood cell transfusions classified as compliant or noncompliant with blood transfusion guidelines, or indeterminate 6 months before and 6 months after an experimental educational intervention. Results.--Based on analyses of 1449 medical record audits of red blood cell transfusions that occurred 6 months before and 6 months after the educational intervention, the average proportion of transfusions not in compliance with criteria declined from 0.40 to 0.24 among study surgeons (-40%) compared with an increase from 0.40 to 0.44 (+9%) among control surgeons (P=.006). These effects were consistent across procedure type and specialty. On average, study surgeons in the postintervention period performed transfusions when hematocrits were 2.0 percentage points lower than before the intervention (28.3% preintervention vs 26.3% postintervention), and lower than in the control group (28.3% preintervention and postintervention; P=.04). Likely savings in blood use for surgical services probably exceeded program costs, even without considering reduced risks of infection. No effects were observed among transfusions occurring in medical services, possibly because of substantially lower transfusion rates and lower pretransfusion hematocrits. Conclusions.--Brief, focused educational outreach visits by transfusion specialists can substantially improve the appropriateness and cost-effectiveness of blood product use in surgery. More data are needed regarding the durability of changes in practice patterns and the health and economic benefits of such interventions. (JAMA. 1993;270:961-966)

An educational program for health care workers at a nursing home decreased the use of psychoactive drugs to treat nursing home residents. The program was designed to educate physicians, nurses and aides on the side effects of psychoactive drugs and on alternatives to their use. Of 678 nursing home residents, 349 lived at a nursing home that participated in the educational program and 329 lived at one that did not. A 27% decrease in the use of psychoactive drugs occurred at nursing homes that participated in the program, compared to an 8% decrease at those where the educational program was not presented. Treatment with antipsychotic drugs was discontinued for 32% of the patients in nursing homes that participated, and for 14% of those in nursing homes that did not participate. Residents of nursing homes whose staff participated in the educational program showed less deterioration of cognitive functions such as memory, and reported less depression after discontinuation of psychoactive drugs.

Abstract Background This paper has two goals. First, we explore the feasibility of conducting online expert panels to facilitate consensus finding among a large number of geographically distributed stakeholders. Second, we test the replicability of panel findings across four panels of different size. Method We engaged 119 panelists in an iterative process to identify definitional features of Continuous Quality Improvement (CQI). We conducted four parallel online panels of different size through three one-week phases by using the RAND's ExpertLens process. In Phase I, participants rated potentially definitional CQI features. In Phase II, they discussed rating results online, using asynchronous, anonymous discussion boards. In Phase III, panelists re-rated Phase I features and reported on their experiences as participants. Results 66% of invited experts participated in all three phases. 62% of Phase I participants contributed to Phase II discussions and 87% of them completed Phase III. Panel disagreement, measured by the mean absolute deviation from the median (MAD-M), decreased after group feedback and discussion in 36 out of 43 judgments about CQI features. Agreement between the four panels after Phase III was fair (four-way kappa = 0.36); they agreed on the status of five out of eleven CQI features. Results of the post-completion survey suggest that participants were generally satisfied with the online process. Compared to participants in smaller panels, those in larger panels were more likely to agree that they had debated each others' view points. Conclusion It is feasible to conduct online expert panels intended to facilitate consensus finding among geographically distributed participants. The online approach may be practical for engaging large and diverse groups of stakeholders around a range of health services research topics and can help conduct multiple parallel panels to test for the reproducibility of panel conclusions.

BACKGROUND/OBJECTIVES: Suspected urinary tract infection (UTI) is the most common indication for antibiotic use in long‐term care (LTC). Due to the high prevalence of asymptomatic bacteriuria, for which antibiotics are not warranted, these antibiotics are frequently unnecessary. We implemented a collaborative quality improvement program to improve the management of suspected UTI in LTC residents by increasing awareness of current guidelines, with a focus on decreasing treatment in the absence of symptoms. DESIGN/INTERVENTION: Two separate collaboratives included workshops, webinars, and coaching calls. PARTICIPANTS: A total of 31 facilities participated in the first collaborative, with 17 submitting sufficient data for analysis and 34 in the second, with data analyzed from 25. MEASUREMENTS: Facilities reported monthly numbers of urine cultures, UTI diagnoses, Clostridioides difficile infections (CDIs), and resident days. RESULTS: When comparing the baseline period to the first collaborative period, the intercollaborative period to the second collaborative period, and the first collaborative period to the second, the incident rate ratios (95% confidence intervals) were 0.74 (0.68‐0.81), 0.83 (0.73‐0.94), and 0.63 (0.57‐0.69), respectively, for urine culturing rate; 0.73 (0.64‐0.83), 0.86 (0.70‐1.05), and 0.60 (0.51‐0.69), respectively, for UTI diagnosis rate; and 0.56 (0.40‐0.82), 1.61 (0.71‐4.14), and 0.45 (0.27‐0.74), respectively, for CDI rate. CONCLUSION: The program we implemented was associated with reductions in urine cultures, UTI diagnosis, and CDI; and it suggests that this type of intervention can promote appropriate management of UTI in the LTC setting. J Am Geriatr Soc 68:62–69, 2019 See related editorial by Furuno et al. in this issue. [ABSTRACT FROM AUTHOR]

Nonhealing chronic wounds in the constantly growing elderly population represent a major public health problem with high socioeconomic burden. Yet, the underlying mechanism of age‐related impairment of wound healing remains elusive. Here, we show that the number of dermal cells expressing cyclin‐dependent kinase inhibitor p21 was elevated upon skin injury, particularly in aged population, in both man and mouse. The nuclear expression of p21 in activated wound fibroblasts delayed the onset of the proliferation phase of wound healing in a p53‐independent manner. Further, the local and transient inhibition of p21 expression by in vivo delivered p21‐targeting siRNA ameliorated the delayed wound healing in aged mice. Our results suggest that the increased number of p21+ wound fibroblasts enforces the age‐related compromised healing, and targeting p21 creates potential clinical avenues to promote wound healing in aged population. [ABSTRACT FROM AUTHOR]