Search

Background In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. Objectives Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. Methods This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. Results Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). Conclusion The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

Background.Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown.Objective.To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing.Design and Setting.Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs.Methods.Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities.Results.We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant (P = .32).Conclusions.Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity.Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines.This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review.Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews).The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

Background: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. Objectives: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. Methods: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. Results: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). Conclusion: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

Rapid response activation (RRA), triggered chiefly by surpassing threshold vital sign abnormalities (TVSAs), is designed to intervene at the earliest point in a patient's deteriorating course. The authors aimed to quantify the incidence of TVSA among patients hospitalized on acute care units in a hospital that uses rapid response. During the course of 6 months, the authors compared adverse events (mortality, unexpected intensive care unit [ICU] transfers, and cardiopulmonary arrest) and TVSA among patients who triggered an RRA, patients with TVSAs and no RRA, and all other patients. At least 1 TVSA was recorded in 31.9% of stays and 12.2% of patient-days. RRA patients were more likely (22.5%) than other TVSA patients (7.9%) and other patients (1.8%) to have an adverse event (P < .01). Incidence varied by vital sign. During the investigation, only 2.5% of TVSA opportunities triggered an RRA. As systems engage electronic workflows, automatically triggering RRAs based solely on TVSAs could place a tremendous burden on systems.

Background. Little is known about the decline of kidney function in patients with normal kidney function at baseline. Our objectives were to (i) identify predictors of incident chronic kidney disease (CKD) and (ii) to estimate rate of decline in kidney function. Methods. The study used a retrospective cohort of adult patients in a hypertension registry in an inner-city health care delivery system in Denver, Colorado. The primary outcome was development of incident CKD, and the secondary outcome was rate of change of estimated glomerular filtration rate (eGFR) over time. Results. After a mean follow-up of 45 months, 429 (4.1%) of 10 420 patients with hypertension developed CKD. In multivariate models, factors that independently predicted incident CKD were baseline age [odds ratio (OR) 1.13 per 10 years, 95% confidence interval (CI), 1.03–1.24], baseline eGFR (OR 0.69 per 10 units, 95% CI 0.65–0.73), diabetes (OR 3.66, 95% CI 2.97–4.51) and vascular disease (OR 1.67, 95% CI 1.32–2.10). We found no independent association between age, gender or race/ethnicity and eGFR slope. In patients who did not have diabetes or vascular disease, eGFR declined at 1.5 mL/min/1.73 m2 per year. Diabetes at baseline was associated with an additional decline of 1.38 mL/min/1.73 m2. Conclusions. Diabetes was the strongest predictor of both incident CKD as well as eGFR slope. Rates of incident CKD or in decline of kidney function did not differ by race or ethnicity in this cohort.

Because of high rates of trimethoprim-sulfamethoxazole resistance in Escherichia coli, Denver Health switched to levofloxacin as the initial therapy for urinary tract infections (UTIs) in 1999. We evaluated the effects of that switch 6 years later.Levofloxacin prescriptions per 1000 outpatient visits and levofloxacin resistance in outpatient E. coli were evaluated over time. E. coli isolated in 2005 were further characterized by specimen source and antimicrobial susceptibilities. Risk factors for levofloxacin-resistant E. coli UTI among nonpregnant adult outpatients were evaluated in a case-control study.Between 1998 and 2005, levofloxacin use increased from 3.1 to 12.7 prescriptions per 1000 visits (P.01) and resistance in outpatients increased from 1% to 9% (P.01). Although prescriptions for sulfonamide antibiotics decreased by half during the same period, E. coli resistance to trimethoprim-sulfamethoxazole increased from 26.1% to 29.6%. Levofloxacin-resistant E. coli were more likely resistant to other antibiotics than levofloxacin-susceptible isolates (90% vs 43%, P.0001). Risk factors for levofloxacin-resistant E. coli UTI were hospitalization (odds ratio for each week of hospitalization, 2.0; 95% confidence interval, 1.0-3.9) and use of levofloxacin (odds ratio, 5.6; 95% confidence interval, 2.1-27.5) within the previous year.Fluoroquinolone prescriptions increased markedly after an institutional policy change for empiric treatment of UTI, and a rapid increase in fluoroquinolone resistance among outpatient E. coli followed. Risk factors for infection with resistant E. coli were recent hospitalization and levofloxacin use. Risk factors should be considered before initiating empiric treatment with a fluoroquinolone.

