Background Diabetes group clinics can effectively control hypertension, but data to support glycemic control is equivocal. This study evaluated the comparative effectiveness of two diabetes group clinic interventions on glycosolated hemoglobin (HbA1c) levels in primary care. Methods Participants (n = 87) were recruited from a diabetes registry of a single regional VA medical center to participate in an open, randomized comparative effectiveness study. Two primary care based diabetes group interventions of three months duration were compared. Empowering Patients in Care (EPIC) was a clinician-led, patient-centered group clinic consisting of four sessions on setting self-management action plans (diet, exercise, home monitoring, medications, etc.) and communicating about progress with action plans. The comparison intervention consisted of group education sessions with a diabetes educator and dietician followed by an additional visit with one’s primary care provider. HbA1c levels were compared post-intervention and at one-year follow-up. Results Participants in the EPIC intervention had significantly greater improvements in HbA1c levels immediately following the active intervention (8.86 to 8.04 vs. 8.74 to 8.70, mean [SD] between-group difference 0.67±1.3, P=.03) and these differences persisted at 1 year follow-up (.59±1.4, P=.05). A repeated measures analysis using all study time points found a significant time-by-treatment interaction effect on HbA1c levels favoring the EPIC intervention (F(2,85) =3.55, P= .03). The effect of the time-by-treatment interaction appears to be partially mediated by diabetes self-efficacy (F(1,85) =10.39, P= .002). Conclusions Primary care based diabetes group clinics that include structured goal-setting approaches to self-management can significantly improve HbA1c levels post-intervention and maintain improvements for 1-year. Trial registration ClinicalTrials.gov Identifier: NCT00481286
Decision making in cardiology concentrates on diseasespecific outcomes following practice guidelines for specific conditions. Quality metrics implemented for valuebased purchasing and public reporting also largely focus on individual diseases. Disease-centered approaches are appropriate when individuals have a single predominant disease and everyone with the disease desires the same outcome, such as prolonged survival or stroke prevention. 1 This disease-centered framework is illsuited, however, for persons with multiple chronic conditions, including most older adults with cardiovascular conditions and the majority of adult health care users of all ages. 2 Disease-centered decision making for this population results in treatment burden when patients must adhere to multiple guidelines and harm when guideline recommendations conflict. 3 Furthermore, disease-centered recommendations may not address what matters most to these patients who vary in their health priorities. 4 To consider an alternative to disease-centered decision making that better aligns care with what matters most to patients and reduces treatment burden, it is helpful to think of health care decisions as value propositions in which value = health outcome / cost. From the population perspective, health care value is defined as survival or disease benefit (output) per dollar spent (input). From patients' perspective, however, the personal health outcomes that they hope to achieve are more appropriate outputs. 4 The appropriate inputs may include financial costs, but often more relevant are costs in terms of the time, discomfort, harms, and workload required to achieve their health outcomes. 3 When defined as what patients are willing and able to do for their health, these broader costs inform care preferences. An alternative approach to decision making, therefore, is predicated on achieving patients' specific health outcome goals within the context of their acceptable workload. High-value care is defined as achievement of each patient's highest-level health outcome goals given the workload each is willing and able to perform. This is not as daunting a task as it may seem; patients implicitly consider trade-offs between outcome and workload even if it is not explicitly discussed. 3 Examples of health outcome goals and patient workload are shown in the Box. This approach represents a shift from diseasecentered to patient goals-directed care. The idea that health care decisions should include patients' health
