The increased number of prescriptions written for hydrocodone and oxycodone between 1995 and 2004 was associated with similar increases in non-medical use and the number of ED visits during this time period.
Trigger tools have a potential role in driving quality improvement in ambulatory primary care. In our study using a 39-item ADE trigger tool, most triggers had very low PPVs. Nine of the 39 triggers accounted for 94.4% of ADEs detected, suggesting the possibility of a much briefer tool. Practical issues related to adoption of such tools by practising physicians should be further explored.
Objective To determine if asthma control improves in patients who receive physician-pharmacist collaborative management (PPCM) during visits to primary care medical offices. Design Prospective pre-post study of patients who received the intervention in primary care offices for 9 months. The primary outcome was the sum of asthma-related emergency department (ED) visits and hospitalizations at 9 months before, 9 months during, and 9 months following the intervention. Events were analyzed using linear mixed effects regression. Secondary analysis was conducted for patients with uncontrolled asthma (Asthma Control Test [ACT]<20). Additional secondary outcomes included the ACT, the Asthma Quality of Life Questionnaire by Marks (AQLQ-M) scores, and medication changes. Intervention Pharmacists provided patients with an asthma self-management plan and education and made pharmacotherapy recommendations to physicians when appropriate. Results Of 126 patients, the number of emergency department (ED) visits and/or hospitalizations decreased 30% during the intervention (p=0.052) and then returned to pre-enrollment levels after the intervention was discontinued (p=0.83). Secondary analysis of patients with uncontrolled asthma at baseline (ACT<20), showed 37 ED visits and hospitalizations prior to the intervention, 21 during the intervention, and 33 after the intervention was discontinued (p=0.019). ACT and AQLQ-M scores improved during the intervention (ACT mean absolute increase of 2.11, AQLQ-M mean absolute decrease of 4.86, p<0.0001 respectively) and sustained a stable effect after discontinuation of the intervention. Inhaled corticosteroid use increased during the intervention (p=0.024). Conclusions The PPCM care model reduced asthma-related ED visits and hospitalizations and improved asthma control and quality of life. However, the primary outcome was not statistically significant for all patients. There was a significant reduction in ED visits and hospitalizations during the intervention for patients with uncontrolled asthma at baseline. Our findings support the need for further studies to investigate asthma outcomes achievable with the PPCM model.
PURPOSE Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined. METHODSIn a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute's Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre-and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar's test and multivariate modeling were used to evaluate the impact of the interventions.RESULTS Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7-3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5-3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation.CONCLUSIONS Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines. Ann Fam Med 2014;233-240. doi: 10.1370/afm.1624. INTRODUCTIONI mplementation of clinical practice guidelines for managing chronic diseases can be challenging for primary care practices. Despite the availability since 1991 of the guidelines sponsored by the National Heart, Lung and Blood Institute (NHLBI) and produced by the National Asthma Education and Prevention Program (NAEPP), fewer than 40% of asthma care notes include information about symptoms, missed activities, and environmental triggers.1-4 A 2001 survey of more than 60,000 patients treated by 4,901 primary care physicians found that while 62% of pediatric patients and 68% of adult patients reported more than 2 symptomatic days in the past week, only 60% had a prescription for a controller medication. 5 Other studies found that practices prescribing a corticosteroid inhaler ranged from 15% among patients with moderate to severe asthma to 72% among patients with severe asthma. 6,7 Between 0% and 50% of parents of asthmatic children report having received an action plan. [16][17][18][19] Two promising types of assistance are practice facilitation (PF) [20][21][22] and learning coll...
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