Study objective We evaluate the effectiveness of an educational program in hospital emergency departments (EDs) targeting reduction in antibiotic overuse for acute respiratory tract infections. Methods Sixteen hospitals participated in the cluster randomized trial, selecting a Veterans Administration (VA) and non-VA hospital within each of 8 metropolitan regions. Intervention sites received performance feedback, clinician education, and patient educational materials, including an interactive computer kiosk located in the waiting room. Medical records were reviewed at each site during the baseline year 1 and intervention year 2. The primary measure of effect was the percentage of visits for upper respiratory tract infections and acute bronchitis that were treated with antibiotics. Secondary outcomes, including return visits and visit satisfaction, were assessed by follow-up telephone interviews of patients. Alternating logistic regression models were used to adjust for baseline treatment rates, case mix differences, and provider characteristics. Results The adjusted antibiotic prescription level for upper respiratory tract infection/acute bronchitis visits was 47% for control sites and 52% for intervention sites in year 1. Antibiotic prescriptions at control sites increased by 0.5% between year 1 and year 2 (95% confidence interval −3% to 5%) and at intervention sites decreased by 10% (95% confidence interval −18% to −2%). There were no significant differences between control and intervention sites in the proportions of upper respiratory tract infection/bronchitis patients with return ED visits or in overall visit satisfaction. Conclusion Multidimensional educational interventions can reduce antibiotic overuse in the treatment of patients with upper respiratory tract infections and acute bronchitis in EDs. However, substantial antibiotic overuse persists despite this educational intervention.

Background . This study examined the potential for tobacco use and other health risk behavior interventions in the context of an urban sexually transmitted diseases (STD) clinic. Methods . A cross-sectional survey of two populations. Adolescents seen at an STD clinic or at the teen clinic of a community health center completed a self-administered computer survey in 1996. Risk behaviors, attitudes, and readiness to stop smoking were analyzed for 225 patients at the STD clinic and 248 patients at the teen clinic. Results . Compared with adolescents in the teen clinic, adolescents in the STD clinic were more likely to have smoked frequently (OR 1.7, 95% CI 1.1, 3.0), used any illegal drug (OR 2.7, 95% CI 1.3, 5.5), recently binged on alcohol (OR 1.7, 95% CI 1.0, 2.8), and had more than 10 lifetime sexual partners (OR 1.9, 95% CI 1.0, 3.4). Weapon carrying, readiness to stop smoking, and attitudes toward smoking did not differ between sites. Conclusions . Cigarette smoking and other health risk behaviors are more prevalent among adolescents in an STD clinic than among adolescents in a community health center. STD clinics are potential sites for cigarette, alcohol, and drug use interventions among “hard to reach” adolescents.

Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

A general review of global trends in cigarette smoking is presented and smokings negative effects are described. The authors note that despite growing awareness of the dangers of smoking "cigarette smoking has stopped declining in the U.S. and is rising in other parts of the world. Aggressive marketing and permissive regulations are largely to blame." (EXCERPT)

Acute care hospitals struggle to manage complex patients who no longer require acute care services but who present medical and psychosocial challenges that make safe discharge to a lower level of care difficult. These challenges can be particularly acute at safety-net hospitals that cater predominantly to the poor and uninsured. For a person with a serious illness, such as a spinal cord injury, lack of insurance for long-term care services may add many weeks of medically unnecessary hospital days and result in higher costs. We describe safety-net system Denver Health's efforts to facilitate appropriate nonhospital care for these complex patients through the formation of a Complex Discharge Subcommittee. Successful solutions include accelerating legal guardianship approval to facilitate patient acceptance by skilled nursing facilities, as well as providing specialized equipment such as bariatric beds to nursing facilities to enable them to accommodate these patients. However, further policy interventions, such as updated reimbursement policies, are warranted.