IMPORTANCE Overtreatment of asymptomatic bacteriuria (ASB) in patients with urinary catheters remains high. Health care professionals have difficulty differentiating cases of ASB from catheter-associated urinary tract infections.OBJECTIVES To evaluate the effectiveness and sustainability of an intervention to reduce urine culture ordering and antimicrobial prescribing for catheter-associated ASB compared with standard quality improvement methods. DESIGN, SETTING, AND PARTICIPANTSA preintervention and postintervention comparison with a contemporaneous control group from July 2010 to June 2013 at 2 Veterans Affairs health care systems. Study populations were patients with urinary catheters on acute medicine wards and long-term care units and health care professionals who order urine cultures and prescribe antimicrobials.INTERVENTION A multifaceted guidelines implementation intervention. MAIN OUTCOMES AND MEASURESThe primary outcomes were urine cultures ordered per 1000 bed-days and cases of ASB receiving antibiotics (overtreatment) during intervention and maintenance periods compared with baseline at both sites. Patient-level analysis of inappropriate antimicrobial use adjusted for individual covariates.RESULTS Study surveillance included 289 754 total bed-days. The overall rate of urine culture ordering decreased significantly during the intervention period (from 41.2 to 23.3 per 1000 bed-days; incidence rate ration [IRR], 0.57; 95% CI, 0.53-0.61) and further during the maintenance period (to 12.0 per 1000 bed-days; IRR, 0.29; 95% CI, 0.26-0.32) (P < .001 for both). At the comparison site, urine cultures ordered did not change significantly across all 3 periods. There was a significant difference in the number of urine cultures ordered per month over time when comparing the 2 sites using longitudinal linear regression (P < .001). Overtreatment of ASB at the intervention site fell significantly during the intervention period (from 1.6 to 0.6 per 1000 bed-days; IRR, 0.35; 95% CI, 0.22-0.55), and these reductions persisted during the maintenance period (to 0.4 per 1000 bed-days; IRR, 0.24; 95% CI, 0.13-0.42) (P < .001 for both). Overtreatment of ASB at the comparison site was similar across all periods (odds ratio, 1.32; 95% CI, 0.69-2.52). When analyzed by type of ward, the decrease in ASB overtreatment was significant in long-term care. CONCLUSIONS AND RELEVANCEA multifaceted intervention targeting health care professionals who diagnose and treat patients with urinary catheters reduced overtreatment of ASB compared with standard quality improvement methods. These improvements persisted during a low-intensity maintenance period. The impact was more pronounced in long-term care, an emerging domain for antimicrobial stewardship.
OBJECTIVES To identify a taxonomy of health-related values that frame goals of care of older, multimorbid adults who recently faced cancer diagnosis and treatment. DESIGN Qualitative analysis of data from a longitudinal cohort study of multimorbid cancer survivors. SETTING Cancer registries from regional Department of Veterans Affairs networks in New England and southeast Texas. PARTICIPANTS Multimorbid adults who completed interviews 12 months after diagnosis of head and neck, colorectal, gastric, or esophageal cancer and after cancer treatment (N = 146). MEASUREMENTS An interdisciplinary team conducted thematic analyses of participants’ intuitive responses to two questions: Now that you have had cancer and may face ongoing decisions about medical care in the future, what would you want your family, friends, and doctors to know about you, in terms of what is most important to you in your life? If your cancer were to recur, is there anything you’d want to be sure your loved ones knew about you and your goals of care? RESULTS Analysis revealed five distinct health-related values that guide how multimorbid cancer survivors conceptualize specific health care goals and medical decisions: self-sufficiency, life enjoyment, connectedness and legacy, balancing quality and length of life, and engagement in care. Participants typically endorsed more than one value as important. CONCLUSION Older multimorbid adults who recently faced life-threatening cancer endorsed a multidimensional taxonomy of health-related values. These health-related values guide how they frame their goals for care and treatment preferences. Eliciting individuals’ sense of their values during clinical encounters may improve their experiences with health care and more effectively align treatments with goals of care.
Objectives To develop a values‐based, clinically feasible process to help older adults identify health priorities that can guide clinical decision‐making. Design Prospective development and feasibility study. Setting Primary care practice in Connecticut. Participants Older adults with 3 or more conditions or taking 10 or more medications (N=64). Intervention The development team of patients, caregivers, and clinicians used a user‐centered design framework—ideate → prototype → test →redesign—to develop and refine the value‐based patient priorities care process and medical record template with trained clinician facilitators. Measurements We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions). Results We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians. Conclusion Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.
Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record.
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