We assessed the effectiveness of a quality improvement project to reduce routine labs in clinically stable patients, while also promoting sleep-friendly lab timing. The electronic health record was modified with an “Order Sleep” shortcut to facilitate sleep-friendly lab draws. A “4 am Labs” column was added to electronic patient lists to signal which patients had early morning labs ordered. Among 7,045 patients over 50,951 total patient-days, on average we observed 26.3% fewer routine lab draws per patient-day per week postintervention (4.68 before vs 3.45 after; difference, 1.23; 95% CI, 0.82-1.63; P < .05). In interrupted time series analysis, the “Order Sleep” tool was associated with a significant increase in sleep-friendly lab orders per encounter per week on resident medicine services (intercept, 1.03; standard error (SE), 0.29; P < .001). The “4 am Labs” column was associated with a significant increase in sleep-friendly lab orders per patient encounter per week on the hospitalist medical service (intercept, 1.17; SE, 0.50; P = .02). We demonstrate the success of an initiative to simultaneously reduce daily labs and improve sleep-friendly ordering. Journal of Hospital Medicine 2020;15:XXX-XXX. © 2020 Society of Hospital Medicine
BackgroundThe WHO recently recognised stigma as a fundamental cause for health inequalities. Weight stigma is associated with negative health consequences, and patients experience it commonly in healthcare settings. This study forms part of systematic review that aimed to understand how weight stigma can be reduced through the adoption of whole systems approaches.AimTo generate new understandings of the roles primary care can take in reducing weight stigma.MethodA systematic international literature review of peer-reviewed articles utilising EPPI guidance, and using PICOS terms in Web of Science searches. Recommendations for policy, practice and/or research were extracted and conceptually synthesised as guided by Research Unit for Research Utilisation.ResultsThe search identified 194 full texts with 540 total recommendations. Approximately 45% of recommendations (248 of 540) were coded under healthcare, of which 75% were in primary care including general practice (189 of 248). Findings indicate areas where weight stigma could be addressed in primary care: 1) Training; 2) Self-awareness; 3) Non-stigmatising approaches; 4) Formal patient assessments; 5. Coping strategies; 6) Organisational/structural support; 7) Cross-sector working; 8) Anti-discrimination legislation and classify obesity as a disease.ConclusionLiterature on reducing weight stigma focuses substantially on healthcare, and there is a range of approaches that could be taken. Tensions arise between the medicalisation of obesity and need to consider social determinants of obesity. Healthcare is only one of many settings in which the weight stigma needs to be addressed and whole systems approaches, for example working with local government, are required in particular to reduce health inequalities.
What is known and objective The use of generic oral contraceptives (OCPs) can improve adherence and reduce healthcare costs, yet scepticism of generic drugs remains a barrier to generic OCP discussion and prescription. An educational web module was developed to reduce generic scepticism related to OCPs, improve knowledge of generic drugs and increase physician willingness to discuss and prescribe generic OCPs. Methods A needs assessment was completed using in‐person focus groups at American College of Physicians (ACP) Annual Meeting and a survey targeting baseline generic scepticism. Insights gained were used to build an educational web module detailing barriers and benefits of generic OCP prescription. The module was disseminated via email to an ACP research panel who completed our baseline survey. Post‐module evaluation measured learner reaction, knowledge and intention to change behaviour along with generic scepticism. Results and discussion The module had a response rate of 56% (n = 208/369). Individuals defined as generic sceptics at baseline were significantly less likely to complete our module compared to non‐sceptics (responders 9.6% vs non‐responders 16.8%, P = 0.04). The majority (85%, n = 17/20) of baseline sceptics were converted to non‐sceptics (P < 0.01) following completion of the module. Compared to non‐sceptics, post‐module generic sceptics reported less willingness to discuss (sceptic 33.3% vs non‐sceptic 71.5%, P < 0.01), but not less willingness to prescribe generic OCPs (sceptic 53.3% vs non‐sceptic 67.9%, P = 0.25). Non‐white physicians and international medical graduates (IMG) were more likely to be generic sceptics at baseline (non‐white 86.9% vs white 69.9%, P = 0.01, IMG 13.0% vs USMG 5.0% vs unknown 18.2%, P = 0.03) but were also more likely to report intention to prescribe generic OCPs as a result of the module (non‐white 78.7% vs white 57.3%, P < 0.01, IMG 76.1% vs USMG 50.3% vs unknown 77.3%, P = 0.03). What is new and conclusion A brief educational web module can be used to promote prescribing of generic OCPs and reduce generic scepticism.
Although generic oral contraceptives (OCPs) can improve adherence and reduce health care expenditures, use of generic OCPs remains low, and the factors that affect generic prescribing are not well understood. We aimed to understand the barriers and facilitators of generic OCP prescribing and potential solutions to increase generic OCP prescribing, as well as pilot an educational module to address clinician misconceptions about generic OCPs. We developed focus group scripts using the 4D model of appreciative inquiry. A total of four focus groups occurred, two at the American Association of Nurse Practitioners (AANP) national conference and two at the American College of Physicians (ACP) Internal Medicine meeting. Focus group transcripts were analyzed using a constant comparative method with no a priori hypothesis to generate emerging and reoccurring themes. Findings from these focus groups were used to develop an educational module promoting generic OCP prescribing. Participants were recruited from the AANP Network for Research and the ACP Research Panel. This study demonstrates that health system factors, workflow factors, clinician factors, and patient factors were the main barriers to and facilitators of generic OCP prescribing. Nurse practitioners were responsive to an educational module and reported increased willingness to discuss and prescribe generic OCPs after completing the module. Interventions to increase generic OCP prescribing must address clinician and patient factors within the context of workflow and larger health system factors.
In the increasingly complex health care system, physicians require skills and knowledge to participate with multidisciplinary team members in quality improvement (QI) that adds value to health care organizations. The Educational and Clinical Leaders Improving Performance with Structured E3L training (ECLIPSE) program was developed to address this challenge. Clinically relevant components of lean management were leveraged to create an online, flipped-classroom curriculum, and this was paired with Kaizen adapted specifically for physicians and multidisciplinary clinicians to promote experiential skills utilization. The focus of each adapted Kaizen was a topic of institutional QI priority, such as improving patient throughput or reducing readmission rates. Participants were awarded certification in the E3 Leadership management system—a patient-centered, equity-focused system based on lean principles. After 4 years, 50 E3 Leadership certificates were awarded to multidisciplinary clinicians, including 30 to physicians; participants scored an average 85% on module quizzes. The ECLIPSE program has improved physician participation in multidisciplinary QI projects with institutional alignment.
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