To assess the feasibility of engaging adults with diabetes in self management behaviors between clinic visits by using cell phone text messaging to provide blood sugar measurement prompts and appointment reminders.Quasi-experimental pilot among adult diabetic patients with cell phones who receive regular care at a federally qualified community health center in Denver, Colorado, which serves a population that is predominantly either uninsured (41%) or on Medicaid or Medicare (56%).Patients (N = 47) received text message prompts over a 3-month period. Blood sugar readings were requested 3 times per week (Monday, Wednesday, and Friday). Reminders were sent 7, 3, and 1 day(s) before each scheduled appointment. Acknowledgments were returned for all patient-sent messages. Focus groups were conducted in English and Spanish with selected patients (n = 8).Patients of all ages were active participants. Correctly formatted responses were received for 67.3% of 1585 prompts. More than three-fourths (79%) of the cohort responded to more than 50% of their prompts. The appointment analysis was underpowered to detect significant changes in attendance. Participants reported increased social support, feelings that the program "made them accountable," and increased awareness of health information. Two-thirds (66%) of patients provided glucose readings when prompted during the study, compared with 12% at 2 preceding clinic visits.For certain patients, cell phone-based text messaging may enhance chronic disease management support and patient-provider communications beyond the clinic setting.

There is a need for randomized, prospective trials of case management interventions with resource utilization analyses.To determine whether algorithm-driven telephone care by nurses improves lipid control in patients with diabetes.Prospective, randomized, controlled trial.Adults with diabetes at a federally funded community health center were randomly assigned to intervention (n = 381) or usual-care (n = 381) groups.Nurses independently initiated and titrated lipid therapy and promoted behavioral change through motivational interviewing and self-management techniques. Other parameters of diabetes care were addressed based on time constraints.The primary outcome was the proportion of patients with a low-density lipoprotein (LDL) less than 100 mg/dL. Secondary outcomes included the number of hospital admissions, total hospital charges per patient, and the proportion of patients meeting other lipid, glycemic, and blood pressure guidelines.The percent of patients with an LDL100 mg/dL increased from 52.0% to 58.5% in the intervention group and decreased from 55.6% to 46.7% in the control group (P.01). Average cost per patient to the healthcare system was less for the intervention group ($6600 vs $9033, P = .03). Intervention patients trended toward fewer hospital admissions (P = .06). The intervention did not affect glycemic and blood pressure outcomes.Nurses can improve lipid control in patients with diabetes in a primarily indigent population through telephone care using moderately complex algorithms, but a more targeted approach is warranted. Telephone-based outreach may decrease resource utilization, but more study is needed.

It has been 30 years since the surgeon general of the United States released the first report of the Advisory Committee on Smoking and Health. In each of the subsequent reports, cigarette smoking has been identified as the most important source of preventable morbidity and premature mortality in the United States. A total of 418,690 deaths in the United States were attributed to smoking in 19901. That figure included approximately twice as many male as female smokers. Of the 2,148,000 U.S. residents who died in 1990, approximately half died of particular preventable causes2 (Table 1). The prominence of tobacco . . .

Introduction: Little has been published on the impact of telephone visits on diabetes outcome performance. Research Design and Methods: An attending and resident physician prioritized telephone visits based on glycemic, blood pressure, and lipid performance. The resident and attending panel was compared with all other diabetic patients at the clinic for baseline and end-intervention performance. Results: The intervention patients had an absolute percentage of increase versus control patients of 14.9 (p

Over-use of antibiotics for acute respiratory infections (ARIs) increases antimicrobial resistance, treatment costs, and side effects. Patient desire for antibiotics contributes to over-use.To explore whether a point-of-care interactive computerized education module increases patient knowledge and decreases desire for antibiotics.Bilingual (English/Spanish) interactive kiosks were available in 8 emergency departments as part of a multidimensional intervention to reduce antibiotic prescribing for ARIs. The symptom-tailored module included assessment of symptoms, knowledge about ARIs (3 items), and desire for antibiotics on a 10-point visual analog scale. Multivariable analysis assessed predictors of change in desire for antibiotics.Of 686 adults with ARI symptoms, 63% initially thought antibiotics might help. The proportion of patients with low (1-3 on the scale) desire for antibiotics increased from 22% pre-module to 49% post-module (p.001). Self-report of "learning something new" was associated with decreased desire for antibiotics, after adjusting for baseline characteristics (p=.001).An interactive educational kiosk improved knowledge about antibiotics and ARIs. Learning correlated with changes in personal desire for antibiotics.By reducing desire for antibiotics, point-of-care interactive educational computer technology may help decrease inappropriate use for antibiotics for ARIs.

Background We conducted an Internet-based randomized trial comparing three valence framing presentations of the benefits of antihypertensive medication in preventing cardiovascular disease (CVD) for people with newly diagnosed hypertension to determine which framing presentation resulted in choices most consistent with participants' values. Methods and Findings In this second in a series of televised trials in cooperation with the Norwegian Broadcasting Company, adult volunteers rated the relative importance of the consequences of taking antihypertensive medication using visual analogue scales (VAS). Participants viewed information (or no information) to which they were randomized and decided whether or not to take medication. We compared positive framing over 10 years (the number escaping CVD per 1000); negative framing over 10 years (the number that will have CVD) and negative framing per year over 10 years of the effects of antihypertensive medication on the 10-year risk for CVD for a 40 year-old man with newly diagnosed hypertension without other risk factors. Finally, all participants were shown all presentations and detailed patient information about hypertension and were asked to decide again. We calculated a relative importance score (RIS) by subtracting the VAS-scores for the undesirable consequences of antihypertensive medication from the VAS-score for the benefit of CVD risk reduction. We used logistic regression to determine the association between participants' RIS and their choice. 1,528 participants completed the study. The statistically significant differences between the groups in the likelihood of choosing to take antihypertensive medication in relation to different values (RIS) increased as the RIS increased. Positively framed information lead to decisions most consistent with those made by everyone for the second, more fully informed decision. There was a statistically significant decrease in deciding to take antihypertensives on the second decision, both within groups and overall. Conclusions For decisions about taking antihypertensive medication for people with a relatively low baseline risk of CVD (70 per 1000 over 10 years), both positive and negative framing resulted in significantly more people deciding to take medication compared to what participants decided after being shown all three of the presentations. Trial Registration International Standard Randomised Controlled Trial Number Register ISRCTN 33771631

Objective: To systematically review the evidence supporting treatment of osteopenia and osteoporosis in patients with anorexia nervosa (AN). Data sources: We identified controlled clinical studies of interventions for low bone mass in AN via searches of MEDLINE; the Cochrane Library; EMBASE; PsycINFO; and cumulative index to nursing and allied health literature. Outcomes of interest were changes in bone mineral density and fracture incidence. Results: Six randomized controlled trials (RCTs) and two cohort trials examined five classes of medical therapy on bone mineral density outcomes. One RCT of bisphosphonates showed no benefit and a second flawed RCT showed some benefit; one RCT showed a benefit of insulin-like growth factor-I; none of the five trials evaluating estrogen therapy showed benefit. Discussion: Although patients with AN are often losing bone mass when they should be optimizing bone growth, there is no good evidence to guide medicinal interventions. Therefore, early detection and weight restoration are of utmost importance whereas ongoing trials define effective therapies.

This randomized, controlled trial tested the effectiveness of a nurse-run, telephone-based intervention to improve lipid control in patients with diabetes. Our patient population is predominantly low-income and Latino. Using our diabetes registry, we randomly assigned 381 patients to continue with their usual care and 381 to participate in our nurse-run program. Three registered nurses learned algorithms for diabetes care. These algorithms address management of lipids, glycemic control, blood pressure, nephropathy, aspirin use, eye screening, pneumovax and influenza vaccines, obesity, and cigarette smoking. The nurses were also trained in motivational interviewing techniques and facilitation of patient self-management. The primary goal was to improve lipid control in our diabetic population. Secondary outcomes address blood pressure control, glycemic control, renal function, and medication adherence. In addition, a cost-effective analysis is being performed. This article summarizes the design of the intervention.

In a randomized trial, Cheryl Carling and colleagues evaluate how people respond to different statistical presentations regarding the consequences of taking antibiotic treatment for sore throat., Background We conducted an Internet-based randomized trial comparing four graphical displays of the benefits of antibiotics for people with sore throat who must decide whether to go to the doctor to seek treatment. Our objective was to determine which display resulted in choices most consistent with participants' values. Methods and Findings This was the first of a series of televised trials undertaken in cooperation with the Norwegian Broadcasting Company. We recruited adult volunteers in Norway through a nationally televised weekly health program. Participants went to our Web site and rated the relative importance of the consequences of treatment using visual analogue scales (VAS). They viewed the graphical display (or no information) to which they were randomized and were asked to decide whether to go to the doctor for an antibiotic prescription. We compared four presentations: face icons (happy/sad) or a bar graph showing the proportion of people with symptoms on day three with and without treatment, a bar graph of the average duration of symptoms, and a bar graph of proportion with symptoms on both days three and seven. Before completing the study, all participants were shown all the displays and detailed patient information about the treatment of sore throat and were asked to decide again. We calculated a relative importance score (RIS) by subtracting the VAS scores for the undesirable consequences of antibiotics from the VAS score for the benefit of symptom relief. We used logistic regression to determine the association between participants' RIS and their choice. 1,760 participants completed the study. There were statistically significant differences in the likelihood of choosing to go to the doctor in relation to different values (RIS). Of the four presentations, the bar graph of duration of symptoms resulted in decisions that were most consistent with the more fully informed second decision. Most participants also preferred this presentation (38%) and found it easiest to understand (37%). Participants shown the other three presentations were more likely to decide to go to the doctor based on their first decision than everyone based on the second decision. Participants preferred the graph using faces the least (14.4%). Conclusions For decisions about going to the doctor to get antibiotics for sore throat, treatment effects presented by a bar graph showing the duration of symptoms helped people make decisions more consistent with their values than treatment effects presented as graphical displays of proportions of people with sore throat following treatment. Clinical Trials Registration ISRCTN58507086 Please see later in the article for the Editors' Summary, Editors' Summary Background In the past, patients usually believed that their doctor knew what was best for them and that they had little say in deciding what treatment they would receive. But many modern interventions have complex trade-offs. Patients' opinions about the relative desirability of the possible outcomes of health care interventions depend on their lifestyle and expectations, and these “values” need to be considered when making decisions about medical treatments. Consequently, shared decision-making is increasingly superseding the traditional, paternalistic approach to medical decision-making. In shared decision-making, health care professionals talk to their patients about the risks and benefits of the various treatment options, and patients tell the health care professionals what they expect and/or require from their treatment. Why Was This Study Done? Shared decision-making can only succeed if patients know about the treatment options that are available for their medical condition and understand the consequences of each option. But how does the presentation of information about treatment options to patients affect their decisions? In 2002, a series of internet-based randomized trials (studies in which participants are randomly allocated to different “treatment” groups) called the Health Information Project: Presentation Online (HIPPO) was initiated to answer this question. Here, the researchers describe HIPPO 3, a trial that investigates how alternative graphical displays of the benefits of antibiotics for the treatment of sore throat affect whether people decide to seek treatment. In particular, the researchers ask which display results in people making a treatment decision most consistent with their values, i.e., in terms of the relative importance to them of the treatment's desirable and undesirable outcomes. What Did the Researchers Do and Find? Adult Norwegians recruited through a television health program numerically rated the importance of symptom relief and of several negative consequences (for example, side effects) of antibiotic treatment for sore throat on the trial's Web site. Relative importance scores (which indicate the participants' values) were calculated for each participant by subtracting their ratings for the importance of the negative consequences of seeking antibiotic treatment from his or her rating for the importance of symptom relief. The participants were then asked to decide whether to visit a doctor for antibiotics without receiving any further information or after being shown one of four graphical displays illustrating the benefits of antibiotic treatment. Two bar charts and one display of happy- and sad-face icons showed the proportion of people with symptoms at specific times after sore throat onset with and without treatment. A third bar chart indicated symptom duration with and without antibiotics. Finally, all the participants were shown all the displays and other information about sore throat and were asked to decide again about seeking treatment. The researchers found a clear association between the participants' values and the likelihood of their deciding to go to the doctor, and this likelihood depended on which graphical display the participants saw. People shown information on the proportion of patients with symptoms were more likely to decide to visit a doctor than those shown information on symptom duration. Furthermore, first decisions reached after being given information on symptom duration or no information were more consistent with the fully informed second decision than first decisions reached after seeing the other displays. What Do These Findings Mean? These findings suggest that, for people considering whether to seek antibiotic treatment for sore throat, a bar graph showing the duration of symptoms is more likely to help them make a decision that is consistent with their own values than a bar chart showing the proportions of people with sore throat following treatment. The researchers also found that the bar chart showing symptom duration was preferred by more of the participants than any of the other representations. Whether these results can be applied to other health care decisions or in other settings is not known. However, the researchers suggest that these findings may be most relevant to treatments that, like antibiotic treatment of sore throat, have a short-lived benefit and relatively important downsides. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000140. A PLoS Medicine Editorial discusses this trial and the results of another HIPPO trial that are presented in a separate PLoS Medicine Research Article by Carling et al.; details of a pilot HIPPO trial are also available The Foundation for Informed Medical Decision Making (a US-based nonprofit organization) provides information on many aspects of medical decision making The Dartmouth-Hitchcock Medical Center provides information to help people make health care decisions through its Center for Shared Decision Making The Ottawa Hospital Research Institute provides information on patient decision aids, including an inventory of decision aids available on the Web (in English and French) MedlinePlus provides links to information and advice about sore throat (in English and Spanish)

We evaluated the acceptability and impact of an audiovisual, bilingual, interactive computer module relating to appropriate antibiotic use. In winter 2001, adults seeking urgent care for acute respiratory infections at an inner-city urgent care clinic were invited to complete the computer module and survey (N = 296). After responding to questions about their symptoms, patients were provided information about their illness and appropriate antibiotic use, and then asked several questions about the acceptability of the module. The main outcomes, reflecting qualities known to enhance diffusion of innovations, were "learning something new about colds and flu" and trusting the computer information. Spanish-language respondents (16%) were much less likely to report prior computer experience, more likely to need help, and strongly preferred answering to a person compared with English-language respondents. In multivariable analysis, Spanish-language respondents were more likely to report learning something new (OR = 5.0; 95% CI: 2.0, 12.4) and trusting the information (OR = 2.5; 95% CI: 1.0, 6.0). We conclude that an interactive computer module was well received among a medically underserved urgent care clinic population. Benefits appear greatest among populations having the least experience with this medium.

Burden of suffering It is estimated that approximately 15,000 women will be diagnosed with invasive carcinoma of the cervix and 4,800 women will die from this disease in 1995. (1) Rates for carcinoma in situ peak between the ages of 20 and 30, and the incidence of invasive cervical cancer increases with age. (2) Twenty-five percent of all invasive cervical cancers occur in women over age 65. Any woman who has been sexually active is at risk for cervical cancer. (3) Additional risk factors include early onset of sexual intercourse, (4,5) history of multiple sexual partners, (5) history of sexually transmitted disease (especially HPV (6) and HIV(7)), smoking, (8) and never having been screened. (9)

Background. Our objective was to explore the relationship between baseline characteristics of hospitalized smokers and 6-month to 2-year self-reported quit rates. Methods. We surveyed adult smokers (n = 154) admitted to the Medicine service of an urban public hospital. We used the pharmacy database, a follow-up telephone survey, and medical records to characterize nicotine patch use and post-discharge smoking abstinence. Results. Among the 102 patients for whom smoking status at least 6 months after discharge was known, 18 (18%) were not smoking at last contact (mean follow-up 20 months). Individual factors associated with quitting include confidence to quit within 1 week, stage of change other than precontemplation, filling a nicotine patch prescription after discharge, number of previous quit attempts, and increasing age. With multivariate modeling, only confidence to quit [OR 9.8, confidence interval (CI), 2.8–35.0] and the number of previous quit attempts (OR 1.3 per attempt, 95% CI, 1.0–1.5) remained significantly associated with future abstinence. Conclusions. A high level of confidence to quit and multiple prior quit attempts are strongly associated with future abstinence among hospitalized patients who smoke. Using a simple confidence-to-quit scale to target interventions to patients with high confidence may improve the effectiveness of smoking cessation programs.

Background Antibiotic resistance is increasing in Escherichia coli , the most common cause of urinary tract infections, but its epidemiology has not been well described. We evaluated the epidemiology of trimethoprim-sulfamethoxazole–resistant E. coli in a large, public health care system in Denver, Colorado. Methods Outpatients with E. coli urinary tract infections during the first 6 months of 1998 were evaluated retrospectively. A prospective study was then performed to confirm the rate of trimethoprim-sulfamethoxazole resistance. We used several strain-typing methods (pulsed-field gel electrophoresis, ribotyping, serotyping) to evaluate the molecular epidemiology of the resistance. Results The rate of trimethoprim-sulfamethoxazole resistance was similar in the retrospective (24% [161/681]) and prospective (23% [30/130]) phases of the study ( P = 0.89). Almost all trimethoprim-sulfamethoxazole–resistant strains (98%) were resistant to at least one other antibiotic. Risk factors for infection with a resistant strain included age ≤3 years, Hispanic ethnicity, recent travel outside the United States, and a prior urinary tract infection. However, rates of resistance were >15% among nearly all of the subgroups. Most strains had high-level resistance (>1000 μg/mL) to trimethoprim-sulfamethoxazole. Of the 23 resistant isolates evaluated, 10 (43%) belonged to the clone A group. There was no correlation between conventional epidemiologic characteristics and the molecular mechanism of resistance or strain type. Conclusion Resistance to trimethoprim-sulfamethoxazole among E. coli isolates among patients in a Denver public health care system is common, with high rates of resistance even among patients without risk factors.

Background.This study characterizes adult smokers on the medicine service of an urban, public hospital, including stage of change, self-efficacy to quit, and nicotine dependence, and explores relationships between perceived and actual smoking-related illness and these three predictive variables. Methods.Adult patients (n= 154) admitted to the Medicine service of Denver Health Medical Center in October and November 1996 were surveyed using a written questionnaire. Results.The proportion of smokers in this population was 45.7% (95% CI = 42.0%, 49.4%). Adjusted for age and sex, the proportion of smokers in this population was significantly greater than in Colorado (28.8% vs 21.8%,P< 0.001). About half (54.2%) were willing to try free nicotine patches during hospitalization. Among smokers with diseases recognized as smoking-related, 30.4% believed their reason for admission was related to smoking, compared to 20.4% among those with no smoking-related diseases (P= 0.18). Patients who believed their hospitalization was due to smoking had greater intentions (P= 0.001) and self-efficacy (P< 0.001) to quit. Conclusions.Targeting smokers who perceive that their illness is smoking-related may optimize inpatient smoking interventions.

Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use.Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period.In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group.This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.

Article-at-a-Glance Background Lean principles have been used at Denver Health Medical Center since 2005 to streamline nonclinical processes. Despite allocation of significant resources, particularly the expense of low molecular weight heparin (LMWH), to prophylaxis of venous thromboembolism (VTE), the incidence of postoperative VTE was significantly worse than national benchmarks. VTE risk factors were not consistently assessed, and the prescribing of prophylaxis varied widely. Lean was employed to standardize and implement risk assessment and evidence-based VTE prophylaxis for the institution. Methods In a rapid improvement event, a multidisciplinary group formulated an evidence-based risk assessment tool and clinical practice guideline for VTE prophylaxis, with plans for hospitalwide implementation and monitoring. Results The effects were immediate and improved steadily with feedback to clinicians. Within six months, compliance with the standard approached 100%. One year after implementation, the use of LMWH decreased more than 60% below baseline, and the use of sequential compression devices decreased by nearly 30%. With increased use of unfractionated heparin, the cost savings on VTE prophylaxis exceeded $15,000 per month, for a total of $425,000 since implementation. Moreover, the incidence of VTE decreased markedly during the same period. By reducing VTE rates, a total cost savings of $6.2 million was estimated for the past 28 months. Conclusions Applying Lean to the clinical management of VTE prophylaxis improved compliance with standards and saved the hospital a significant amount of money. This was achieved without compromising clinical outcomes. This experience could be replicated at other institutions.

Denver Health includes a central hospital with 18 000 admissions per year, and a large integrated network of 11 community health centres with 350 000 visits per year. Fifty per cent of patients are uninsured, 40% have incomes below the poverty level, and 70% are from a minority group. Denver Health has had outpatient cessation classes in the community health centres since the early 1980s. In 1994, we convened a tobacco control committee to address issues such as a tobacco free campus, smoking status assessment as a fifth vital sign, and publication of a tobacco control newsletter. In 1996, when nicotine gum had already gone over the counter (OTC) and nicotine patches were about to become OTC, our payers were deciding not to cover most OTC products. Our challenge was to convince two groups—the hospital pharmacy committee and the Medicaid managed care organisation—that nicotine replacement therapy should be covered. Our approach was to suggest that patches, when used in conjunction with outpatient counselling, are very cost effective—in the order of 10 times more cost effective than screening for hypertension. Knowing that both groups would want to contain costs, we proposed to put …

To the Editor: We read with interest the article by Carney et al.1 on the association of schizophrenia with other medical illnesses. In reality, the migration of psychiatric patients into general Internal Medicine practice has been progressively increasing since the deinstitutionalization of the severely mentally ill over 40 years ago. At Denver Health, a large vertically integrated public safety net hospital system, we responded to this phenomenon almost 10 years ago by establishing clinics within our Internal Medicine practices, specifically geared to caring for the complex medical comorbidities of severely mentally ill patients.2,3 A key component to our clinics is having 1 provider with interest in the population who can bridge communication with mental health providers and facilitate care coordination. This initiative was also spawned because we often treated these patients when their disease process had advanced beyond when it should have been treated. These patients are often reticent to seek timely medical care caused by their inherent paranoia, the stigma they have perceived when seeking care previously, and as the editorial on Carney’s article points out, “for patients with schizophrenia, negotiating a separate complex, medical health care system can be challenging...”4 Although there is an increasing need for General Internists to became more familiar with prescribing psychiatric medication, as services for mental health patients continue to shrink,5 this perhaps should be limited to the care of the less complex mental health patient who also has medical comorbidities. However, for those patients with severe and persistent complex mental illness, our model of designating some Internists, with a special interest in these patients and clinic times solely for the care of these patients, may ultimately be the most efficient and tenable manner to attend to their mental health and medical needs. This in turn may avert the impediments that challenge the health of these patients and minimize the impact on health care systems, which by default must provide the care. Philip S. Mehler, MD, Denver Health Medical Center, 660 Bannock Street, MC 0278, Denver, CO 80204, USA; (e-mail: David.bekelman@UCHSC.edu);Cynthia K. Crews, MD, Thomas Mackenzie, MD,Department of General Internal Medicine, Denver Health Medical Center, Denver, CO, USA.

Purpose Dyslipidemia treatment dramatically decreases coronary heart disease risk in diabetes, yet only a minority of these patients are screened or achieve optimal low-density lipoprotein (LDL) cholesterol levels. Our aim was to increase the percentage of diabetic patients in whom lipid management was achieved through electronic and direct educational detailing. Methods The study cohort comprised 884 diabetic patients at 12 primary care practices. Practice sites were randomized to one of three intervention groups: electronic educational detailing, direct (face-to-face) educational detailing, or control. Direct and electronic detailing were performed over a 12-month period. All sites were notified of our goal to enhance lipid testing among diabetic patients. Chart abstraction was performed 15 months after the start of the intervention. For the entire population (n=884), the proportion of patients with lipid testing was calculated, and changes from pre- to postintervention were compared across groups. We compared pre- and postintervention LDL-cholesterol changes between groups using least square means to account for site variation. Results Favorable provider actions increased significantly with the intervention (+22% compared with +6% in controls, P =.01). By logistic regression, electronic detailing increased the likelihood of lipid testing (odds ratio 3.0, confidence interval 1.6-5.7), as did direct detailing (odds ratio 1.8, confidence interval 0.9-3.7) in patients with no preintervention LDL test (n=432). Lipid testing tended to increase to a greater extent at intervention sites (+23% for the combination of electronic and direct detailing vs +11% for controls, P =.06). Conclusions Brief educational detailing either through direct or electronic communication favorably impacts provider behavior regarding dyslipidemia care for diabetic patients.

(1909). XC. The relation between uranium and radium.—IV. The London, Edinburgh, and Dublin Philosophical Magazine and Journal of Science: Vol. 18, No. 108, pp. 846-858.

In a recent paper one of us has described the use of metallic calcium at high temperature for the production of high vacua, and in spectroscopic work as a very perfect chemical absorbent of all except the chemically inert gases. It was shown that helium and argon purified by calcium from traces of common gases or vapours, with which they are in practice invariably contaminated during manipulation, showed a great disinclination to conduct the discharge. In ordinary spectrum-tubes, helium offered a resistance equivalent to an alternative spark-gap of an inch in air, at a pressure of 0·05 mm., and argon at 0·02 mm. of mercury. This behaviour of the monatomic gases, together with the closely-allied phenomenon shown by spectrum-tubes filled with these gases of becoming non-conducting, or “running out,” under the action of the discharge, have now been investigated in detail. A great number of experiments have been performed and a short summary will be given in the present paper. The main object was to settle whether electric conduction in the monatomic gases is essentially different from that in other gases. The first results raised at least a presumption that perfectly pure helium might be unable to conduct the discharge at all, so that the running out of spectrum-tubes might be due to the absorption of the impurities only by the electrodes and not by the absorption of the inert gas itself. This view, however, proved to be untenable.

In the continued development of a Consultation Liaison Outcome Evaluation System (CLOES), we have now examined consultee responses to a number of consultant actions and identified variables critical to the respective outcomes. Concordance rates in these additional studies have been either lower or comparable to those we reported in response to consultants' recommendations for psychotropic medication. Kramer et al ask if consultants in other medical specialties elicit comparable consultee responses to their interventions. Preliminary results from companion studies of the cardiology consultation service in our hospital indicate that cardiology consultants elicit significantly greater overall concordance than their psychiatric counterparts in both recommendations for medication and diagnostic action.